Factors underlying prefrontal and insula structural alterations in smokers

Based upon previous reports of alterations in white matter integrity and gray matter density in smokers, we examined these markers in a large, well-matched sample of smokers and non-smokers. We further investigated the effect of heavy cigarette exposure by using pack-years and the effects of two relatively stable, highly heritable traits in smokers (Fagerström Test of Nicotine Dependence (FTND), a measure of severity of nicotine dependence and Toronto Alexithymia Scale (TAS-20), a stable personality trait related to smoking). Forty-eight nicotine-dependent subjects and 48 matched controls were included in the analyses, with smokers also subdivided into high/low dependence and high/low pack-years smokers. White matter integrity (fractional anisotropy (FA)) and gray matter density (voxel-based morphometry (VBM)) were measured and compared across groups. Gray matter density was lower in left prefrontal cortex (PFC) in high pack-years smokers and was inversely related to pack-years. In contrast, left insular cortex gray matter density was higher in smokers and associated with TAS-20 total score and with difficulty-identifying-feelings factor. Further, the most highly dependent smokers showed lower prefrontal FA, which was negatively correlated with FTND. There was no correlation between pack-years and FTND in our smoker population. These data suggest chronic tobacco use is correlated with prefrontal gray matter damage , while differences in insula gray matter and PFC white matter appear to reflect stable and heritable differences between smokers and non-smokers.

Pre-cessation nicotine replacement therapy: pragmatic randomized trial

AIMS

To determine the effectiveness of 2 weeks' pre-cessation nicotine patches and/or gum on smoking abstinence at 6 months.

DESIGN

Pragmatic randomized controlled trial.

SETTING

New Zealand.

PARTICIPANTS

Eleven hundred adult, dependent smokers who called the New Zealand Quitline between March 2006 and May 2007 for support to stop smoking were randomized to 2 weeks of nicotine patches and/or gum prior to their target quit day followed by usual care (8 weeks of patches and/or gum plus support calls from a Quitline adviser), or to usual care alone.

MEASUREMENTS

The primary outcome was self-reported 7-day point prevalence smoking abstinence 6 months after quit day. Secondary outcomes included continuous abstinence, cotinine-verified abstinence, daily cigarette consumption, withdrawal symptoms and adverse events.

FINDINGS

Six months after quit day 125 (22.7%) participants in the pre-cessation group and 116 (21.0%) in the control group reported 7-day point prevalence abstinence (relative risk 1.08 95% CI: 0.86, 1.35, P = 0.4, risk difference 1.7%, 95% CI: -3.2%, 6.6%). However, when pooled in a meta-analysis with other pre-cessation trials a moderate benefit of about a one-quarter increase in cessation rates was evident. There was no difference in adverse events between groups.

CONCLUSIONS

In this, the largest pre-cessation NRT trial to date, using NRT 2 weeks before the target quit day was safe and well tolerated but offered no benefit over usual care. However, in conjunction with previous pre-cessation trials there appears to be a moderate benefit, but not as large as that seen in most smaller trials.

Unplanned attempts to quit smoking: missed opportunities for health promotion?

OBJECTIVES

To investigate the occurrence, determinants and reported success of unplanned and planned attempts to quit smoking, and sources of support used in these attempts.

DESIGN

Cross-sectional questionnaire survey of 3512 current and ex-smokers.

SETTING

Twenty-four general practices in Nottinghamshire, UK.

PARTICIPANTS

Individuals who reported making a quit attempt within the last 6 months.

MEASUREMENTS

Occurrence, triggers for, support used and success of planned and unplanned quit attempts.

RESULTS

A total of 1805 (51.4%) participants returned completed questionnaires, reporting 394 quit attempts made within the previous 6 months of which 37% were unplanned. Males were significantly more likely to make an unplanned quit attempt [adjusted odds ratio (OR) 1.60, 95% confidence interval (CI) 1.04-2.46], but the occurrence of unplanned quit attempts did not differ significantly by socio-economic group or amount smoked. The most common triggers for unplanned quit attempts were advice from a general practitioner or health professional (27.9%) and health problems (24.5%). 5.4% and 4.1% of unplanned quit attempts used National Health Service cessation services on a one to one and group basis, respectively, and more than half (51.7%) were made without any support. Nevertheless, unplanned attempts were more likely to be reported to be successful (adjusted OR 2.01, 95% CI 1.23-3.27, P < 0.01).

CONCLUSIONS

Unplanned quit attempts are common among smokers in all socio-demographic groups, are triggered commonly by advice from a health professional and are more likely to succeed; however, the majority of these unplanned attempts are unsupported. It is important to develop methods of providing behavioural and/or pharmacological support for these attempts, and determine whether these increase cessation rates still further.

Practices participating in a dental PBRN have substantial and advantageous diversity even though as a group they have much in common with dentists at large

BACKGROUND

Practice-based research networks offer important opportunities to move recent advances into routine clinical practice. If their findings are not only generalizable to dental practices at large, but can also elucidate how practice characteristics are related to treatment outcome, their importance is even further elevated. Our objective was to determine whether we met a key objective for The Dental Practice-Based Research Network (DPBRN): to recruit a diverse range of practitioner-investigators interested in doing DPBRN studies.

METHODS

DPBRN participants completed an enrollment questionnaire about their practices and themselves. To date, more than 1100 practitioners from the five participating regions have completed the questionnaire. The regions consist of: Alabama/Mississippi, Florida/Georgia, Minnesota, Permanente Dental Associates, and Scandinavia (Denmark, Norway, and Sweden). We tested the hypothesis that there are statistically significant differences in key characteristics among DPBRN practices, based on responses from dentists who participated in DPBRN's first network-wide study (n = 546).

RESULTS

There were statistically significant, substantive regional differences among DPBRN-participating dentists, their practices, and their patient populations.

CONCLUSION

Although as a group, participants have much in common with practices at large; their substantial diversity offers important advantages, such as being able to evaluate how practice differences may affect treatment outcomes, while simultaneously offering generalizability to dentists at large. This should help foster knowledge transfer in both the research-to-practice and practice-to-research directions.

Women and tobacco control policies: social-structural and psychosocial contributions to vulnerability to tobacco use and exposure

This article explores the psychosocial and social-structural vulnerability in relation to women's tobacco use, smoke exposure and responses to policy, and examines these issues in the context of women's lives and roles, describing forward looking strategies that could improve research and equity in outcomes for women. Various literatures on smoking among women and girls, and how women and sub-populations of women respond to tobacco control policies are reviewed. Specific sub-populations exhibiting more tobacco use and exposure are described, such as young pregnant and mothering women and low-income women. Emerging evidence also reveals links between smoking and experiences such as childhood sexual abuse, interpersonal violence, post-traumatic stress disorder, mental health issues and alcohol and drug dependence. Varied sub-populations of women respond in different ways to price and taxation, sales restrictions and location restrictions. However, tobacco control policies have, to date, been fashioned as broad instruments, not taking into account social context, trauma backgrounds, gendered roles such as mothering, unequal power relations affecting women in relationships and workplaces, and differences in access to resources and social support. When these issues are considered, the implications for tobacco policy development include: widening the policy purview, accounting for uneven and differential responses to policies, committing to an ethical framework, extending sex, gender and diversity based analyses, and improving research methods and approaches.

The effectiveness of NHS smoking cessation services: a systematic review

OBJECTIVES

To analyse evidence on the effectiveness of intensive NHS treatments for smoking cessation in helping smokers to quit.

METHODS

A systematic review of studies published between 1990 and 2007. Electronic databases were searched for published studies. Unpublished reports were identified from the national research register and experts.

RESULTS

Twenty studies were included. They suggest that intensive NHS treatments for smoking cessation are effective in helping smokers to quit. The national evaluation found 4-week carbon monoxide monitoring validated quit rates of 53%, falling to 15% at 1 year. There is some evidence that group treatment may be more effective than one-to-one treatment, and the impact of 'buddy support' varies based on treatment type. Evidence on the effectiveness of in-patient interventions is currently very limited. Younger smokers, females, pregnant smokers and more deprived smokers appear to have lower short-term quit rates than other groups.

CONCLUSION

Further research is needed to determine the most effective models of NHS treatment for smoking cessation and the efficacy of those models with subgroups. Factors such as gender, age, socio-economic status and ethnicity appear to influence outcomes, but a current lack of diversity-specific analysis of results makes it impossible to ascertain the differential impact of intervention types on particular subpopulations.

Improving access to smoking cessation services for disadvantaged groups: a systematic review

BACKGROUND

Smoking is a main contributor to health inequalities. Identifying strategies to find and support smokers from disadvantaged groups is, therefore, of key importance.

METHODS

A systematic review was carried out of studies identifying and supporting smokers from disadvantaged groups for smoking cessation, and providing and improving their access to smoking-cessation services. A wide range of electronic databases were searched and unpublished reports were identified from the national research register and key experts.

RESULTS

Over 7500 studies were screened and 48 were included. Some papers were of poor quality, most were observational studies and many did not report findings for disadvantaged smokers. Nevertheless, several methods of recruiting smokers, including proactively targeting patients on General Physician's registers, routine screening or other hospital appointments, were identified. Barriers to service use for disadvantaged groups were identified and providing cessation services in different settings appeared to improve access. We found preliminary evidence of the effectiveness of some interventions in increasing quitting behaviour in disadvantaged groups.

CONCLUSIONS

There is limited evidence on effective strategies to increase access to cessation services for disadvantaged smokers. While many studies collected socioeconomic data, very few analysed its contribution to the results. However, some potentially promising interventions were identified which merit further research.

Tobacco quitlines and persons with mental illnesses: perspective, practice, and direction

The prevalence of tobacco use among persons with mental illnesses is 2 to 3 times that of the general population, and these individuals suffer significant related health disparities. Many people with mental illnesses contact tobacco quitlines for cessation assistance. With free telephone counseling and in some cases nicotine replacement therapy, quitlines offer a potentially effective resource for this population. However, quitlines are still trying to determine how best to meet these callers' unique needs. The authors discuss emerging practices regarding quitline services for persons with mental illnesses, as well as expert opinion for enhancing work with these individuals.

A comparison of the effectiveness of group-based and pharmacy-led smoking cessation treatment in Glasgow

AIM

To compare the characteristics and outcomes of users accessing pharmacy and group-based smoking treatment.

DESIGN

Observational study of administrative information linked with survey data.

SETTING

Glasgow, Scotland.

PARTICIPANTS

A total of 1785 service users who set a quit date between March and May 2007.

INTERVENTION

Smoking treatment services based in pharmacies providing one-to-one support, and in the community offering group support.

MEASUREMENTS

Routine monitoring data included information about basic demographic characteristics, deprivation category of residence, nature of intervention and smoking status at 4-week follow-up determined by carbon monoxide (CO) readings < or = 10. These data were supplemented by information about socio-economic status and smoking-related behaviours obtained from consenting service recipients by treatment advisers.

FINDINGS

In the pharmacy-based service 18.6 % of users (n = 1374) were CO-validated as a quitter at 4 weeks, compared with 35.5 % (n = 411) in the group-based service. In a multivariate model, restricted to participants (n = 1366) with data allowing adjustment for socio-demographic and behavioural characteristics and including interaction terms, users who accessed the group-based services were almost twice as likely (odds ratio 1.980; confidence interval 1.50-2.62) as those who used pharmacy-based support to have quit smoking at 4-week follow-up.

CONCLUSIONS

Specialist-led group-based services appear to have higher quit rates than one-to-one services provided by pharmacies but the pharmacy services treat many more smokers. More research is needed to determine what can be done to bring the success rates of pharmacy services up to those of specialist-led groups and how to expand access to group-based services.

Exercise interventions for smoking cessation

BACKGROUND

Taking regular exercise may help people give up smoking by moderating nicotine withdrawal and cravings, and by helping to manage weight gain.

OBJECTIVES

To determine whether exercise-based interventions alone or combined with a smoking cessation programme are more effective than a smoking cessation intervention alone.

SEARCH STRATEGY

In July 2008, we searched the Cochrane Tobacco Addiction Group Specialized Register for studies including the terms 'exercise' or 'physical activity'. We also searched MEDLINE, EMBASE, PsycINFO, Dissertation Abstracts and CINAHL.

SELECTION CRITERIA

We included randomized trials which compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme, recruiting smokers or recent quitters, and with a follow up of six months or more.

DATA COLLECTION AND ANALYSIS

We extracted data on study characteristics and smoking outcomes. Because of differences in studies we summarized the results narratively, making no attempt at meta-analysis.

MAIN RESULTS

We identified 13 trials, six of which had fewer than 25 people in each treatment arm. They varied in the timing and intensity of the smoking cessation and exercise programmes. Three studies showed significantly higher abstinence rates in a physically active group versus a control group at end of treatment. One of these studies also showed a significant benefit for exercise versus control on abstinence at the three-month follow up and a benefit for exercise of borderline significance (P = 0.05) at the 12-month follow up. One study showed significantly higher abstinence rates for the exercise group versus a control group at the three-month follow up but not at the end of treatment or 12-month follow up. The other studies showed no significant effect for exercise on abstinence.

AUTHORS' CONCLUSIONS

Only one of the 13 trials offered evidence for exercise aiding smoking cessation at a 12-month follow up. All the other trials were too small to exclude reliably an effect of intervention, or included an exercise intervention which was insufficiently intense to achieve the desired level of exercise. Trials are needed with larger sample sizes, sufficiently intense interventions, equal contact control conditions, measures of exercise adherence and change in physical activity in both exercise and comparison groups.

Physical activity as an aid to smoking cessation during pregnancy: two feasibility studies

BACKGROUND

Pharmacotherapies for smoking cessation have not been adequately tested in pregnancy and women are reluctant to use them. Behavioural support alone has a modest effect on cessation rates; therefore, more effective interventions are needed. Even moderate intensity physical activity (e.g. brisk walk) reduces urges to smoke and there is some evidence it increases cessation rates in non-pregnant smokers. Two pilot studies assessed i) the feasibility of recruiting pregnant women to a trial of physical activity for smoking cessation, ii) adherence to physical activity and iii) women' perceptions of the intervention.

METHODS

Pregnant smokers volunteered for an intervention combining smoking cessation support, physical activity counselling and supervised exercise (e.g. treadmill walking). The first study provided six weekly treatment sessions. The second study provided 15 sessions over eight weeks. Physical activity levels and continuous smoking abstinence (verified by expired carbon monoxide) were monitored up to eight months gestation.

RESULTS

Overall, 11.6% (32/277) of women recorded as smokers at their first antenatal booking visit were recruited. At eight months gestation 25% (8/32) of the women achieved continuous smoking abstinence. Abstinent women attended at least 85% of treatment sessions and 75% (6/8) achieved the target level of 110 minutes/week of physical activity at end-of-treatment. Increased physical activity was maintained at eight months gestation only in the second study. Women reported that the intervention helped weight management, reduced cigarette cravings and increased confidence for quitting.

CONCLUSION

It is feasible to recruit pregnant smokers to a trial of physical activity for smoking cessation and this is likely to be popular. A large randomised controlled trial is needed to examine the efficacy of this intervention.

An algorithm for choosing among smoking cessation treatments

Currently, there are nine validated medications, four validated psychosocial strategies, and three validated ways to deliver psychosocial treatments for smoking cessation. This article presents an algorithm based on a literature review and the author's clinical experience. The algorithm integrates the recommendations of the major guidelines and meta-analyses and provides rationales for its treatment decisions. The algorithm suggests a brief assessment followed by use of one to two medications and counseling in most smokers. Because all treatments appear equally effective and have few adverse events, the algorithm suggests clinicians inform smokers of the pros and cons of the different treatments, and recommend use of one or more of each. If a smoker fails to quit, the algorithm suggests an assessment of why relapse occurred and then a more intense treatment, a new treatment, or both.

Tobacco cessation interventions for young people

BACKGROUND

Teenage smoking prevalence is around 15% in developing countries (with wide variation from country to country), and around 26% in the UK and USA. Although most tobacco control programmes for adolescents are based around prevention of uptake, there are also a number of initiatives to help those who want to quit. Since those who do not smoke before the age of 20 are significantly less likely to start as adults, there is a strong case for programmes for young people that address both prevention and treatment.

OBJECTIVES

To evaluate the effectiveness of strategies that help young people to stop smoking tobacco.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Tobacco Addiction Group's Specialized Register, MEDLINE, EMBASE, PsyclNFO, ERIC, CINAHL, and the bibliographies of identified trials. We also searched the 'grey' literature (unpublished materials), and contacted authors and experts in the field where necessary.

SELECTION CRITERIA

Types of studies: Randomized controlled trials, cluster-randomized controlled trials and controlled trials.

TYPES OF PARTICIPANTS

Young people, aged less than 20, who are regular tobacco smokers. Types of interventions: The interventions ranged from simple ones such as pharmacotherapy, targeting individual young people, through complex programmes targeting people or organizations associated with young people (for example, their families or schools), or the community in which young people live. We included cessation programmes but excluded programmes primarily aimed at prevention of uptake. Types of outcome measures: The primary outcome was smoking status at six months follow up, among those who smoked at baseline. We report the definition of cessation used in each trial (e.g seven- or thirty-day point prevalence abstinence, or sustained or prolonged abstinence), and we preferred biochemically verified cessation when that measure was available.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed the eligibility of candidate trials identified by the searches, and extracted data from them. We categorized included trials as being at low, medium or high risk of bias, based on concealment of allocation, blinding (where applicable) and the handling of attrition and losses to follow up. We conducted limited meta-analyses of some of the trials, provided that it was appropriate to group them and provided that there was minimal heterogeneity between them. We estimated pooled odds ratios using the Mantel-Haenszel method, based on the quit rates at longest follow up for trials with at least six months follow up from the start of the intervention.

MAIN RESULTS

We found 15 trials, covering 3605 young people, which met our inclusion criteria (seven cluster-randomized controlled trials, six randomized controlled trials and two controlled trials). Three trials used or tested the transtheoretical model (stages of change) approach, two tested pharmacological aids to quitting (nicotine replacement and bupropion), and the remaining trials used various psycho-social interventions, such as motivational enhancement or behavioural management. The trials evaluating TTM interventions achieved moderate long-term success, with a pooled odds ratio (OR) at one year of 1.70 ( 95% confidence interval (CI) 1.25 to 2.33) persisting at two-year follow up with an OR of 1.38 (95% CI 0.99 to 1.92). Neither of the pharmacological intervention trials achieved statistically significant results (data not pooled), but both were small-scale, with low power to detect an effect. The three interventions (5 trials) which used cognitive behavioural therapy interventions did not individually achieve statistically significant results, although when the three Not on Tobacco trials were pooled the OR 1.87; (95% CI 1.00 to 3.50) suggested some measure of effectiveness. Although the three trials that incorporated motivational interviewing as a component of the intervention achieved a pooled OR of 2.05 (95% CI 1.10 to 3.80), the impossibility of isolating the effect of the motivational interviewing in these trials meant that we could not draw meaningful inferences from that analysis.

AUTHORS' CONCLUSIONS

Complex approaches show promise, with some persistence of abstinence (30 days point prevalence abstinence at six months), especially those incorporating elements sensitive to stage of change. There were few trials with evidence about pharmacological interventions (nicotine replacement and bupropion), and none demonstrated effectiveness for adolescent smokers. Psycho-social interventions have not so far demonstrated effectiveness, although pooled results for the Not on Tobacco trials suggest that that this approach may yet prove to be effective; however, their definition of cessation (one or more smoke-free days) may not adequately account for the episodic nature of much adolescent smoking. There is a need for well-designed adequately powered randomized controlled trials for this population of smokers, with a minimum of six months follow up and rigorous definitions of cessation (sustained and biochemically verified). Attrition and losses to follow up are particularly problematic in trials for young smokers, and need to be kept to a minimum, so that management and interpretation of missing data need not compromise the findings.