The effectiveness and cost effectiveness of telephone counselling and the nicotine patch in a state tobacco quitline

Predictors of engagement in post-discharge quitline counseling among hospitalized smokers

Quitlines provide evidence-based tobacco treatment and multiple calls yield higher quit rates. This study aimed to identify subgroups of smokers with greater quitline engagement following referral during hospitalization. Data were from a randomized clinical trial assessing the effectiveness of fax referral (referral faxed to proactive quitline) versus warm handoff (patient connected to quitline at bedside) (n = 1054). Classification and regression trees analyses evaluated individual and treatment/health system-related variables and their interactions. Among all participants, warm handoff, higher ratings of the tobacco treatment care transition, and being older predicted completing more quitline calls. Among patients enrolled in the quitline, higher transition of care ratings, being older, and use of cessation medication post-discharge predicted completing more calls. Three of the four factors influencing engagement were characteristics of treatment within the hospital (quality of tobacco treatment care transition and referral method) and therapy (use of cessation medications), suggesting potential targets to increase quitline engagement post-discharge.

Cost-effectiveness of alternative smoking cessation scenarios in Spain: results from the EQUIPTMOD

AIMS

To assess the cost-effectiveness of alternative smoking cessation scenarios from the perspective of the Spanish National Health Service (NHS).

DESIGN

We used the European study on Quantifying Utility of Investment in Protection from Tobacco model (EQUIPTMOD), a Markov-based state transition economic model, to estimate the return on investment (ROI) of: (a) the current provision of smoking cessation services (brief physician advice and printed self-helped material + smoking ban and tobacco duty at current levels); and (b) four alternative scenarios to complement the current provision: coverage of proactive telephone calls; nicotine replacement therapy (mono and combo) [prescription nicotine replacement therapy (Rx NRT)]; varenicline (standard duration); or bupropion. A rate of 3% was used to discount life-time costs and benefits.

SETTING

Spain.

PARTICIPANTS

Adult smoking population (16+ years).

MEASUREMENTS

Health-care costs associated with treatment of smoking attributable diseases (lung cancer, coronary heart disease, chronic obstructive pulmonary infection and stroke); intervention costs; quality-adjusted life years (QALYs). Costs and outcomes were summarized using various ROI estimates.

FINDINGS

The cost of implementing the current provision of smoking cessation services is approximately €61 million in the current year. This translates to 18 quitters per 1000 smokers and a life-time benefit-cost ratio of 5, compared with no such provision. All alternative scenarios were dominant (cost-saving: less expensive to run and generated more QALYs) from the life-time perspective, compared with the current provision. The life-time benefit-cost ratios were: 1.87 (proactive telephone calls); 1.17 (Rx NRT); 2.40 (varenicline-standard duration); and bupropion (2.18). The results remained robust in the sensitivity analysis.

CONCLUSIONS

According to the EQUIPTMOD modelling tool it would be cost-effective for the Spanish authorities to expand the reach of existing GP brief interventions for smoking cessation, provide pro-active telephone support, and reimburse smoking cessation medication to smokers trying to stop. Such policies would more than pay for themselves in the long run.

Cost-Effectiveness of a Health System-Based Smoking Cessation Program

Introduction

Project CLIQ (Community Link to Quit) was a proactive population-outreach strategy using an electronic health records-based smoker registry and interactive voice recognition technology to connect low- to moderate-income smokers with cessation counseling, medications, and social services. A randomized trial demonstrated that the program increased cessation. We evaluated the cost-effectiveness of CLIQ from a provider organization's perspective if implemented outside the trial framework.

Methods

We calculated the cost, cost per smoker, incremental cost per additional quit, and, secondarily, incremental cost per additional life year saved of the CLIQ system compared to usual care using data from a 2011-2013 randomized trial assessing the effectiveness of the CLIQ system. Sensitivity analyses considered economies of scale and initial versus ongoing costs.

Results

Over a 20-month period (the duration of the trial) the program cost US $283 027 (95% confidence interval [CI] $209 824-$389 072) more than usual care in a population of 8544 registry-identified smokers, 707 of whom participated in the program. The cost per smoker was $33 (95% CI 28-40), incremental cost per additional quit was $4137 (95% CI $2671-$8460), and incremental cost per additional life year saved was $7301 (95% CI $4545-$15 400). One-time costs constituted 28% of costs over 20 months. Ongoing costs were dominated by personnel costs (71% of ongoing costs). Sensitivity analyses showed sharp gains in cost-effectiveness as the number of identified smokers increased because of the large initial costs.

Conclusions

The CLIQ system has favorable cost-effectiveness compared to other smoking cessation interventions. Cost-effectiveness will be greatest for health systems with high numbers of smokers and with the high smoker participation rates.

Implications

Health information systems capable of establishing registries of patients who are smokers are becoming more prevalent. This economic analysis illustrates the cost implications for health care systems adopting a proactive tobacco treatment outreach strategy for low- and middle-income smokers. We find that under many circumstances, the CLIQ system has a favorable cost-per-quit compared to other population-based tobacco treatment strategies. The strategy could be widely disseminable if health systems leverage economies of scale.

Race/Ethnic Variations in Quitline Use Among US Adult Tobacco Users in 45 States, 2011-2013

Introduction

State quitlines provide free telephone-based cessation services and are available in all states. However, quitlines presently reach 1% of US cigarette smokers. We assessed variations in quitline reach by race/ethnicity across 45 US states included in the National Quitline Data Warehouse, a repository on non-identifiable data reported by state quitlines.

Methods

During 2011 to 2013, we analyzed 1 220 171 records from the National Quitline Data Warehouse. Annual quitline reach was defined as the proportion of cigarette smokers and smokeless tobacco users who utilized quitline services during each year, and was calculated by dividing the number of state-specific quitline registrants in each year by the number of adult cigarette smokers and smokeless tobacco users in the state.

Results

Average annual reach ranged from: 0.08% (Tennessee) to 3.42% (Hawaii) among non-Hispanic whites; 0.17% (Tennessee) to 3.85% (Delaware) among non-Hispanic blacks; 0.27% (Nevada) to 9.98% (Delaware) among non-Hispanic American Indians/Alaska Native; 0.03% (Alabama) to 2.43% (Hawaii) among non-Hispanic Asian/Pacific Islanders; and from 0.08% (Tennessee) to 3.18% (Maine) among Hispanics. Average annual reach was highest among non-Hispanic American Indians/Alaska Native in 27 states, non-Hispanic blacks in 14 states, and non-Hispanic whites in four states.

Conclusions

Quitlines appear to be reaching minority populations; however, overall reach remains low and variations in quitline reach exist by race/ethnicity. Opportunities exist to increase the utilization of quitlines and other effective cessation treatments among racial/ethnic minority populations.

Implications

Some studies have assessed quitline reach across demographic groups in individual states; however, no studies have provided multistate data about quitline reach across race/ethnic groups. Ongoing monitoring of the use of state quitlines can help guide targeted outreach to particular race/ethnic groups with the goal of increasing the overall proportion and number of tobacco users that use quitlines. These efforts should be complemented by comprehensive tobacco control initiatives that increase cessation including mass media campaigns, smoke-free policies, increased tobacco prices, expansion of health insurance coverage, and health systems change.

Impact and Effectiveness of a Stand-Alone NRT Starter Kit in a Statewide Tobacco Cessation Program

PURPOSE

To examine 2-week nicotine replacement therapy (NRT) starter kit quit outcomes and predictors and the impact of adding this new service on treatment reach.

DESIGN

Observational study of a 1-year cohort of QUITPLAN Services enrollees using registration and utilization data and follow-up outcome survey data of a subset of enrollees who received NRT starter kits.

SETTING

ClearWay Minnesota's QUITPLAN Services provides a quit line that is available to uninsured and underinsured Minnesotans and NRT starter kits (a free 2-week supply of patches, gum, or lozenges) that are available to all Minnesota tobacco users.

PARTICIPANTS

A total of 15 536 adult QUITPLAN Services enrollees and 818 seven-month follow-up survey NRT starter kit respondents.

MEASURES

Treatment reach for all services and tobacco quit outcomes and predictors for starter kit recipients.

ANALYSIS

Descriptive analyses, χ² analyses, and logistic regression.

RESULTS

Treatment reach increased 3-fold after adding the 2-week NRT starter kit service option to QUITPLAN Services compared to the prior year (1.86% vs 0.59%). Among all participants enrolling in QUITPLAN services during a 1-year period, 83.8% (13 026/15 536) registered for a starter kit. Among starter kit respondents, 25.6% reported being quit for 30 days at the 7-month follow-up. After controlling for other factors, using all NRT and selecting more cessation services predicted quitting.

CONCLUSION

An NRT starter kit brought more tobacco users to QUITPLAN services, demonstrating interest in cessation services separate from phone counseling. The starter kit produced high quit rates, comparable to the quit line in the same time period. Cessation service providers may want to consider introducing starter kits to reach more tobacco users and ultimately improve population health.

Improving quit rates of web-delivered interventions for smoking cessation: full-scale randomized trial of WebQuit.org versus Smokefree.gov

BACKGROUND AND AIMS

Millions of people world-wide use websites to help them quit smoking, but effectiveness trials have an average 34% follow-up data retention rate and an average 9% quit rate. We compared the quit rates of a website using a new behavioral approach called Acceptance and Commitment Therapy (ACT; WebQuit.org) with the current standard of the National Cancer Institute's (NCI) Smokefree.gov website.

DESIGN

A two-arm stratified double-blind individually randomized trial (n = 1319 for WebQuit; n = 1318 for Smokefree.gov) with 12-month follow-up.

SETTING

United States.

PARTICIPANTS

Adults (n = 2637) who currently smoked at least five cigarettes per day were recruited from March 2014 to August 2015. At baseline, participants were mean [standard deviation (SD)] age 46.2 years (13.4), 79% women and 73% white.

INTERVENTIONS

WebQuit.org website (experimental) provided ACT for smoking cessation; Smokefree.gov website (comparison) followed US Clinical Practice Guidelines for smoking cessation.

MEASUREMENTS

The primary outcome was self-reported 30-day point prevalence abstinence at 12 months.

FINDINGS

The 12-month follow-up data retention rate was 88% (2309 of 2637). The 30-day point prevalence abstinence rates at the 12-month follow-up were 24% (278 of 1141) for WebQuit.org and 26% (305 of 1168) for Smokefree.gov [odds ratio (OR) = 0.91; 95% confidence interval (CI) = 0.76, 1.10; P = 0.334] in the a priori complete case analysis. Abstinence rates were 21% (278 of 1319) for WebQuit.org and 23% (305 of 1318) for Smokefree.gov (OR = 0.89 (0.74, 1.07; P = 0.200) when missing cases were imputed as smokers. The Bayes factor comparing the primary abstinence outcome was 0.17, indicating 'substantial' evidence of no difference between groups.

CONCLUSIONS

WebQuit.org and Smokefree.gov had similar 30-day point prevalence abstinence rates at 12 months that were descriptively higher than those of prior published website-delivered interventions and telephone counselor-delivered interventions.

Oral Health Promotion and Smoking Cessation Program Delivered via Tobacco Quitlines: The Oral Health 4 Life Trial

OBJECTIVES

To assess the effects of a novel oral health promotion program (Oral Health 4 Life; OH4L) delivered through state-funded tobacco quitlines.

METHODS

Using a semipragmatic design to balance experimental control and generalizability, we randomized US quitline callers (n = 718) to standard care or standard care plus OH4L. We followed participants for 6 months to assess effects on professional dental care and smoking abstinence. We collected data between 2015 and 2017.

RESULTS

Participants were racially diverse (42% non-White) and socioeconomically disadvantaged. Most (71%) reported fair or poor oral health, and all were overdue for routine dental care. At 6 months, professional dental care and abstinence did not significantly differ between arms, but abstinence favored the experimental arm and was significantly higher among experimental participants at 2 months in a complete case sensitivity analysis.

CONCLUSIONS

OH4L was not effective for promoting dental care, but integrating oral health counseling with quitline counseling may offer some advantage for smoking cessation. Public Health Implications. We offer a model for conducting semipragmatic trials and partnering with tobacco quitlines to evaluate population-level public health interventions.

Tobacco dependence treatment in the emergency department: A randomized trial using the Multiphase Optimization Strategy

BACKGROUND

Tobacco dependence remains the leading preventable cause of death in the developed world. Smokers are disproportionately from lower socioeconomic groups, and may use the hospital emergency department (ED) as an important source of care. A recent clinical trial demonstrated the efficacy of a multicomponent intervention to help smokers quit, but the independent contributions of those components is unknown.

METHODS

This is a full-factorial (16-arm) randomized trial in a busy hospital ED of 4 tobacco dependence interventions: brief motivational interviewing, nicotine replacement therapy, referral to a telephone quitline, and a texting program. The trial utilizes the Multiphase Optimization Strategy (MOST) and a novel mixed methods analytic design to assess clinical efficacy, cost effectiveness, and qualitative participant feedback. The primary endpoint is tobacco abstinence at 3months, verified by participants' exhaled carbon monoxide.

RESULTS

Study enrollment began in February 2017. As of April 2017, 52 of 1056 planned participants (4.9%) were enrolled. Telephone-based semi-structured participant interviews and in-person biochemical verification of smoking abstinence are completed at the 3-month follow-up. Efficacy and cost effectiveness analyses will be conducted after follow-up is completed.

DISCUSSION

The goal of this study is to identify a clinically efficacious, cost-effective intervention package for the initial treatment of tobacco dependence in ED patients. The efficacy of this combination can then be tested in a subsequent confirmatory trial. Our approach incorporates qualitative feedback from study participants in evaluating which intervention components will be tested in the future trial.

TRIAL REGISTRATION

Trial (NCT02896400) registered in ClinicalTrials.gov on September 6, 2016.

Motivational Benefits of Social Support and Behavioural Interventions for Smoking Cessation

This study examined the role of social support and behavioral interventions used during the last unsuccessful quit attempt for smokers' intentions to quit smoking within the next 6 months, and identified smokers' attributes associated with use of social support and behavioral interventions. The analytic sample included 7,195 adult daily smokers who responded to the 2010-2011 Tobacco Use Supplement to the Current Population Survey, conducted in the US, and indicated having a serious quit attempt in the past 12 months. Smokers who relied on social support from friends and family had higher odds of intending to quit than those who did not (OR= 1.39, 95% CI= 1.22:1.58), and smokers who used interventions had higher odds of intending to quit than those who did not (OR= 1.36, 95% CI= 1.07:1.74). These associations were similar for both sexes, all age groups, and nicotine dependence levels. Both, relying on social support and use of behavioral interventions were more common among smokers who were female, higher educated, residing in the Western US region, and those who used pharmacological aids for smoking cessation. Social support and behavioral interventions are associated with higher intentions to quit among attempters who relapsed and thus, may aid future smoking cessation.

Evaluation and Implementation of a Proactive Telephone Smoking Cessation Counseling for Parents: A Study Protocol of an Effectiveness Implementation Hybrid Design

Detrimental health consequences of smoking for both parents and children stress the importance for parents to quit. A Dutch efficacy trial supported the efficacy of proactive telephone counseling on parents. Still, how this program would function in "real world" conditions and how parents could be optimally reached is unclear. Therefore, this study will use an innovative method to examine the recruitment success of two implementation approaches (i.e., via a healthcare approach and a mass media approach) to test the (cost)effectiveness of the program. A two-arm randomized controlled trial and an implementation study (i.e., process evaluation) are conducted. Parents (N = 158) will be randomly assigned to the intervention (i.e., telephone counseling) or control conditions (i.e., self-help brochure). Primary outcome measure is 7-day point prevalence abstinence at three months post-intervention. Qualitative and quantitative research methods are used for the process evaluation. We expect that parents in the intervention condition have higher cessation rates than parents in the control condition. We also expect that the recruitment of parents via (youth) health care services is a more promising implementation approach compared to mass media. Results will have implications for the effectiveness of a proactive telephone counseling and provide directions for its successful implementation.

Providing Antismoking Socialization to Children After Quitting Smoking: Does It Help Parents Stay Quit?

PURPOSE

To test whether an antismoking parenting program provided to parents who had quit smoking for ≥24 hours increased parents' likelihood of remaining abstinent 2 and 3 years postbaseline.

DESIGN

Two-group randomized controlled trial with 3-year follow-up.

SETTING

Eleven states (Colorado, Indiana, Michigan, Minnesota, Montana, New York, Ohio, Pennsylvania, South Dakota, Utah, and Vermont).

PARTICIPANTS

Five hundred seventy-seven adults (286 treatment and 291 control) who had smoked ≥10 cigarettes daily at baseline, had quit smoking for ≥24 hours after calling a Quitline, and were parents of an 8- to 10-year-old child; 358 (62%) completed the 2-year follow-up interview, and 304 (53%) completed the 3-year follow-up interview.

INTERVENTION

Theory-driven, home-based, self-help parenting program.

MEASURES

Sociodemographic, smoking history, and 30-day point prevalence.

ANALYSIS

Multivariable regression analyses tested for group differences in 30-day abstinence. Attriters were coded as having relapsed.

RESULTS

Between-group differences in abstinence rates were 5.6% and 5.9% at 2 and 3 years, respectively. Treatment group parents had greater odds of abstinence, an effect that was significant only at the latter time point (odds ratio [OR] = 1.49, P = .075 at 2 years; OR = 1.70, P = .026 at 3 years).

CONCLUSIONS

This study obtained preliminary evidence that engaging parents who recently quit smoking as agents of antismoking socialization of children has the potential to reduce the long-term odds of relapse.

IMPLEMENTATION, RECRUITMENT AND BASELINE CHARACTERISTICS: A RANDOMIZED TRIAL OF COMBINED TREATMENTS FOR SMOKING CESSATION AND WEIGHT CONTROL

Background

Two-thirds of treatment-seeking smokers are obese or overweight. Most smokers are concerned about gaining weight after quitting. The average smoker experiences modest post-quit weight gain which discourages many smokers from quitting. Although evidence suggests that combined interventions to help smokers quit smoking and prevent weight gain can be helpful, studies have not been replicated in real world settings.

Methods

This paper describes recruitment and participant characteristics of the Best Quit Study, a 3-arm randomized controlled trial testing tobacco cessation treatment alone or combined with simultaneous or sequential weight management. Study participants were recruited via tobacco quitlines from August 5, 2013 to December 15, 2014.

Results

Statistical analysis on baseline data was conducted in 2015/2016. Among 5082 potentially eligible callers to a tobacco quitline, 2540 were randomized (50% of eligible). Compared with individuals eligible but not randomized, those randomized were significantly more likely to be female (65.7% vs 54.5%, p < 0.01), overweight or obese (76.3% vs 62.5%, p < 0.01), more confident in quitting (p < 0.01), more addicted (first cigarette within 5 min: 50.0% vs 44.4%, p < 0.01), and have a chronic disease (28.6% vs. 24.4%, p < 0.01). Randomized groups were not statistically significantly different on demographics, tobacco or weight variables. Two-thirds of participants were female and white with a mean age of 43.

Conclusions

Adding weight management interventions to tobacco cessation quitlines was feasible and acceptable to smokers. If successful for cessation and weight outcomes, a combined intervention may provide a treatment approach for addressing weight gain with smoking cessation through tobacco quitlines.

Trial registration

Clinicaltrials.gov NCT01867983.

Implementation evaluation of the Telephone Lifestyle Coaching (TLC) program: organizational factors associated with successful implementation

The Telephone Lifestyle Coaching (TLC) program provided telephone-based coaching for six lifestyle behaviors to 5321 Veterans at 24 Veterans Health Administration (VHA) medical facilities. The purpose of the study was to conduct an evaluation of the TLC program to identify factors associated with successful implementation. A mixed-methods study design was used. Quantitative measures of organizational readiness for implementation and facility complexity were used to purposively select a subset of facilities for in-depth evaluation. Context assessments were conducted using interview transcripts. The Consolidated Framework for Implementation Research (CFIR) was used to guide qualitative data collection and analysis. Factors most strongly correlated with referral rates included having a skilled implementation leader who used effective multi-component strategies to engage primary care clinicians as well as general clinic structures that supported implementation. Evaluation findings pointed to recommendations for local and national leaders to help anticipate and mitigate potential barriers to successful implementation.

Clickotine, A Personalized Smartphone App for Smoking Cessation: Initial Evaluation

Background

Tobacco smoking is the leading cause of preventable death in the United States, and the annual economic burden attributable to smoking exceeds US $300 billion. Obstacles to smoking cessation include limited access and adherence to effective cessation interventions. Technology can help overcome these obstacles; many smartphone apps have been developed to aid smoking cessation, but few that conform to the US clinical practice guideline (USCPG) have been rigorously tested and reported in the literature. Clickotine is a novel smartphone app for smoking cessation, designed to deliver the essential features of the USCPG and engineered to engage smokers by personalizing intervention components.

Objective

Our objective was to assess the engagement, efficacy, and safety of Clickotine in an initial, single-arm study. Outcomes measured were indicators of engagement with the smartphone app (number of app opens, number of interactions with the Clickotine program, and weeks active with Clickotine), cessation outcomes of 7- and 30-day self-reported abstinence from smoking, and negative health events.

Methods

We recruited US residents between 18 and 65 years of age who owned an iPhone and smoked 5 or more cigarettes daily for the study via online advertising. Respondents were prescreened for eligibility by telephone and, if appropriate, directed to a Web portal to provide informed consent, confirm eligibility, and download the Clickotine app. Participants completed study assessments via the online portal at baseline and after 8 weeks. Data were collected in Amazon S3 with no manual data entry, and access to all data was maximally restrictive, logged, and auditable.

Results

A total of 416 participants downloaded the app and constituted the intention-to-treat (ITT) sample. On average, participants opened the Clickotine app 100.6 times during the 8-week study (median 69), logged 214.4 interactions with the Clickotine program (median 178), and remained engaged with Clickotine for 5.3 weeks (median 5). Among the ITT sample, 45.2% (188/416) reported 7-day abstinence and 26.2% (109/416) reported 30-day abstinence from smoking after 8 weeks. Completer analysis focused on 365 (87.7%) of the 416 enrolled participants who completed the 8-week questionnaire revealed that 51.5% (188/365) of completers reported 7-day abstinence and 29.9% (109/365) reported 30-day abstinence. Few adverse events, mostly consistent with nicotine withdrawal symptoms, were reported and overall no safety signal was detected.

Conclusions

In this initial single-arm trial, Clickotine users appeared to demonstrate encouraging indicators of engagement in terms of the number of app opens, number of program interactions, and continued engagement over time. Clickotine users reported encouraging quit rates while reporting few adverse events. Future research is warranted to assess Clickotine’s efficacy in a randomized controlled trial.

Trial Registration

Clinicaltrials.gov NCT02656745; https://clinicaltrials.gov/ct2/show/NCT02656745 (Archived by WebCite at http://www.webcitation.org/6peTT4x60)

Financial benefit of a smoking cessation program prior to elective colorectal surgery

BACKGROUND

Cigarette smoking increases the risk of postoperative complications nearly 2-fold. Preoperative smoking cessation programs may reduce complications as well as overall postoperative costs. We aim to create an economic evaluation framework to estimate the potential value of preoperative smoking cessation programs for patients undergoing elective colorectal surgery.

METHODS

A decision-analytic model from the payer perspective was developed to integrate the costs and incidence of 90-day postoperative complications and readmissions for a cohort of patients undergoing elective colorectal surgery after a smoking cessation program versus usual care. Complication, readmission, and cost data were derived from a cohort of 534 current smokers and recent quitters undergoing elective colorectal resections in Washington State's Surgical Care and Outcomes Assessment Program linked to Washington State's Comprehensive Hospital Abstract Reporting System. Smoking cessation program efficacy was obtained from the literature. Sensitivity analyses were performed to account for uncertainty.

RESULTS

For a cohort of patients, the base case estimates imply that the total direct medical costs for patients who underwent a preoperative smoking cessation program were on average $304 (95% CI: $40-$571) lower per patient than those under usual care during the first 90 days after surgery. The model was most sensitive to the odds of recent quitters developing complications or requiring readmission, and smoking program efficacy.

CONCLUSIONS

A preoperative smoking cessation program is predicted to be cost-saving over the global postoperative period if the cost of the intervention is below $304 per patient. This framework allows the value of smoking cessation programs of variable cost and effectiveness to be determined.

Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial

PURPOSE

To examine the impact of a nurse-initiated tobacco cessation intervention focused on providing guideline-recommended care to hospitalized smokers.

DESIGN

Pre-post quasi-experimental trial.

SETTING

General medical units of four US Department of Veterans Affairs hospitals.

SUBJECTS

898 adult Veteran smokers (503 and 395 were enrolled in the baseline and intervention periods, respectively).

INTERVENTION

The intervention included academic detailing, adaptation of the computerized medical record, patient self-management support, and organizational support and feedback.

MEASURES

The primary outcome was self-reported 7-day point prevalence abstinence at six months.

ANALYSIS

Tobacco use was compared for the pre-intervention and intervention periods with multivariable logistic regression using generalized estimating equations to account for clustering at the nurse level. Predictors of abstinence at six months were investigated with best subsets regression.

RESULTS

Seven-day point prevalence abstinence during the intervention period did not differ significantly from the pre-intervention period at either three (adjusted odds ratio (AOR) and 95% confidence interval (CI₉₅)=0.78 [0.51-1.18]) or six months (AOR=0.92; CI₉₅=0.62-1.37). Predictors of abstinence included baseline self-efficacy for refraining from smoking when experiencing negative affect (p=0.0004) and perceived likelihood of staying off cigarettes following discharge (p<0.0001).

CONCLUSIONS

Tobacco use interventions in the VA inpatient setting likely require more substantial changes in clinician behavior and enhanced post-discharge follow-up to improve cessation outcomes.

Long-term Quit Rates in Fax-Referred as Compared to Self-Referred Tobacco Quitline Registrants

INTRODUCTION

To increase the use of quitlines for treating tobacco use and dependence, quitline referral interventions are recommended for healthcare systems and providers. Research is limited as to whether fax-referred smokers have quit outcomes similar to those of traditional self-callers to quitlines.

METHODS

Oklahoma Tobacco Helpline registration data from March 2013 to October 2014 and 7-month follow-up data were used to compare hospital- and clinic-based fax-referred registrants (n=537) to self-callers (n=2,577). Contingency table chi-square tests and relative risks were used to identify differences in 30-day point prevalence abstinence at 7-month follow-up. Two-sided p-values <0.05 were considered statistically significant. Analyses were conducted in 2015.

RESULTS

Fax-referred registrants versus self-callers were significantly more likely to be older (49.4 vs 47.6 years), white (70.6% vs 59.1%), non-Hispanic (96.8% vs 94.2%), and to have smoked fewer than one pack of cigarettes per day (54.0% vs 44.9%). Self-callers versus fax-referred registrants were significantly more likely to be uninsured (36.5% vs 29.4%) and have received nicotine-replacement therapy from the Helpline (92.3% vs 79.9%). At 7-month follow-up, a similar proportion of fax-referred registrants reported not using tobacco in the past 30 days as compared to self-callers (29.3% vs 31.8%, p=0.2945).

CONCLUSIONS

Although differences in sociodemographics, tobacco use behavior, and Helpline services were observed between fax-referred registrants and self-callers, quit outcomes at follow-up did not differ. This observational study has important implications for tobacco control initiatives as it shows patients fax-referred by hospitals and clinics to quitlines may be as successful as self-callers in quitting smoking.

Telephone care co-ordination for tobacco cessation: randomised trials testing proactive versus reactive models

OBJECTIVES

We conducted two parallel studies evaluating the effectiveness of proactive and reactive engagement approaches to telephone treatment for smoking cessation.

METHODS

Patients who smoked and were interested in quitting were referred to this study and were eligible if they were current smokers and had an address and a telephone number. The data were collected at 35 Department of Veterans Affairs (VA) sites, part of four VA medical centres in both California and Nevada. In study 1, participants received multisession counselling from the California Smokers' Helpline (quitline). In study 2, they received self-help materials only. Patients were randomly assigned by week to either proactive or reactive engagement, and primary care staff were blind to this assignment. Providers gave brief advice and referred them via the electronic health record to a tobacco co-ordinator. All patients were offered cessation medications.

OUTCOME

Using complete case analysis, in study 1 (quitline), patients in the proactive condition were more likely than those in the reactive condition to report abstinence at 6 months (21.0% vs 16.4%, p=0.03). No difference was found between conditions in study 2 (self-help) (16.9% vs 16.5%, p=0.88). Proactive outreach resulted in increased use of cessation medications in both the quitline (70.1% vs 57.6%, p<0.0001) and the self-help studies (74.5% vs 48.2%, p<0.0001).

CONCLUSION

Proactive outreach with quitline intervention was associated with greater long-term abstinence. Both studies resulted in high rates of medication use. Sites should use a proactive outreach approach and provide counselling whenever possible.

TRIAL REGISTRATION NUMBER

NCT00123682.

Single-arm trial of the second version of an acceptance & commitment therapy smartphone application for smoking cessation

BACKGROUND

The first randomized trial of a smartphone application (app) for adult smoking cessation (SmartQuit 1.0) revealed key features that predict cessation. These findings guided the revision of this Acceptance & Commitment Therapy (ACT)-based application (SmartQuit 2.0), which was primarily tested to examine participant receptivity, short-term cessation and reduction, and the relationship between program completion, smoking cessation and reduction. Secondarily, outcomes were descriptively compared with the SmartQuit1.0 trial.

METHOD

Adult participants (78% female, 25% with high school or less education, 30% unemployed) were recruited into the single-arm pilot trial (N=99) of SmartQuit 2.0 with a two-month follow-up (85% retention).

RESULTS

Regarding receptivity, 84% of participants were satisfied with SmartQuit 2.0 (vs. 59% for SmartQuit1.0), 73% would recommend it to a friend (vs. 48% for SmartQuit1.0), 81% found the ACT exercises useful for quitting (vs. 44% for SmartQuit1.0). At the 2-month follow-up, the quit rates were 21% for 7-day point prevalence (vs. 23% for SmartQuit1.0), 11% for 30-day point prevalence (vs. 13% for SmartQuit1.0), and 75% of participants reduced their smoking frequency (vs. 57% for SmartQuit1.0). Among program completers (24% of total sample), the quit rates were 33% for 7-day point prevalence, 28% for 30-day point prevalence, and 88% of participants reduced their smoking frequency.

CONCLUSIONS

The revised app had high user receptivity, modest quit rates, and high smoking reduction rates. Program completion may be key to boosting the app's effectiveness.

Costs of the Smoking Cessation Program in Brazil

OBJECTIVE

To assess the costs of the Smoking Cessation Program in the Brazilian Unified Health System and estimate the cost of its full implementation in a Brazilian municipality.

METHODS

The intensive behavioral therapy and treatment for smoking cessation includes consultations, cognitive-behavioral group therapy sessions, and use of medicines. The costs of care and management of the program were estimated using micro-costing methods. The full implementation of the program in the municipality of Goiania, Goias was set as its expansion to meet the demand of all smokers motivated to quit in the municipality that would seek care at Brazilian Unified Health System. We considered direct medical and non-medical costs: human resources, medicines, consumables, general expenses, transport, travels, events, and capital costs. We included costs of federal, state, and municipal levels. The perspective of the analysis was that from the Brazilian Unified Health System. Sensitivity analysis was performed by varying parameters concerning the amount of activities and resources used. Data sources included a sample of primary care health units, municipal and state secretariats of health, and the Brazilian Ministry of Health. The costs were estimated in Brazilian Real (R$) for the year of 2010.

RESULTS

The cost of the program in Goiania was R$429,079, with 78.0% regarding behavioral therapy and treatment of smoking. The cost per patient was R$534, and, per quitter, R$1,435. The full implementation of the program in the municipality of Goiania would generate a cost of R$20.28 million to attend 35,323 smokers.

CONCLUSIONS

The Smoking Cessation Program has good performance in terms of cost per patient that quit smoking. In view of the burden of smoking in Brazil, the treatment for smoking cessation must be considered as a priority in allocating health resources.

OBJETIVO

Analisar os custos do Programa de Tratamento do Tabagismo no Sistema Único de Saúde e estimar o custo de sua implementação plena em um município brasileiro.

MÉTODOS

A abordagem intensiva e tratamento do tabagismo engloba consultas, sessões de terapia cognitivo-comportamental em grupo e uso de medicamentos. Os custos do atendimento e gerenciamento do programa foram estimados utilizando a metodologia do microcusteio. A implementação plena do programa no município de Goiânia, Goiás, foi definida como sua expansão para suprir a demanda de todos os fumantes motivados a parar de fumar no município que seriam atendidos pelo Sistema Único de Saúde. Foram considerados custos médicos e não médicos diretos: recursos humanos, medicamentos, material de consumo, despesas gerais, transporte, viagens, eventos e custos de capital. Foram incluídos custos dos níveis federal, estadual e municipal de gestão. A perspectiva da análise foi a do Sistema Único de Saúde. Análise de sensibilidade foi realizada variando parâmetros referentes à quantidade de atividades e aos recursos utilizados. As fontes de dados incluíram uma amostra de unidades de saúde da Atenção Primária, secretarias de saúde municipal e estadual e Ministério da Saúde. Os custos foram estimados em reais (R$) para o ano de 2010.

RESULTADOS

O custo do programa em Goiânia foi de R$429.079, sendo 78,0% referentes à abordagem e tratamento do tabagismo. O custo por paciente foi de R$534 e, por paciente que deixou de fumar, de R$1.435. A implementação plena do programa no município de Goiânia geraria custo de R$20,28 milhões, para atender 35.323 fumantes.

CONCLUSÕES

O Programa de Tratamento do Tabagismo tem bom desempenho em termos de custo por paciente que deixa de fumar. Tendo em vista a carga do tabagismo no Brasil, o tratamento para cessação de fumar deve ser considerado prioritário ao se programar a alocação de recursos de saúde.

Impact of a Temporary NRT Enhancement in a State Quitline and Web-Based Program

Purpose:

To examine the impact of a nicotine replacement therapy (NRT) enhancement on quit outcomes.

Design:

Observational study using an intent to treat as treated analysis.

Setting:

Not available.

Participants:

A total of 4022 Idaho tobacco users aged ≥18 years who received services from the Idaho Tobacco Quitline or Idaho’s web-based program.

Intervention:

One-call phone or web-based participants were sent a single 4- or 8-week NRT shipment. Multiple-call participants were sent NRT in a single 4-week shipment or two 4-week shipments (second shipment sent only to those completing a second coaching call).

Measures:

North American Quitline Consortium recommended Minimal Data Set items collected at registration and follow-up. Thirty-day point prevalence quit rates were assessed at 7-month follow-up.

Analysis:

Multiple logistic regression models were used to examine the effects of program type and amount of NRT sent to participants while controlling for demographic and tobacco use characteristics.

Results:

Abstinence rates were significantly higher among 8-week versus 4-week NRT recipients (42.5% vs 33.3%). The effect was only significant between multiple-call program participants who received both 4-week NRT shipments versus only the first of 2 possible 4-week shipments (51.1% vs 31.1%). Costs per quit were lowest among web-based participants who received 4 weeks of NRT (US$183 per quit) and highest among multiple-call participants who received only 1 of 2 possible NRT shipments (US$557 per quit).

Conclusion:

To better balance cost with clinical effectiveness, funders of state-based tobacco cessation services may want to consider (1) allowing tobacco users to choose between phone- and web-based programs while (2) limiting longer NRT benefits only to multiple-call program participants.

A Post-Discharge Smoking-Cessation Intervention for Hospital Patients: Helping Hand 2 Randomized Clinical Trial

INTRODUCTION

Hospitalization provides an opportunity for smokers to quit, but tobacco-cessation interventions started in hospital must continue after discharge to be effective. This study aimed to improve the scalability of a proven effective post-discharge intervention by incorporating referral to a telephone quitline, a nationally available cessation resource.

STUDY DESIGN

A three-site RCT compared Sustained Care, a post-discharge tobacco-cessation intervention, with Standard Care among hospitalized adult smokers who wanted to quit smoking and received in-hospital tobacco-cessation counseling.

SETTING/PARTICIPANTS

A total of 1,357 daily smokers admitted to three hospitals were enrolled from December 2012 to July 2014.

INTERVENTION

Sustained Care started at discharge and included automated interactive voice response telephone calls and the patient's choice of cessation medication for 3 months. Each automated call advised cessation, supported medication adherence, and triaged smokers seeking additional counseling or medication support directly to a telephone quitline. Standard Care provided only medication and counseling recommendations at discharge.

MAIN OUTCOME MEASURES

Biochemically confirmed past 7-day tobacco abstinence 6 months after discharge (primary outcome) and self-reported tobacco abstinence and tobacco-cessation treatment use at 1, 3, and 6 months and overall (0-6 months). Analyses were done in 2015-2016.

RESULTS

Smokers offered Sustained Care (n=680), versus those offered Standard Care (n=677), did not have greater biochemically confirmed abstinence at 6 months (17% vs 16%, p=0.58). However, the Sustained Care group reported more tobacco-cessation counseling and medication use at each follow-up and higher rates of self-reported past 7-day tobacco abstinence at 1 month (43% vs 32%, p<0.0001) and 3 months (37% vs 30%, p=0.008). At 6 months, the difference narrowed (31% vs 27%, p=0.09). Overall, the intervention increased self-reported 7-day abstinence over the 6-month follow-up (relative risk, 1.25; 95% CI=1.10, 1.40; p=0.0006).

CONCLUSIONS

A 3-month post-discharge smoking-cessation intervention for hospitalized smokers who wanted to quit did not increase confirmed tobacco abstinence at 6 months but did increase self-reported abstinence during the treatment period (3 months). Real-time linkage of interactive voice response calls to a quitline, done in this trial to increase scalability of a previously proven cessation intervention, demonstrated short-term promise but did not sustain long-term intervention effectiveness.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01714323.

Association Between Utilization of Quitline Services and Probability of Tobacco Abstinence in Low-Income Smokers

INTRODUCTION

Quitlines (QL) are an effective means for smoking cessation, but a paucity of data exist examining the dose-response relationship between use of QL services and quit rates, especially among low-income smokers. The purpose of this study was to study the relationship between tobacco abstinence and use of QL services among low-income smokers.

METHODS

Secondary analysis of a randomized trial of every- or some-day smokers aged 18 years or older visiting an urban emergency department. Inclusion criteria included self-pay or Medicaid insurance, as a proxy for low-income and low socioeconomic status. Intervention participants received a motivational interview, 6 weeks of nicotine patches and gum, a referral faxed to the state-sponsored QL, a booster call, and a quitline brochure. Control participants received the brochure. Smoking status was assessed by phone at 1 and 3 months, with confirmation via exhaled carbon monoxide testing at 3 months for those reporting abstinence. QL usage was obtained by utilization data from the QL database.

RESULTS

Of 778 subjects, 197 (25.3%) reported any use of QL services at 3 months. Participants were trichotomized: no QL usage, 1 call only, and >1 call (583, 99, and 98 participants, respectively). Quit rates at 3 months in these no, low-, and high-use groups were, respectively, 7.2%, 9.1%, and 15.3% (P=0.03). Participants who used the QL had a median of 28 total minutes of telephone contact.

CONCLUSION

Among low-income smokers, greater use of QL services is associated with higher abstinence. Whether this resulted from a direct effect of the QL, or greater motivation among smokers using QL services cannot be determined from these data.

An individually-tailored smoking cessation intervention for rural Veterans: a pilot randomized trial

BACKGROUND

Tobacco use remains prevalent among Veterans of military service and those residing in rural areas. Smokers frequently experience tobacco-related issues including risky alcohol use, post-cessation weight gain, and depressive symptoms that may adversely impact their likelihood of quitting and maintaining abstinence. Telephone-based interventions that simultaneously address these issues may help to increase treatment access and improve outcomes.

METHODS

This study was a two-group randomized controlled pilot trial. Participants were randomly assigned to an individually-tailored telephone tobacco intervention combining counseling for tobacco use and related issues including depressive symptoms, risky alcohol use, and weight concerns or to treatment provided through their state tobacco quitline. Selection of pharmacotherapy was based on medical history and a shared decision interview in both groups. Participants included 63 rural Veteran smokers (mean age = 56.8 years; 87 % male; mean number of cigarettes/day = 24.7). The primary outcome was self-reported 7-day point prevalence abstinence at 12 weeks and 6 months.

RESULTS

Twelve-week quit rates based on an intention-to-treat analysis did not differ significantly by group (Tailored = 39 %; Quitline Referral = 25 %; odds ratio [OR]; 95 % confidence interval [CI] = 1.90; 0.56, 5.57). Six-month quit rates for the Tailored and Quitline Referral conditions were 29 and 28 %, respectively (OR; 95 % CI = 1.05; 0.35, 3.12). Satisfaction with the Tailored tobacco intervention was high.

CONCLUSIONS

Telephone-based treatment that concomitantly addresses other health-related factors that may adversely affect quitting appears to be a promising strategy. Larger studies are needed to determine whether this approach improves cessation outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier number NCT01592695 registered 11 April 2012.

Comparative effectiveness of adding weight control simultaneously or sequentially to smoking cessation quitlines: study protocol of a randomized controlled trial

Background

Prevalence of multiple health risk behaviors is growing, and obesity and smoking are costly. Weight gain associated with quitting smoking is common and can interfere with quit success. Efficacy of adding weight management to tobacco cessation treatment has been tested with women in group sessions over an extended period of time, but has never been tested in real-world settings with men and women seeking help to quit. This paper describes the Best Quit study which tests the effectiveness of delivering tobacco and weight control interventions via existing quitline infrastructures.

Methods

Eligible and consenting smokers (n = 2550) who call a telephone quitline will be randomized to one of three groups; the standard quitline or standard quitline plus a weight management program added either simultaneously or sequentially to the tobacco program. The study aims to test: 1) the effectiveness of the combined intervention on smoking cessation and weight, 2) the cost-effectiveness of the combined intervention on cessation and weight and 3) theoretically pre-specified mediators of treatment effects on cessation: reduced weight concerns, increased outcome expectancies about quitting and improved self-efficacy about quitting without weight gain.

Baseline, 6 month and 12 month data will be analyzed using multivariate statistical analyses and groups will be compared on treatment adherence, quit rates and change in weight among abstinent participants. To determine if the association between group assignment and primary outcomes (30-day abstinence and change in weight at 6 months) is moderated by pre-determined baseline and process measures, interaction terms will be included in the regression models and their significance assessed.

Discussion

This study will generate information to inform whether adding weight management to a tobacco cessation intervention delivered by phone, mail and web for smokers seeking help to quit will help or harm quit rates and whether a simultaneous or sequential approach is better at increasing abstinence and reducing weight gain post quit. If proven effective, the combined intervention could be disseminated across the U.S. through quitlines and could encourage additional smokers who have not sought cessation treatment for fear of gaining weight to make quit attempts.

Trial registration

Clinicaltrials.gov NCT01867983. Registered: May 30, 2013

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3231-6) contains supplementary material, which is available to authorized users.

Reasons for Electronic Nicotine Delivery System use and smoking abstinence at 6 months: a descriptive study of callers to employer and health plan-sponsored quitlines

Objective

Describe cigarette smoking abstinence among employer and health plan-sponsored quitline registrants who were not using Electronic Nicotine Delivery Systems (ENDS), were using ENDS to quit smoking or were using ENDS for other reasons at the time of quitline registration.

Methods

We examined 6029 quitline callers aged ≥18 years who smoked cigarettes at registration, and completed ≥1 counselling calls, baseline ENDS use questions and a 6-month follow-up survey (response rate: 52.4%). 30-day point prevalence smoking quit rates (PPQRs) were assessed at 6-month follow-up (ENDS-only users were considered quit). Data were weighted for non-response bias. Logistic regression analyses controlled for participant characteristics and programme engagement.

Results

At registration, 13.8% of respondents used ENDS (7.9% to quit smoking, 5.9% for other reasons). 30-day PPQRs were: 55.1% for callers using ENDS to quit, 43.1% for callers using ENDS for other reasons, and 50.8% for callers not using ENDS at registration. Callers using ENDS for other reasons were less likely to quit than other groups (adjusted ORs=0.65–0.77); quit rates did not significantly differ between non-ENDS users and those using ENDS to quit. Among callers using ENDS to quit at baseline, 40% used ENDS regularly at follow-up.

Conclusions

ENDS users not using ENDS to quit smoking were less successful at quitting at 6-month follow-up compared with callers using ENDS to quit smoking and callers who did not use ENDS at programme registration. Incorporating reasons for ENDS use may be important for future studies examining the role of ENDS in tobacco cessation.

Combined pharmacotherapy and behavioural interventions for smoking cessation

BACKGROUND

Both behavioural support (including brief advice and counselling) and pharmacotherapies (including nicotine replacement therapy (NRT), varenicline and bupropion) are effective in helping people to stop smoking. Combining both treatment approaches is recommended where possible, but the size of the treatment effect with different combinations and in different settings and populations is unclear.

OBJECTIVES

To assess the effect of combining behavioural support and medication to aid smoking cessation, compared to a minimal intervention or usual care, and to identify whether there are different effects depending on characteristics of the treatment setting, intervention, population treated, or take-up of treatment.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register in July 2015 for records with any mention of pharmacotherapy, including any type of NRT, bupropion, nortriptyline or varenicline.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials evaluating combinations of pharmacotherapy and behavioural support for smoking cessation, compared to a control receiving usual care or brief advice or less intensive behavioural support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

Search results were prescreened by one author and inclusion or exclusion of potentially relevant trials was agreed by two authors. Data was extracted by one author and checked by another.The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Fifty-three studies with a total of more than 25,000 participants met the inclusion criteria. A large proportion of studies recruited people in healthcare settings or with specific health needs. Most studies provided NRT. Behavioural support was typically provided by specialists in cessation counselling, who offered between four and eight contact sessions. The planned maximum duration of contact was typically more than 30 minutes but less than 300 minutes. Overall, studies were at low or unclear risk of bias, and findings were not sensitive to the exclusion of any of the six studies rated at high risk of bias in one domain. One large study (the Lung Health Study) contributed heterogeneity due to a substantially larger treatment effect than seen in other studies (RR 3.88, 95% CI 3.35 to 4.50). Since this study used a particularly intensive intervention which included extended availability of nicotine gum, multiple group sessions and long term maintenance and recycling contacts, the results may not be comparable with the interventions used in other studies, and hence it was not pooled in other analyses. Based on the remaining 52 studies (19,488 participants) there was high quality evidence (using GRADE) for a benefit of combined pharmacotherapy and behavioural treatment compared to usual care, brief advice or less intensive behavioural support (RR 1.83, 95% CI 1.68 to 1.98) with moderate statistical heterogeneity (I² = 36%).The pooled estimate for 43 trials that recruited participants in healthcare settings (RR 1.97, 95% CI 1.79 to 2.18) was higher than for eight trials with community-based recruitment (RR 1.53, 95% CI 1.33 to 1.76). Compared to the first version of the review, previous weak evidence of differences in other subgroup analyses has disappeared. We did not detect differences between subgroups defined by motivation to quit, treatment provider, number or duration of support sessions, or take-up of treatment.

AUTHORS' CONCLUSIONS

Interventions that combine pharmacotherapy and behavioural support increase smoking cessation success compared to a minimal intervention or usual care. Updating this review with an additional 12 studies (5,000 participants) did not materially change the effect estimate. Although trials differed in the details of their populations and interventions, we did not detect any factors that modified treatment effects apart from the recruitment setting. We did not find evidence from indirect comparisons that offering more intensive behavioural support was associated with larger treatment effects.

Identifying effective intervention components for smoking cessation: a factorial screening experiment

AIMS

To identify promising intervention components intended to help smokers to attain and maintain abstinence in their quit smoking attempts.

DESIGN

A fully crossed, six-factor randomized fractional factorial experiment.

SETTING

Eleven primary care clinics in southern Wisconsin, USA.

PARTICIPANTS

A total of 637 adult smokers (55% women, 88% white) motivated to quit smoking who visited primary care clinics.

INTERVENTIONS

Six intervention components designed to prepare smokers to quit, and achieve and maintain abstinence (i.e. for the preparation, cessation and maintenance phases of smoking treatment): (1) preparation nicotine patch versus none; (2) preparation nicotine gum versus none; (3) preparation counseling versus none; (4) intensive cessation in-person counseling versus minimal; (5) intensive cessation telephone counseling versus minimal; and (6) 16 versus 8 weeks of combination nicotine replacement therapy (nicotine patch  +  nicotine gum).

MEASUREMENTS

Seven-day self-reported point-prevalence abstinence at 16 weeks.

FINDINGS

Preparation counseling significantly improved week 16 abstinence rates (P = .04), while both forms of preparation nicotine replacement therapy interacted synergistically with intensive cessation in-person counseling (P < 0.05). Conversely, intensive cessation phone counseling and intensive cessation in-person counseling interacted antagonistically (P < 0.05)-these components produced higher abstinence rates by themselves than in combination.

CONCLUSIONS

Preparation counseling and the combination of intensive cessation in-person counseling with preparation nicotine gum or patch are promising intervention components for smoking and should be evaluated as an integrated treatment package.

Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation

BACKGROUND

Effective pharmacotherapies are available to help people who are trying to stop smoking, but quitting can still be difficult and providing higher levels of behavioural support may increase success rates further.

OBJECTIVES

To evaluate the effect of increasing the intensity of behavioural support for people using smoking cessation medications, and to assess whether there are different effects depending on the type of pharmacotherapy, or the amount of support in each condition.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register in May 2015 for records with any mention of pharmacotherapy, including any type of nicotine replacement therapy (NRT), bupropion, nortriptyline or varenicline that evaluated the addition of personal support or compared two or more intensities of behavioural support.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials in which all participants received pharmacotherapy for smoking cessation and conditions differed by the amount of behavioural support. The intervention condition had to involve person-to-person contact. The control condition could receive less intensive personal contact, or just written information. We did not include studies that used a contact-matched control to evaluate differences between types or components of support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

One author prescreened search results and two authors agreed inclusion or exclusion of potentially relevant trials. One author extracted data and another checked them.The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Forty-seven studies met the inclusion criteria with over 18,000 participants in the relevant arms. There was little evidence of statistical heterogeneity (I² = 18%) so we pooled all studies in the main analysis. There was evidence of a small but statistically significant benefit from more intensive support (RR 1.17, 95% CI 1.11 to 1.24) for abstinence at longest follow-up. All but four of the included studies provided four or more sessions of support to the intervention group. Most trials used NRT. We did not detect significant effects for studies where the pharmacotherapy was nortriptyline (two trials) or varenicline (one trial), but this reflects the absence of evidence.In subgroup analyses, studies that provided at least four sessions of personal contact for the intervention and no personal contact for the control had slightly larger estimated effects (RR 1.25, 95% CI 1.08 to 1.45; 6 trials, 3762 participants), although a formal test for subgroup differences was not significant. Studies where all intervention counselling was via telephone (RR 1.28, 95% CI 1.17 to 1.41; 6 trials, 5311 participants) also had slightly larger effects, and the test for subgroup differences was significant, but this subgroup analysis was not prespecified. In this update, the benefit of providing additional behavioural support was similar for the subgroup of trials in which all participants, including controls, had at least 30 minutes of personal contact (RR 1.18, 95% CI 1.06 to 1.32; 21 trials, 5166 participants); previously the evidence of benefit in this subgroup had been weaker. This subgroup was not prespecified and a test for subgroup differences was not significant. We judged the quality of the evidence to be high, using the GRADE approach. We judged a small number of trials to be at high risk of bias on one or more domains, but findings were not sensitive to their exclusion.

AUTHORS' CONCLUSIONS

Providing behavioural support in person or via telephone for people using pharmacotherapy to stop smoking has a small but important effect. Increasing the amount of behavioural support is likely to increase the chance of success by about 10% to 25%, based on a pooled estimate from 47 trials. Subgroup analysis suggests that the incremental benefit from more support is similar over a range of levels of baseline support.

Smoking cessation strategies in vascular surgery

Tobacco abuse is a highly prevalent modifiable risk factor in vascular surgery patient populations. Despite the known benefits of smoking cessation, quitting smoking is difficult for most patients. Physician advice to stop smoking can help, though more intensive or multifactorial interventions have greater impact. Smoking cessation initiatives based in vascular clinics are feasible, although currently there is significant variation in physician delivery of smoking cessation interventions. Vascular surgeons are optimally poised to be able to capitalize on the "teachable moment" of the vascular procedure to encourage smoking cessation. Concise and effective smoking cessation strategies include standardized physician "very brief advice" (a standardized advice delivery developed and validated by the National Health Service), referral to telephone counseling, and prescription of pharmacotherapy, all of which are best utilized together. This review will discuss different smoking cessation strategies, as well as their inclusion in multicenter trials designed to study delivery of smoking cessation interventions in vascular surgery patients.

Engaging Parents Who Quit Smoking in Antismoking Socialization of Children: A Novel Approach to Relapse Prevention

INTRODUCTION

Data from a randomized controlled trial designed primarily to test the effect of an antismoking socialization parenting program on child initiation of smoking were used to test the subsidiary hypothesis that providing antismoking socialization to children would lower the odds of relapse within a sub-sample of parents who had recently quit smoking.

METHODS

Over 13 months, 11 state Quitlines provided contact information for callers who were parents of 8- to 10-year-old children. Of 1604 parents enrolled in the trial, 689 (344 treatment; 345 control) had quit smoking cigarettes for at least 24 hours after calling a Quitline. Their data were used to test for group differences in 30-day abstinence measured using telephone interviews conducted 7 and 12 months post-baseline. Analyses of parents with complete follow-up data and intent-to-treat analyses incorporating parents lost to follow-up are presented.

RESULTS

Among 465 parents with complete follow-up data, treatment group parents had twice the odds of being abstinent 12 months post-baseline (adjusted OR = 2.01; P = .001) relative to controls. Intent-to-treat analysis with all 689 parents, in which those lost to follow-up were coded as having relapsed, showed a smaller though significant treatment effect on 30-day abstinence at 12 months (adjusted OR = 1.58; P = .017).

CONCLUSIONS

This study is the first to observe that engaging parents who have quit smoking in antismoking socialization of children can lower their odds of relapse. Additional research is needed to replicate this finding and to identify the psychological mechanisms underlying the observed effect.

IMPLICATIONS

There is a clear the need for research to develop new relapse prevention strategies. This study is the first to observe that engaging parents who have quit smoking in antismoking socialization of children can lower their odds of relapse.

Successful Tobacco Dependence Treatment in Low-Income Emergency Department Patients: A Randomized Trial

STUDY OBJECTIVE

Tobacco use is common among emergency department (ED) patients, many of whom have low income. Our objective is to study the efficacy of an intervention incorporating motivational interviewing, nicotine replacement, and quitline referral for adult smokers in an ED.

METHODS

This was a 2-arm randomized clinical trial conducted from October 2010 to December 2012 in a northeastern urban US ED with 90,000 visits per year. Eligible subjects were aged 18 years or older, smoked, and were self-pay or had Medicaid insurance. Intervention subjects received a motivational interview by a trained research assistant, 6 weeks' worth of nicotine patches and gum initiated in the ED, a faxed referral to the state smokers' quitline, a booster call, and a brochure. Control subjects received the brochure, which provided quitline information. The primary outcome was biochemically confirmed tobacco abstinence at 3 months. Secondary endpoints included quitline use.

RESULTS

Of 778 enrolled subjects, 774 (99.5%) were alive at 3 months. The prevalence of biochemically confirmed abstinence was 12.2% (47/386) in the intervention arm versus 4.9% (19/388) in the control arm, for a difference in quit rates of 7.3% (95% confidence interval 3.2% to 11.5%). In multivariable logistic modeling controlling for age, sex, and race or ethnicity, study subjects remained more likely to be abstinent than controls (odds ratio 2.72; 95% confidence interval 1.55 to 4.75).

CONCLUSION

An intensive intervention improved tobacco abstinence rates in low-income ED smokers. Because approximately 20 million smokers, many of whom have low income, visit US EDs annually, these results suggest that ED-initiated treatment may be an effective technique to treat this group of smokers.

Quitline Use and Outcomes among Callers with and without Mental Health Conditions: A 7-Month Follow-Up Evaluation in Three States

Objectives. To examine abstinence outcomes among tobacco users with and without a reported mental health condition (MHC) who enrolled in state tobacco quitline programs. Methods. Data were analyzed from a 7-month follow-up survey (response rate: 41% [3,132/7,459]) of three state-funded telephone quitline programs in the United States that assessed seven self-reported MHCs at quitline registration. We examined 30-day point prevalence tobacco quit rates for callers with any MHC versus none. Data were weighted to adjust for response bias and oversampling. Multivariable logistic regression was used to examine cessation outcomes. Results. Overall, 45.8% of respondents reported ≥1 MHC; 57.4% of those reporting a MHC reported ≥2 MHCs. The unadjusted quit rate for callers with any MHC was lower than for callers with no MHC (22.0% versus 31.0%, P < 0.001). After adjusting for demographics, nicotine dependence, and program engagement, callers reporting ≥1 MHC were less likely to be abstinent at follow-up (adjusted OR = 0.63, 95% CI = 0.51–0.78, P < 0.001). Conclusions. More intensive or tailored quitline programs may need to be developed among callers with MHCs as their quit rates appear to be lower than callers without MHCs.

Cessation Outcomes Among Quitline Callers in Three States During a National Tobacco Education Campaign

Introduction

Antismoking mass media campaigns, such as the Centers for Disease Control and Prevention’s Tips from Former Smokers (Tips) campaign, increase the number of tobacco users calling tobacco quitlines. Few studies have investigated long-term tobacco use cessation for callers during antismoking media campaigns. Studies have suggested that callers during campaigns may be less committed to quitting and have lower quit rates. This study examines tobacco user cessation outcomes 7 months after quitline enrollment during the 2012 Tips campaign (March 19 through June 10, 2012).

Methods

We analyzed data for 715 tobacco users who enrolled in the Nebraska, North Carolina, or Texas state quitline multiple-call programs during the 2012 Tips campaign and responded to a 7-month postenrollment survey (38.5% survey response rate). We used multivariable logistic regression analyses to determine whether 7-day and 30-day point prevalence abstinence rates 7 months after enrollment were related to level of exposure to the campaign.

Results

In multivariable models, only lower nicotine dependence and higher call completion were associated with higher odds of 7-day and 30-day abstinence 7 months after enrollment. Tips campaign exposure was not associated with abstinence.

Conclusion

Once enrolled in quitline counseling, quitline callers achieved similar outcomes regardless of Tips campaign exposure levels. While the campaign did not appear to directly affect odds of tobacco abstinence through quitlines, antismoking mass media campaigns such as Tips are valuable in increasing tobacco users’ exposure to quitlines and thus increasing their likelihood of making a quit attempt and eventually achieving tobacco abstinence.

A randomised controlled trial to prevent smoking relapse among recently quit smokers enrolled in employer and health plan sponsored quitlines

OBJECTIVE

To test adding an interactive voice response (IVR)-supported protocol to standard quitline treatment to prevent relapse among recently quit smokers.

DESIGN

Parallel randomised controlled trial with three arms: standard quitline, standard plus technology enhanced quitline with 10 risk assessments (TEQ-10), standard plus 20 TEQ assessments (TEQ-20).

SETTING

Quit For Life (QFL) programme.

PARTICIPANTS

1785 QFL enrolees through 19 employers or health plans who were 24+ h quit.

INTERVENTIONS

QFL is a 5-call telephone-based cessation programme including medications and web-based support. TEQ interventions included 10 or 20 IVR-delivered relapse risk assessments over 8 weeks with automated transfer to counselling for those at risk.

MAIN OUTCOME MEASURES

Self-reported 7-day and 30-day abstinence assessed at 6-month and 12-month post-enrolment (response rates: 61% and 59%, respectively). Missing data were imputed.

RESULTS

1785 were randomised (standard n=592, TEQ-10 n=602, TEQ-20 n=591). Multiple imputation-derived, intent-to-treat 30-day quit rates (95% CI) at 6 months were 59.4% (53.7% to 63.8%) for standard, 62.3% (57.7% to 66.9%) for TEQ-10, 59.4% (53.7% to 65.1%) for TEQ-20 and 30-day quit rates at 12 months were 61.2% (55.6% to 66.8%) for standard, 60.6% (56.0% to 65.2%) for TEQ-10, 54.9% (49.0% to 60.9%) for TEQ-20. There were no significant differences in quit rates. 73.3% of TEQ participants were identified as at-risk by IVR assessments; on average, participants completed 0.41 IVR-transferred counselling calls. Positive risk assessments identified participants less likely (OR=0.56, 95% CI 0.42 to 0.76) to be abstinent at 6 months.

CONCLUSIONS

Standard treatment was highly effective, with 61% remaining abstinent at 12 months using multiple imputation intent-to-treat (intent-to-treat missing=smoking quit rate: 38%). TEQ assessments identified quitters at risk for relapse. However, adding IVR-transferred counselling did not yield higher quit rates. Research is needed to determine if alternative designs can improve outcomes.

TRIAL REGISTRATION NUMBER

NCT00888992.

Efficacy of a tobacco quitline among adult survivors of childhood cancer

INTRODUCTION

The purpose of this investigation was to determine the efficacy of two evidence-based tobacco quitlines in adult survivors of childhood cancer who regularly smoke cigarettes.

METHODS

A total of 519 adult survivors of childhood cancer were randomized to either Proactive + 4 weeks of medication (Counselor-initiated intervention, n = 260) or a Reactive + 2 weeks of medication (Participant-initiated intervention, n = 259) condition. Both conditions received telephone counseling to quit smoking as well as nicotine replacement therapy. The primary outcome was biochemically verified (i.e. cotinine) point prevalence smoking cessation at 12 months follow-up.

RESULTS

Participants randomized to the Proactive + 4 weeks of medication condition self-reported a higher rate of cessation than those survivors in the Reactive + 2 weeks of medication condition at 8 weeks (33.2% vs. 17.0%, p < .001), but cessation rates were not significantly different at 12 months (23.0% vs. 18.7%, p = .29). However, 80% of participants claiming abstinence failed biochemical verification, indicating marked falsification of self-reported smoking status. Adjusted cessation rates were less than 2% in both intervention conditions.

CONCLUSIONS

Our results indicate that neither a Proactive + 4 weeks of medication or Reactive + 2 weeks of medication quitline significantly impacted long-term smoking cessation rates. Our results further indicate that self-reports of smoking status are unreliable in survivors of childhood cancer, a population in considerable need of tobacco abstinence. Rates of smoking cessation may be markedly overestimated in studies of childhood cancer survivors that rely on self-reports of tobacco abstinence, and future studies need to include biochemical verification of tobacco status in this population.

A randomized trial for hazardous drinking and smoking cessation for callers to a quitline

OBJECTIVE

This study evaluated whether tobacco quitline telephone coaches can be trained to counsel hazardous-drinking smokers to improve smoking cessation success and to limit or abstain from alcohol use.

METHOD

Smokers (N = 1,948) who called the New York State Smokers' Quitline and reported hazardous drinking (exceeding sex-specific weekly limits [14 drinks for men, 7 drinks for women] or meeting/exceeding daily drinking limits [5 drinks for men, 4 drinks for women] at least once in the past year) were randomized to receive either brief motivational counseling to limit or abstain from alcohol plus an alcohol reduction booklet added to standard care (Alcohol + Tobacco Counseling; ATC), or only smoking cessation counseling plus a smoking cessation booklet added to standard care (Tobacco-Only Counseling; TOC).

RESULTS

Acceptable coach adherence was achieved. The intention-to-treat (ITT) analysis showed that ATC was associated with a significantly higher rate of smoking abstinence at 7-month follow-up (13.5%) compared with TOC (10.3%; p = .03). The respondent analysis (ATC= 26.2%; TOC = 20.4%) paralleled the ITT findings. When controlling for treatment condition, participants who did not report any heavy drinking were significantly more likely to quit smoking than those who reported any heavy drinking (OR = 1.87, 95% CI [1.29, 2.71]; p = .001).

CONCLUSIONS

A brief alcohol intervention plus standard care via a telephone quitline resulted in significantly higher smoking cessation rates for hazardous-drinking callers. Given that quitline coaches were trained to provide the intervention with acceptable adherence, the potential to extend this intervention for wide-scale implementation and impact is promising.

The effectiveness of telephone counselling in the treatment of illicit drug and alcohol use concerns

INTRODUCTION

Technology-assisted substance use interventions such as 'high-tech' internet-based treatments are thought to be effective; however, the relatively 'low-tech' use of telephone counselling does not yet have an established evidence base. This paper reviews the literature including articles with information on the use of telephone counselling for the treatment of illicit drug or alcohol use.

METHODS

A systematic literature search using a set of telephone counselling and substance-related terms was conducted across four electronic databases. English studies prior to June 2014 that involved the use of telephone counselling with the treatment of illicit drug or alcohol use as a primary or secondary outcome were included. Review papers, opinion pieces, letters or editorials, case studies, published abstracts, and posters were excluded. In all, 94 publications were included in the review.

RESULTS AND DISCUSSION

The literature was supportive of telephone counselling for the treatment of alcohol use in the short term; however, literature regarding illicit drug use was particularly scarce. The generalisability of findings was limited by evident methodological issues in the included studies.

Efficacy of a tobacco quitline among adult cancer survivors

OBJECTIVE

The purpose of the study (conducted 2010-2013) was to determine the efficacy of two common types of tobacco quitlines in adult cancer survivors who regularly smoked cigarettes.

METHOD

Adult onset cancer survivors in Memphis, Tennessee (n=427, 67% female, 60% Caucasian) were randomized either to a Proactive (i.e., counselor-initiated calls) or Reactive (i.e., participant-initiated calls) quitline. Both conditions also received nicotine replacement therapy. The primary outcome was biochemically-verified (i.e., salivary cotinine) smoking cessation.

RESULTS

While 12-month self-reported abstinence was consistent with other published studies of smoking cessation (22% and 26% point prevalence abstinence for Proactive and Reactive conditions, respectively), 48% of participants who were tested for cotinine failed biochemical verification, indicating a considerable falsification of self-reported cessation. Adjusted cessation rates were less than 5% in both intervention conditions.

CONCLUSION

Our results are consistent with other studies indicating that traditional smoking cessation interventions are ineffective among cancer survivors. Moreover, self-reports of cessation were unreliable in cancer survivors participating in a quitline intervention, indicating that future studies should include biochemical verification. Given the importance of smoking cessation among cancer survivors and low cessation rates in the current study, it may be necessary to design alternative interventions for this population. ClinicalTrials.gov identifier: NCT00827866.

Motivational interviewing for smoking cessation

BACKGROUND

Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to quit smoking.

OBJECTIVES

To determine whether or not motivational interviewing (MI) promotes smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. Date of the most recent search: August 2014.

SELECTION CRITERIA

Randomized controlled trials in which motivational interviewing or its variants were offered to tobacco users to assist cessation.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate. The main outcome measure was abstinence from smoking after at least six months follow-up. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. We counted participants lost to follow-up as continuing smoking or relapsed. We performed meta-analysis using a fixed-effect Mantel-Haenszel model.

MAIN RESULTS

We identified 28 studies published between 1997 and 2014, involving over 16,000 participants. MI was conducted in one to six sessions, with the duration of each session ranging from 10 to 60 minutes. Interventions were delivered by primary care physicians, hospital clinicians, nurses or counsellors. Our meta-analysis of MI versus brief advice or usual care yielded a modest but significant increase in quitting (risk ratio (RR) 1.26; 95% confidence interval (CI) 1.16 to 1.36; 28 studies; N = 16,803). Subgroup analyses found that MI delivered by primary care physicians resulted in an RR of 3.49 (95% CI 1.53 to 7.94; 2 trials; N = 736). When delivered by counsellors the RR was smaller (1.25; 95% CI 1.15 to 1.63; 22 trials; N = 13,593) but MI still resulted in higher quit rates than brief advice or usual care. When we compared MI interventions conducted through shorter sessions (less than 20 minutes per session) to controls, this resulted in an RR of 1.69 (95% CI 1.34 to 2.12; 9 trials; N = 3651). Single-session treatments might increase the likelihood of quitting over multiple sessions, but both regimens produced positive outcomes. Evidence is unclear at present on the optimal number of follow-up calls.There was variation across the trials in treatment fidelity. All trials used some variant of motivational interviewing. Critical details in how it was modified for the particular study population, the training of therapists and the content of the counselling were sometimes lacking from trial reports.  

AUTHORS' CONCLUSIONS

Motivational interviewing may assist people to quit smoking. However, the results should be interpreted with caution, due to variations in study quality, treatment fidelity, between-study heterogeneity and the possibility of publication or selective reporting bias.

Oklahoma Tobacco Helpline utilization and cessation among American Indians

BACKGROUND

American Indians in Oklahoma have higher rates of tobacco use (29.2%) than any other racial group in the state. The Oklahoma Tobacco Helpline provides free cessation services to all Oklahomans and implements strategies specifically aimed at increasing the utilization and effectiveness of cessation services for American Indians.

PURPOSE

To explore Helpline utilization patterns as well as outcomes, such as participant satisfaction and success in quitting, for American Indians. The utilization patterns and outcomes for American Indians were compared to that of the white population from July 1, 2010, to June 30, 2013, to determine whether the Helpline is equally effective among American Indians compared to whites.

METHODS

Helpline utilization data from July 1, 2010, to June 30, 2013, were analyzed in the fall of 2013 to identify patterns and compare differences between American Indian and white Helpline registrants. Four- and 7-month follow-up survey data were used to compare outcomes related to satisfaction with services and quit rates.

RESULTS

During the 3-year study period, 10.6% of registrants who enrolled in an intervention were American Indian (11,075) and 71.2% were white (74,493). At the 7-month follow-up survey, 31.7% of American Indians reported having used no tobacco in the past 30 days compared to 36.5% of whites, but the differences were not statistically significant between racial groups.

CONCLUSIONS

The Oklahoma Tobacco Helpline is equally effective for American Indian and white tobacco users who register for Helpline services.

Dissemination of the Look AHEAD intensive lifestyle intervention in the United States Air Force: study rationale, design and methods

BACKGROUND

Despite an increase in overweight and obesity similar to the civilian population, there have been few randomized controlled trials examining behavioral weight management interventions in the military settings.

PURPOSE

This paper describes the design, intervention development and analysis plan of the Fit Blue study, a randomized controlled behavioral weight loss trial taking place in the United States Air Force.

DESIGN

This study compares two adapted versions of the efficacious Look AHEAD Intensive Lifestyle Intervention (ILI), a counselor-initiated condition and a self-paced condition. Also described are the unique steps required when conducting military-based health promotion research and adaptations made to the Look AHEAD intervention to accommodate the military environment.

CONCLUSIONS

To our knowledge, this is the first translation of the Look AHEAD ILI in the military setting and one of the first translations of the ILI in general. If successful, this intervention could be disseminated to the entire U.S. Military as this project is designed to overcome the barriers and utilize the facilitators for weight loss that are unique to a military population. Programs validated in military populations can have a major public health impact given that with 1.4 million active duty personnel, the Department of Defense is the nation's largest employer. However, while this intervention is designed for a military population and there are unique aspects of the military that may enhance weight loss interventions, the diversity of the study population should help inform obesity efforts in both civilian and military settings.

Treatment Outcome Assessment of the Pharmacist-Managed Quit Smoking Clinic in Malaysia

Introduction: Evaluating a new health service is different from evaluating a new drug, as the former depends on the local delivery structure and culture. No data are available on the effectiveness of the existing pharmacist-managed quit smoking clinic (PM-QSC) in Malaysia. We evaluated the effectiveness in terms of the quit and default rate, the cost per quitter, cost per patient and the number of days of the patient remained in the managed care of the pharmacist.

Methods: The patients’ medical records at the PM-QSC in a tertiary hospital in Melaka, Malaysia, were examined retrospectively from January 2009 to December 2010. Patients were grouped into current smokers, attempted to quit and quitters. Costs were calculated per patient visit on the basis of resource used (smoking cessation agents (SCAs)) and the personnel involved (time spent by the pharmacist). This study was reviewed and approved by the Malaysia Research Ethics Committee (MREC).

Results: The quit rate between January 2009 and December 2010 was 5.8%, and the default rate was 71.8%. The average quit period for all smokers enrolled was 298 days. From the health provider perspective, the average costs per quitter, per patient and per quit attempt were MYR 953.28 (USD 308), MYR 55.71 (USD 18) and MYR 34.74 (USD 11), respectively.

Conclusion: The pharmacist delivery of cessation services at a public-funded QSC was associated with a high default rate. The pharmacist could not be dismissed entirely as an ineffective health care professional (HCP) for the provision of the cessation service based solely on this preliminary data, but these findings stress the need to address the high default rate prior to the expansion of the service.

Telephone Quitline Use and Effectiveness Among Young Adults

Introduction: Although smoking prevalence has declined dramatically among adults in the past 40 years, 19.3% of adults still smoke, including 20.1% of adults aged 18–24 years. Quitlines are effective, population-based interventions that increase successful cessation.

Aims: This study aims to describe the characteristics of young adult smokers aged 18–24 years who used telephone cessation counselling for assistance with quitting, to assess self-reported quit rates, and to examine predictors of quitting, compared to older adults.

Methods: We examined data from 4,542 young adult smokers aged 18–24 years and 46,094 smokers aged ≥25 years who enrolled in the American Cancer Society's quitline services during 2006–2008.

Results: Young adult smokers aged 18–24 years who called quitlines differed slightly from older adults in demographics and tobacco-use behaviours. There were no age-related differences in self-reported seven-day quit rates or 30-day quit rates at the seven-month follow-up. Predictors of quitting were mostly similar for the young adults and the older adults, although the odds of quitting were lower among young adults for living with vs. not living with a smoker.

Conclusions: Although young adult smokers under-utilise telephone cessation quitlines for assistance with quitting, those who do use these services have quit rates similar to older adults.

How does the emotive content of televised anti-smoking mass media campaigns influence monthly calls to the NHS Stop Smoking helpline in England?

OBJECTIVE

To investigate the effects of different types of televised mass media campaign content on calls to the English NHS Stop Smoking helpline.

METHOD

We used UK government-funded televised tobacco control campaigns from April 2005 to April 2010, categorised as either "positive" (eliciting happiness, satisfaction or hope) or "negative" (eliciting fear, guilt or disgust). We built negative binomial generalised additive models (GAMs) with linear and smooth terms for monthly per capita exposure to each campaign type (expressed as Gross Ratings Points, or GRPs) to determine their effect on calls in the same month. We adjusted for seasonal trends, inflation-adjusted weighted average cigarette prices and other tobacco control policies.

RESULTS

We found non-linear associations between exposure to positive and negative emotive campaigns and quitline calls. The rate of calls increased more than 50% as exposure to positive campaigns increased from 0 to 400 GRPs (rate ratio: 1.58, 95% CI: 1.25-2.01). An increase in calls in response to negative emotive campaigns was only apparent after monthly exposure exceeded 400 GRPs.

CONCLUSION

While positive campaigns were most effective at increasing quitline calls, those with negative emotive content were also found to impact on call rates but only at higher levels of exposure.

Randomised trial of two nicotine patch protocols distributed through a state quitline

BACKGROUND

Most telephone quitlines provide free nicotine replacement therapy (NRT). An 8-week course is recommended, but few users complete it. Information is needed to help quitlines distribute NRT cost-effectively.

DESIGN

Randomised two-group trial.

SETTING/PARTICIPANTS

Colorado QuitLine callers who smoked 16-20 cigarettes per day at enrolment and who were eligible for and agreed to receive free NRT.

INTERVENTION

Provision of 4-week versus 8-week NRT supply; the 8-week supply was shipped in halves and required participants to request the second half (split-shipment protocol). Enrolment occurred during March 2010-February 2011, follow-up concluded in November 2011, and analysis was performed in 2012.

MAIN OUTCOME MEASURES

Point abstinence (7 and 30 day) and prolonged abstinence (6 month) from tobacco use.

RESULTS

Overall, 1495 study participants were enrolled and 57.7% completed follow-up. Abstinence rates did not differ significantly between study conditions: 13.8% versus 12.4% in 4-week versus 8-week arms, respectively, (30-day point abstinence, non-respondents treated as smokers). NRT duration was similar in both groups, due in part to purchase of additional patches in the 4-week group. About one-third of the 8-week group requested the full 8-week supply and had higher abstinence rates. Cost per quit was lower in the 4-week (compared to 8-week) group.

CONCLUSIONS

A randomised trial did not find worse cessation outcomes among quitline users who received half the minimum recommended course of NRT, but offering the full recommended course using a split-shipment protocol may be reasonably cost-effective and supportive of NRT adherers.

TRIAL REGISTRATION NUMBER

NCT01889771.

Feature-level analysis of a novel smartphone application for smoking cessation

BACKGROUND

Currently, there are over 400 smoking cessation smartphone apps available, downloaded an estimated 780,000 times per month. No prior studies have examined how individuals engage with specific features of cessation apps and whether use of these features is associated with quitting.

OBJECTIVES

Using data from a pilot trial of a novel smoking cessation app, we examined: (i) the 10 most-used app features, and (ii) prospective associations between feature usage and quitting.

METHODS

Participants (n = 76) were from the experimental arm of a randomized, controlled pilot trial of an app for smoking cessation called "SmartQuit," which includes elements of both Acceptance and Commitment Therapy (ACT) and traditional cognitive behavioral therapy (CBT). Utilization data were automatically tracked during the 8-week treatment phase. Thirty-day point prevalence smoking abstinence was assessed at 60-day follow-up.

RESULTS

The most-used features - quit plan, tracking, progress, and sharing - were mostly CBT. Only two of the 10 most-used features were prospectively associated with quitting: viewing the quit plan (p = 0.03) and tracking practice of letting urges pass (p = 0.03). Tracking ACT skill practice was used by fewer participants (n = 43) but was associated with cessation (p = 0.01).

CONCLUSIONS

In this exploratory analysis without control for multiple comparisons, viewing a quit plan (CBT) as well as tracking practice of letting urges pass (ACT) were both appealing to app users and associated with successful quitting. Aside from these features, there was little overlap between a feature's popularity and its prospective association with quitting. Tests of causal associations between feature usage and smoking cessation are now needed.

Randomized trial of telephone-delivered acceptance and commitment therapy versus cognitive behavioral therapy for smoking cessation: a pilot study

OBJECTIVE

We conducted a pilot randomized trial of telephone-delivered acceptance and commitment therapy (ACT) versus cognitive behavioral therapy (CBT) for smoking cessation.

METHOD

Participants were 121 uninsured South Carolina State Quitline callers who were adult smokers (at least 10 cigarettes/day) and who wanted to quit within the next 30 days. Participants were randomized to 5 sessions of either ACT or CBT telephone counseling and were offered 2 weeks of nicotine replacement therapy (NRT).

RESULTS

ACT participants completed more calls than CBT participants (M = 3.25 in ACT vs. 2.23 in CBT; p = .001). Regarding satisfaction, 100% of ACT participants reported their treatment was useful for quitting smoking (vs. 87% for CBT; p = .03), and 97% of ACT participants would recommend their treatment to a friend (vs. 83% for CBT; p = .06). On the primary outcome of intent-to-treat 30-day point prevalence abstinence at 6 months postrandomization, the quit rates were 31% in ACT versus 22% in CBT (odds ratio [OR] = 1.5, 95% confidence interval [CI] = 0.7-3.4). Among participants depressed at baseline (n = 47), the quit rates were 33% in ACT versus 13% in CBT (OR = 1.2, 95% CI = 1.0-1.6). Consistent with ACT's theory, among participants scoring low on acceptance of cravings at baseline (n = 57), the quit rates were 37% in ACT versus 10% in CBT (OR = 5.3, 95% CI = 1.3-22.0).

CONCLUSIONS

ACT is feasible to deliver by phone, is highly acceptable to quitline callers, and shows highly promising quit rates compared with standard CBT quitline counseling. As results were limited by the pilot design (e.g., small sample), a full-scale efficacy trial is now needed.