Telephone counselling for smoking cessation

Smoking cessation and the cardiovascular patient

PURPOSE OF REVIEW

Smoking remains the leading cause of preventable morbidity and mortality. Our review highlights research from 2013 to 2015 on the treatment of cigarette smoking, with a focus on heart patients and cardiovascular outcomes.

RECENT FINDINGS

Seeking to maximize the reach and effectiveness of existing cessation medications, current tobacco control research has demonstrated the safety and efficacy of combination treatment, extended use, reduce-to-quit strategies, and personalized approaches to treatment matching. Further, cytisine has gained interest as a lower-cost strategy for addressing the global tobacco epidemic. On the harm reduction front, snus and electronic nicotine delivery systems are being widely distributed and promoted with major gaps in knowledge of the safety of long-term and dual use. Quitlines, comparable in outcome to in-person treatment, make cessation counseling available on a national scale, though use rates remain relatively low. Employee reward programs are gaining attention given the high costs of tobacco use to employers; sustaining quit rates postpayment, however, has proven challenging.

SUMMARY

Evidence-based cessation treatments exist. Broader dissemination, adoption, and implementation are key to addressing the tobacco epidemic. The cardiology team has a professional obligation to advance tobacco control efforts and can play an important role in achieving a smoke-free future.

The Past, Present, and Future of Nicotine Addiction Therapy

The tobacco addiction treatment field is progressing through innovations in medication development, a focus on precision medicine, and application of new technologies for delivering support in real time and over time. This article reviews the evidence for combined and extended cessation pharmacotherapy and behavioral strategies including provider advice, individual counseling, group programs, the national quitline, websites and social media, and incentives. Healthcare policies are changing to offer cessation treatment to the broad population of smokers. With knowledge of the past and present, this review anticipates what is likely on the horizon in the clinical and public health effort to address tobacco addiction.

Barriers to Telephone Quitline Use Among Methadone-Maintained Smokers

INTRODUCTION

Drug users have high rates of tobacco use and tobacco-related disease. Telephone quitlines promote smoking cessation, but their reach among drug users is unknown. We thus aimed to assess utilization of and barriers to telephone quitlines among methadone-maintained smokers.

METHODS

Subjects were opioid-dependent smokers in Bronx, New York, methadone treatment programs who were enrolled in a clinical trial of varenicline. All subjects were offered referral to a free, proactive quitline. We examined quitline records, surveyed barriers to quitline use, and queried reasons for declining referral.

RESULTS

Of the 112 subjects enrolled, 47% were male, 54% were Hispanic, and 28% were Black. All subjects were offered referral, and 25 (22% of study participants) utilized the quitline. Quitline utilizers (vs. nonutilizers) were significantly more likely to have landline phone service (72 vs. 42%, p = .01), interest in quitline participation (92 vs. 62%, p < .01), and willingness to receive calls (96 vs. 76%, p = .02). Nonutilizers were significantly more likely to report cell phone service lapse (38 vs. 14%, p = .04), and difficulty charging cell phones (19 vs. 0%, p = .02). Reasons for quitline refusal included: (a) skepticism of quitline efficacy; (b) aversion to telephone communication; (c) competing life demands (e.g., drug treatment, shelter); and (d) problems with cell phone service or minutes.

CONCLUSIONS

Despite several limitations to quitline access among methadone-maintained smokers, routine quitline referral was associated with 22% utilization. To expand provision of smoking cessation treatment to opioid-dependent smokers, interventions to promote routine quitline referral in substance abuse treatment programs warrant investigation.

The Economic Impact of Smoking and of Reducing Smoking Prevalence: Review of Evidence

BACKGROUND

Tobacco smoking is the cause of many preventable diseases and premature deaths in the UK and around the world. It poses enormous health- and non-health-related costs to the affected individuals, employers, and the society at large. The World Health Organization (WHO) estimates that, globally, smoking causes over US$500 billion in economic damage each year.

OBJECTIVES

This paper examines global and UK evidence on the economic impact of smoking prevalence and evaluates the effectiveness and cost effectiveness of smoking cessation measures.

STUDY SELECTION

SEARCH METHODS We used two major health care/economic research databases, namely PubMed and the National Institute for Health Research (NIHR) database that contains the British National Health Service (NHS) Economic Evaluation Database; Cochrane Library of systematic reviews in health care and health policy; and other health-care-related bibliographic sources. We also performed hand searching of relevant articles, health reports, and white papers issued by government bodies, international health organizations, and health intervention campaign agencies. SELECTION CRITERIA The paper includes cost-effectiveness studies from medical journals, health reports, and white papers published between 1992 and July 2014, but included only eight relevant studies before 1992. Most of the papers reviewed reported outcomes on smoking prevalence, as well as the direct and indirect costs of smoking and the costs and benefits of smoking cessation interventions. We excluded papers that merely described the effectiveness of an intervention without including economic or cost considerations. We also excluded papers that combine smoking cessation with the reduction in the risk of other diseases. DATA COLLECTION AND ANALYSIS The included studies were assessed against criteria indicated in the Cochrane Reviewers Handbook version 5.0.0. OUTCOMES ASSESSED IN THE REVIEWPrimary outcomes of the selected studies are smoking prevalence, direct and indirect costs of smoking, and the costs and benefits of smoking cessation interventions (eg, "cost per quitter", "cost per life year saved", "cost per quality-adjusted life year gained," "present value" or "net benefits" from smoking cessation, and "cost savings" from personal health care expenditure).

MAIN RESULTS

The main findings of this study are as follows: The costs of smoking can be classified into direct, indirect, and intangible costs. About 15% of the aggregate health care expenditure in high-income countries can be attributed to smoking. In the US, the proportion of health care expenditure attributable to smoking ranges between 6% and 18% across different states. In the UK, the direct costs of smoking to the NHS have been estimated at between £2.7 billion and £5.2 billion, which is equivalent to around 5% of the total NHS budget each year. The economic burden of smoking estimated in terms of GDP reveals that smoking accounts for approximately 0.7% of China's GDP and approximately 1% of US GDP. As part of the indirect (non-health-related) costs of smoking, the total productivity losses caused by smoking each year in the US have been estimated at US$151 billion.The costs of smoking notwithstanding, it produces some potential economic benefits. The economic activities generated from the production and consumption of tobacco provides economic stimulus. It also produces huge tax revenues for most governments, especially in high-income countries, as well as employment in the tobacco industry. Income from the tobacco industry accounts for up to 7.4% of centrally collected government revenue in China. Smoking also yields cost savings in pension payments from the premature death of smokers.Smoking cessation measures could range from pharmacological treatment interventions to policy-based measures, community-based interventions, telecoms, media, and technology (TMT)-based interventions, school-based interventions, and workplace interventions.The cost per life year saved from the use of pharmacological treatment interventions ranged between US$128 and US$1,450 and up to US$4,400 per quality-adjusted life years (QALYs) saved. The use of pharmacotherapies such as varenicline, NRT, and Bupropion, when combined with GP counseling or other behavioral treatment interventions (such as proactive telephone counseling and Web-based delivery), is both clinically effective and cost effective to primary health care providers.Price-based policy measures such as increase in tobacco taxes are unarguably the most effective means of reducing the consumption of tobacco. A 10% tax-induced cigarette price increase anywhere in the world reduces smoking prevalence by between 4% and 8%. Net public benefits from tobacco tax, however, remain positive only when tax rates are between 42.9% and 91.1%. The cost effectiveness ratio of implementing non-price-based smoking cessation legislations (such as smoking restrictions in work places, public places, bans on tobacco advertisement, and raising the legal age of smokers) range from US$2 to US$112 per life year gained (LYG) while reducing smoking prevalence by up to 30%-82% in the long term (over a 50-year period).Smoking cessation classes are known to be most effective among community-based measures, as they could lead to a quit rate of up to 35%, but they usually incur higher costs than other measures such as self-help quit-smoking kits. On average, community pharmacist-based smoking cessation programs yield cost savings to the health system of between US$500 and US$614 per LYG.Advertising media, telecommunications, and other technology-based interventions (such as TV, radio, print, telephone, the Internet, PC, and other electronic media) usually have positive synergistic effects in reducing smoking prevalence especially when combined to deliver smoking cessation messages and counseling support. However, the outcomes on the cost effectiveness of TMT-based measures have been inconsistent, and this made it difficult to attribute results to specific media. The differences in reported cost effectiveness may be partly attributed to varying methodological approaches including varying parametric inputs, differences in national contexts, differences in advertising campaigns tested on different media, and disparate levels of resourcing between campaigns. Due to its universal reach and low implementation costs, online campaign appears to be substantially more cost effective than other media, though it may not be as effective in reducing smoking prevalence.School-based smoking prevalence programs tend to reduce short-term smoking prevalence by between 30% and 70%. Total intervention costs could range from US$16,400 to US$580,000 depending on the scale and scope of intervention. The cost effectiveness of school-based programs show that one could expect a saving of approximately between US$2,000 and US$20,000 per QALY saved due to averted smoking after 2-4 years of follow-up.Workplace-based interventions could represent a sound economic investment to both employers and the society at large, achieving a benefit-cost ratio of up to 8.75 and generating 12-month employer cost savings of between $150 and $540 per nonsmoking employee. Implementing smoke-free workplaces would also produce myriads of new quitters and reduce the amount of cigarette consumption, leading to cost savings in direct medical costs to primary health care providers. Workplace interventions are, however, likely to yield far greater economic benefits over the long term, as reduced prevalence will lead to a healthier and more productive workforce.

CONCLUSIONS

We conclude that the direct costs and externalities to society of smoking far outweigh any benefits that might be accruable at least when considered from the perspective of socially desirable outcomes (ie, in terms of a healthy population and a productive workforce). There are enormous differences in the application and economic measurement of smoking cessation measures across various types of interventions, methodologies, countries, economic settings, and health care systems, and these may have affected the comparability of the results of the studies reviewed. However, on the balance of probabilities, most of the cessation measures reviewed have not only proved effective but also cost effective in delivering the much desired cost savings and net gains to individuals and primary health care providers.

Improving the continuity of smoking cessation care delivered by quitline services

OBJECTIVES

This study identified smokers' intended use of new quitline features aimed at improving smoking cessation such as having the same quitline advisor for each call, longer-term telephone counselling and provision of additional cessation treatments.

METHODS

Smokers who had previously used quitline counselling completed a computer-assisted telephone interview examining intended use of potential quitline enhancements.

RESULTS

The majority of smokers (61.1%) thought their chances of quitting would have increased a lot/moderately if they had the same quitline advisor for each call. Most smokers reported likely use of longer-term quitline telephone support after a failed (58.3%) or successful (60%) quit attempt. Smokers were likely to use quitline support long-term (mean=9.9 months). Most smokers would be likely to use free or subsidised nicotine replacement therapy (NRT) (74.9%) if offered by quitlines. Younger smokers had greater odds of being likely to use text messages, whereas less educated smokers had greater odds of being likely to use free or subsidised NRT.

CONCLUSIONS

Smokers appear interested in quitlines offering longer-term telephone support, increased continuity of care and additional effective quitting strategies.

PRACTICE IMPLICATIONS

Quitlines could adopt a stepped care model that involves increasingly intensive treatments and extended telephone counselling delivered by the same quitline advisor.

Psychosocial interventions for smoking cessation in patients with coronary heart disease

BACKGROUND

This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required.

OBJECTIVES

This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI).

MAIN RESULTS

We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR > 5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status).

AUTHORS' CONCLUSIONS

Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.

What are the main sources of smoking cessation support used by adolescent smokers in England? A cross-sectional study

BACKGROUND

Adolescent smoking is a worldwide public health concern. Whilst various support measures are available to help young smokers quit, their utilization of cessation support remains unknown.

METHODS

A cross-sectional study was conducted using data from the 2012 Smoking, Drinking and Drug Use among Young People survey to quantify the use of seven different types of cessation support by adolescents aged 11-16 in England who reported current smoking and having tried to quit, or ex-smoking. Logistic regression was used to calculate odds ratios and 95% confidence intervals for the associations between participant characteristics and reported use of cessation support.

RESULTS

Amongst 617 current and ex-smokers, 67.3% (95% CI 63.0-71.2) reported use of at least one cessation support measure. Not spending time with friends who smoke was the most commonly-used measure, reported by 45.4% of participants (95% CI 41.1-49.8), followed by seeking smoking cessation advice from family or friends (27.4%, 95% CI 23.7-31.5) and using nicotine products (15.4%, 95% CI 12.6-18.7). Support services provided by the National Health Service (NHS) were infrequently utilized. Having received lessons on smoking was significantly associated with reported use of cessation support (adjusted OR 1.55, 95% CI 1.02-2.34) and not spending time with friends who smoked (adjusted OR 1.98, 95% CI 1.33-2.95). Students with family members who smoked were more likely to report asking family or friends for help to quit (adjusted OR 1.74, 95% CI 1.07-2.81). Respondents who smoked fewer cigarettes per week were generally less likely to report use of cessation support measures.

CONCLUSION

The majority of young smokers reported supported attempts to quit, though the support they used tended to be informal rather than formal. Evidence is needed to quantify the effectiveness of cessation support mechanisms which are acceptable to and used by young smokers.

Beyond the Ask and Advise: Implementation of a Computer Tablet Intervention to Enhance Provider Adherence to the 5As for Smoking Cessation

BACKGROUND

The 5As for smoking cessation is an evidence-based intervention to aid providers in counseling patients to quit smoking. While most providers "ask" patients about their tobacco use patterns and "advise" them to quit, fewer patients report being "assessed" for their interest in quitting, and even fewer report subsequent "assistance" in a quit attempt and having follow-up "arranged".

PURPOSE

This article describes the design of an implementation study testing a computer tablet intervention to improve provider adherence to the 5As for smoking cessation. Findings will contribute to the existing literature on technology acceptance for addressing addictive behaviors, and how digital tools may facilitate the broader implementation of evidence-based behavioral counseling practices without adversely affecting clinical flow or patient care.

METHODS

This project develops and tests a computer-facilitated 5As (CF-5As) model that administers the 5As intervention to patients with a computer tablet, then prompts providers to reinforce next steps. During the development phase, 5As' content will be programmed onto computer tablets, alpha and beta-testing of the service delivery model will be done, and pre-intervention interview and questionnaire data will be collected from patients, providers, and clinic staff about 5As fidelity and technology adoption. During the program evaluation phase, a randomized controlled trial comparing a group who receives the CF-5As intervention to one that does not will be conducted to assess 5As fidelity. Using the technology acceptance model, a mixed methods study of contextual and human factors influencing both 5As and technology adoption will also be conducted.

CONCLUSIONS

Technology is increasingly being used in clinical settings. A technological tool that connects patients, providers, and clinic staff to facilitate the promotion of behavioral interventions such as smoking cessation may provide an innovative platform through which to efficiently and effectively implement evidence-based practices.

Tobacco addiction and smoking cessation in Austrian migrants: a cross-sectional study

OBJECTIVE

Recent observations revealed substantial differences in smoking behaviour according to individuals' migration background. However, smoking cessation strategies are rarely tailored on the basis of a migration background. We aimed to determine whether smoking behaviour and preferences for smoking cessation programmes differ between Austrian migrant smokers and Austrian smokers without a migration background.

STUDY DESIGN

Cross-sectional study.

SETTING

Recruitment and interview were performed at public places in Vienna, Austria.

PARTICIPANTS

The 420 smokers included: 140 Bosnian, 140 Turkish migrant smokers of the first or second generation, as well as 140 Austrian smokers without a migration background.

METHODS

We cross-sectionally assessed determinants of smoking behaviour and smoking cessation of every participant with a standardised questionnaire.

PRIMARY OUTCOME MEASURE

The Fagerström Test for Nicotine Dependence.

SECONDARY OUTCOME MEASURES

Determinants of smoking behaviour, willingness to quit smoking and smoking cessation.

RESULTS

Nicotine addiction expressed via the Fagerström score was significantly higher in smokers with a migration background versus those without (Bosnian migrant smokers 4.7 ± 2.5, Turkish migrant smokers 4.0 ± 2.0, Austrian smokers without a migration background 3.4 ± 2.3, p<0.0001). Bosnian and Turkish migrant smokers described a greater willingness to quit, but have had more previous cessation trials than Austrian smokers without a migration background, indicating an increased demand for cessation strategies in these study groups. They also participated in counselling programmes less often than Austrian smokers without a migration background. Finally, we found significant differences in preferences regarding smoking cessation programmes (ie, preferred location, service offered in another language besides German, and group rather than single counselling).

CONCLUSIONS

We found significant differences in addictive behaviour and cessation patterns between smokers with and without a migration background. Our results indicate a strong demand for adjusting cessation programmes to the cultural background.

Developing a Tailored Smoking Cessation Intervention for Rheumatoid Arthritis Patients

PURPOSE

Smoking is associated with an increased risk of comorbidities in rheumatoid arthritis (RA) and may reduce the efficacy of anti-rheumatic therapies. Smoking cessation is therefore an important goal in RA. Our previous qualitative research identified five RA-related barriers to smoking cessation: lack of support; limited knowledge of the relationship between smoking and RA; uncontrolled pain; inability to exercise; and using smoking as a coping strategy. The aim of this article is to describe the process of developing a smoking cessation intervention for RA patients based on these themes.

METHODS

A comprehensive review of the literature on smoking cessation was undertaken. A tailored smoking cessation programme was designed to address each RA-specific barrier. A meeting was convened with key staff of Arthritis New Zealand to develop a consensus on feasible design to deliver a smoking cessation programme based on existing best practice and smoking cessation resources, and tailored within existing Arthritis New Zealand service delivery frameworks.

RESULTS

A three-month intervention was designed to be delivered by trained arthritis educators, with the following key components: nicotine replacement therapy for eight weeks; a telephone or face-to-face interview with each patient to determine their individual specific RA-related barriers to smoking cessation; and individualized education and support activities which addressed these barriers. The intervention also included three follow-up telephone calls; a support website; and 12 weekly smoking cessation advice emails.

CONCLUSIONS

A RA-specific smoking cessation invention was developed, matching support to specific issues within each patient's experience. A pilot study is in progress to evaluate the programme's efficacy. Copyright © 2015 John Wiley & Sons, Ltd.

Randomized Controlled Trial of the Combined Effects of Web and Quitline Interventions for Smokeless Tobacco Cessation

BACKGROUND

Use of smokeless tobacco (moist snuff and chewing tobacco) is a significant public health problem but smokeless tobacco users have few resources to help them quit. Web programs and telephone-based programs (Quitlines) have been shown to be effective for smoking cessation. We evaluate the effectiveness of a Web program, a Quitline, and the combination of the two for smokeless users recruited via the Web.

OBJECTIVES

To test whether offering both a Web and Quitline intervention for smokeless tobacco users results in significantly better long-term tobacco abstinence outcomes than offering either intervention alone; to test whether the offer of Web or Quitline results in better outcome than a self-help manual only Control condition; and to report the usage and satisfaction of the interventions when offered alone or combined.

METHODS

Smokeless tobacco users (N= 1,683) wanting to quit were recruited online and randomly offered one of four treatment conditions in a 2×2 design: Web Only, Quitline Only, Web + Quitline, and Control (printed self-help guide). Point-prevalence all tobacco abstinence was assessed at 3- and 6-months post enrollment.

RESULTS

69% of participants completed both the 3- and 6-month assessments. There was no significant additive or synergistic effect of combining the two interventions for Complete Case or the more rigorous Intent To Treat (ITT) analyses. Significant simple effects were detected, individually the interventions were more efficacious than the control in achieving repeated 7-day point prevalence all tobacco abstinence: Web (ITT, OR = 1.41, 95% CI = 1.03, 1.94, p = .033) and Quitline (ITT: OR = 1.54, 95% CI = 1.13, 2.11, p = .007). Participants were more likely to complete a Quitline call when offered only the Quitline intervention (OR = 0.71, 95% CI = .054, .093, p = .013), the number of website visits and duration did not differ when offered alone or in combination with Quitline. Rates of program helpfulness (p <.05) and satisfaction (p <.05) were higher for those offered both interventions versus offered only quitline.

CONCLUSION

Combining Web and Quitline interventions did not result in additive or synergistic effects, as have been found for smoking. Both interventions were more effective than a self-help control condition in helping motivated smokeless tobacco users quit tobacco. Intervention usage and satisfaction were related to the amount intervention content offered. Usage of the Quitline intervention decreased when offered in combination, though rates of helpfulness and recommendations were higher when offered in combination.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00820495; http://clinicaltrials.gov/ct2/show/NCT00820495.

Why do smokers try to quit without medication or counselling? A qualitative study with ex-smokers

OBJECTIVE

When tobacco smokers quit, between half and two-thirds quit unassisted: that is, they do not consult their general practitioner (GP), use pharmacotherapy (nicotine-replacement therapy, bupropion or varenicline), or phone a quitline. We sought to understand why smokers quit unassisted.

DESIGN

Qualitative grounded theory study (in-depth interviews, theoretical sampling, concurrent data collection and data analysis).

PARTICIPANTS

21 Australian adult ex-smokers (aged 28-68 years; 9 males and 12 females) who quit unassisted within the past 6 months to 2 years. 12 participants had previous experience of using assistance to quit; 9 had never previously used assistance.

SETTING

Community, Australia.

RESULTS

Along with previously identified barriers to use of cessation assistance (cost, access, lack of awareness or knowledge of assistance, including misperceptions about effectiveness or safety), our study produced new explanations of why smokers quit unassisted: (1) they prioritise lay knowledge gained directly from personal experiences and indirectly from others over professional or theoretical knowledge; (2) their evaluation of the costs and benefits of quitting unassisted versus those of using assistance favours quitting unassisted; (3) they believe quitting is their personal responsibility; and (4) they perceive quitting unassisted to be the 'right' or 'better' choice in terms of how this relates to their own self-identity or self-image. Deep-rooted personal and societal values such as independence, strength, autonomy and self-control appear to be influencing smokers' beliefs and decisions about quitting.

CONCLUSIONS

The reasons for smokers' rejection of the conventional medical model for smoking cessation are complex and go beyond modifiable or correctable problems relating to misperceptions or treatment barriers. These findings suggest that GPs could recognise and respect smokers' reasons for rejecting assistance, validate and approve their choices, and modify brief interventions to support their preference for quitting unassisted, where preferred. Further research and translation may assist in developing such strategies for use in practice.

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.

Translating Behavioral Interventions Onto mHealth Platforms: Developing Text Message Interventions for Smoking and Alcohol

The development of mHealth applications is often driven by the investigators and developers with relatively little input from the targeted population. User input is commonly limited to "like/dislike" post- intervention consumer satisfaction ratings or device or application specific user analytics such as usability. However, to produce successful mHealth applications with lasting effects on health behaviors it is crucial to obtain user input from the start of each project and throughout development. The aim of this tutorial is to illustrate how qualitative methods in an iterative process of development have been used in two separate behavior change interventions (targeting smoking and alcohol) delivered through mobile technologies (ie, text messaging). A series of focus groups were conducted to assist in translating a face-to-face smoking cessation intervention onto a text message (short message service, SMS) delivered format. Both focus groups and an advisory panel were used to shape the delivery and content of a text message delivered intervention for alcohol risk reduction. An in vivo method of constructing message content was used to develop text message content that was consistent with the notion of texting as "fingered speech". Formative research conducted with the target population using a participatory framework led to important changes in our approach to intervention structure, content development, and delivery. Using qualitative methods and an iterative approach that blends consumer-driven and investigator-driven aims can produce paradigm-shifting, novel intervention applications that maximize the likelihood of use by the target audience and their potential impact on health behaviors.

Interventions to increase adherence to medications for tobacco dependence

BACKGROUND

Pharmacological treatments for tobacco dependence, such as nicotine replacement therapy (NRT), have been shown to be safe and effective interventions for smoking cessation. Higher levels of adherence to these medications increase the likelihood of sustained smoking cessation, but many smokers use them at a lower dose and for less time than is optimal. It is therefore important to determine the effectiveness of interventions designed specifically to increase medication adherence. Such interventions may include further educating individuals about the value of taking medications and providing additional support to overcome problems with maintaining adherence.

OBJECTIVES

The primary objective of this review was to assess the effectiveness of interventions to increase adherence to medications for smoking cessation, such as NRT, bupropion, nortriptyline and varenicline (and combination regimens). This was considered in comparison to a control group, typically representing standard care. Secondary objectives were to i) assess which intervention approaches are most effective; ii) determine the impact of interventions on potential precursors of adherence, such as understanding of the treatment and efficacy perceptions; and iii) evaluate key outcomes influenced by prior adherence, principally smoking cessation.

SEARCH METHODS

We searched the following databases using keywords and medical subject headings: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OVID SP) (1946 to July Week 3 2014), EMBASE (OVID SP) (1980 to Week 29 2014), and PsycINFO (OVID SP) (1806 to July Week 4 2014). The Cochrane Tobacco Addiction Group Specialized Register was searched on 9th July 2014. We conducted forward and backward citation searches.

SELECTION CRITERIA

Randomised, cluster-randomised or quasi-randomised studies in which participants using active pharmacological treatment for smoking cessation are allocated to an intervention arm or a control arm. Eligible participants were adult (18+) smokers. Eligible interventions comprised any intervention that differed from standard care, and where the intervention content had a clear principal focus on increasing adherence to medications for tobacco dependence. Acceptable comparison groups were those that provided standard care, which depending on setting may comprise minimal support or varying degrees of behavioural support. Included studies used a measure of adherence behaviour that allowed some assessment of the degree of adherence.

DATA COLLECTION AND ANALYSIS

Two review authors searched for studies and independently extracted data for included studies. Risk of bias was assessed according to the Cochrane Handbook guidance. For continuous outcome measures, we report effect sizes as standardised mean differences (SMDs). For dichotomous outcome measures, we report effect sizes as relative risks (RRs). We obtained pooled effect sizes with 95% confidence intervals (CIs) using the fixed effects model.

MAIN RESULTS

Our search strategy retrieved 3165 unique references and we identified 31 studies as potentially eligible for inclusion. Of these, 23 studies were excluded at full-text screening stage or identified as studies awaiting classification subject to further information. We included eight studies involving 3336 randomised participants. The interventions were all additional to standard behavioural support and typically provided further information on the rationale for, and emphasised the importance of, adherence to medication, and supported the development of strategies to overcome problems with maintaining adherence.Five studies reported on whether or not participants achieved a specified satisfactory level of adherence to medication. There was evidence that adherence interventions led to modest improvements in adherence, with a relative risk (RR) of 1.14 (95% CI, 1.02 to 1.28, P = 0.02, n = 1630). Four studies reported continuous measures of adherence to medication. Although the standardised mean difference (SMD) favoured adherence interventions, the effect was small and not statistically significant (SMD 0.07, 95% CI, -0.03 to 0.17, n = 1529). Applying the GRADE system, the quality of evidence for these results was assessed as moderate and low, respectively.There was evidence that adherence interventions led to modest improvements in rates of cessation. The relative risk for achieving abstinence was similar to that for improved adherence. It was not significant in meta-analysis of four studies providing short-term abstinence: RR = 1.07 (95% CI 0.95 to 1.21, n = 1755), but there was statistically significant evidence of improved abstinence at six months or more from a different set of four studies: RR = 1.16 (95% CI, 1.01 to 1.34, P = 0.03, n = 3049). Applying the GRADE system, the quality of evidence for these results was assessed as low for both.As interventions were similar in nature and the number of studies was low, it was not possible to investigate whether different types of intervention approaches were more effective than others. Relevant outcomes other than adherence or cessation were not reported.There was no evidence that interventions to increase adherence to medication led to any adverse events. All included studies were assessed as at high or unclear risk of bias. This was often due to a lack of clarity in reporting - meaning assessments were unclear - rather than clear evidence of failing to sufficiently safeguard against the risk of bias.

AUTHORS' CONCLUSIONS

There is some evidence that interventions that devote special attention to improving adherence to smoking cessation medication through providing information and facilitating problem-solving can improve adherence, though the evidence for this is not strong and is limited in both quality and quantity. There is some evidence that such interventions improve the chances of achieving abstinence but again the evidence for this is relatively weak.

The acceptance and commitment therapy for smoking cessation in the primary health care setting: a study protocol

Background

Access to effective smoking cessation programs is crucial to reducing smoking-related morbidity and mortality. Several studies have shown promising results for the application of Acceptance and Commitment Therapy (ACT) in managing psychological or behavioral health problems. However, to date, only one study has examined the feasibility of a telephone-based ACT for smoking cessation and it was conducted among a Western population, in the United States. This study reports a protocol for a randomized controlled trial (RCT) examining the feasibility and potential efficacy of an individual, telephone-delivered ACT for smoking cessation in primary healthcare settings among a Chinese population.

Methods

A randomized, two-group design was chosen, with assessment at baseline (before intervention) and via telephone follow-ups at three and six months. Subjects will be proactively recruited from primary healthcare centers. Eligible participants will be randomized to either the intervention (ACT) or control group following the baseline assessment. Both groups will receive self-help materials on smoking cessation. Those in the ACT group will undergo an initial face-to-face session and two telephone ACT sessions at one week and one month following the first session, to be delivered by a counselor based on the treatment protocol. All of the participants will be contacted by telephone for follow-up assessments at three and six months. Treatment fidelity will be assessed by reviewing around one-fifth of audio-recorded telephone calls.

Discussion

To the best of our knowledge, this protocol describes the first RCT of a telephone-based ACT for smoking cessation. It is also the first RCT of ACT for smoking cessation on a Chinese population. The study will provide us with information about the feasibility of a telephone-delivered ACT within a Chinese sample. If effective, this trial will support the development of ACT treatment protocols that could be made available for use by a greater range of clinicians, and offer an evidence base to support alternative treatments for smoking cessation.

Trial registration

ClinicalTrials.gov ID NCT01652508. Registered on 26^th July 2012.

Patient perspectives on tobacco use treatment in primary care

Introduction

Evidence-based tobacco cessation interventions increase quit rates, yet most smokers do not use them. Every primary care visit offers the potential to discuss such options, but communication can be tricky for patients and provider alike. We explored smokers’ personal interactions with health care providers to better understand what it is like to be a smoker in an increasingly smoke-free era and the resources needed to support quit attempts and to better define important patient-centered outcomes.

Methods

Three 90-minute focus groups, involving 33 patients from 3 primary care clinics, were conducted. Participants were current or recent (having quit within 6 months) smokers. Topics included tobacco use, quit attempts, and interactions with providers, followed by more pointed questions exploring actions patients want from providers and outcome measures that would be meaningful to patients.

Results

Four themes were identified through inductive coding techniques: 1) the experience of being a tobacco user (inconvenience, shame, isolation, risks, and benefits), 2) the medical encounter (expectations of providers, trust and respect, and positive, targeted messaging), 3) high-value actions (consistent dialogue, the addiction model, point-of-care nicotine patches, educational materials, carbon monoxide monitoring, and infrastructure), and 4) patient-centered outcomes.

Conclusion

Engaged patient-centered smoking cessation counseling requires seeking the patient voice early in the process. Participants desired honest, consistent, and pro-active discussions and actions. Participants also suggested creative patient-centered outcome measures to consider in future research.

The Effect of Survey Nonresponse on Quitline Abstinence Rates: Implications for Practice

INTRODUCTION

Quitline outcome studies are used to maintain and improve the effectiveness of these evidence-based cessation services. Nonresponse has the potential to bias survey results and many US and Canadian quitlines are reporting survey response rates below 50%. This study examines the effect of nonresponse bias on quit rates in three state quitline populations. Results provide implications of nonresponse bias for quitline practice.

METHODS

Quit status, defined as abstinent for 30 days or more 7 months after registering for services, was collected from Minnesota, Hawaii, and Florida quitline participants that responded to a survey. We assigned each responder to a wave based on the number of contacts required to obtain a survey response.

RESULTS

The latest two responder groups had the lowest quit rates within each state, although results were not statistically significant. Quit rates in the latest responder wave (Wave 6) were between 4% and 13% points lower than the earliest responders (Wave 1). The cumulative quit rates show what the quit rate would have been had the study ended after the corresponding wave. In all four studies, the cumulative quit rate was lowest in Wave 6.

CONCLUSION

To increase accuracy of quit rates, quitlines should focus on increasing survey response rates. Suggestions for improving survey response rates are provided.

Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial

IMPORTANCE

Widening socioeconomic disparities in mortality in the United States are largely explained by slower declines in tobacco use among smokers of low socioeconomic status (SES) than among those of higher SES, which points to the need for targeted tobacco cessation interventions. Documentation of smoking status in electronic health records (EHRs) provides the tools for health systems to proactively offer tobacco treatment to socioeconomically disadvantaged smokers.

OBJECTIVE

To evaluate a proactive tobacco cessation strategy that addresses sociocontextual mediators of tobacco use for low-SES smokers.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, randomized clinical trial included low-SES adult smokers who described their race and/or ethnicity as black, Hispanic, or white and received primary care at 1 of 13 practices in the greater Boston area (intervention group, n = 399; control group, n = 308).

INTERVENTIONS

We analyzed EHRs to identify potentially eligible participants and then used interactive voice response (IVR) techniques to reach out to them. Consenting patients were randomized to either receive usual care from their own health care team or enter an intervention program that included (1) telephone-based motivational counseling, (2) free nicotine replacement therapy (NRT) for 6 weeks, (3) access to community-based referrals to address sociocontextual mediators of tobacco use, and (4) integration of all these components into their normal health care through the EHR system.

MAIN OUTCOMES AND MEASURES

Self-reported past-7-day tobacco abstinence 9 months after randomization ("quitting"), assessed by automated caller or blinded study staff.

RESULTS

The intervention group had a higher quit rate than the usual care group (17.8% vs 8.1%; odds ratio, 2.5; 95% CI, 1.5-4.0; number needed to treat, 10). We examined whether use of intervention components was associated with quitting among individuals in the intervention group: individuals who participated in the telephone counseling were more likely to quit than those who did not (21.2% vs 10.4%; P < .001). There was no difference in quitting by use of NRT. Quitting did not differ by a request for a community referral, but individuals who used their referral were more likely to quit than those who did not (43.6% vs 15.3%; P < .001).

CONCLUSIONS AND RELEVANCE

Proactive, IVR-facilitated outreach enables engagement with low-SES smokers. Providing counseling, NRT, and access to community-based resources to address sociocontextual mediators among smokers reached in this setting is effective.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01156610.

Higher price, fewer packs: evaluating a tobacco tax increase with cigarette sales data

In 2013, Minnesota increased cigarette taxes by $1.75, the largest US state increase since 2000. We obtained convenience store data of cigarette sales from January 2012 to December 2013 from the Nielsen Company. Analysis revealed significantly greater year-to-year reductions in numbers of packs purchased during posttax (-12.1%) than pretax (-3.2%; P<.001) periods. The results provide contemporary evidence that, despite reduced prevalence and increased tobacco control efforts, tax increases remain an effective tobacco control strategy.

A mobile app to aid smoking cessation: preliminary evaluation of SmokeFree28

BACKGROUND

Little is known about the effectiveness of mobile apps in aiding smoking cessation or their validity for automated collection of data on smoking cessation outcomes.

OBJECTIVE

We conducted a preliminary evaluation of SF28 (SF28 is the name of the app, short for SmokeFree28)-an app aimed at helping smokers to be smoke-free for 28 days.

METHODS

Data on sociodemographic characteristics, smoking history, number of logins, and abstinence at each login were uploaded to a server from SF28 between August 2012 and August 2013. Users were included if they were aged 16 years or over, smoked cigarettes at the time of registration, had set a quit date, and used the app at least once on or after their quit date. Their characteristics were compared with data from a representative sample of smokers trying to stop smoking in England. The percentage of users recording 28 days of abstinence was compared with a value of 15% estimated for unaided quitting. Correlations were assessed between recorded abstinence for 28 days and well-established abstinence predictors.

RESULTS

A total of 1170 users met the inclusion criteria. Compared with smokers trying to quit in England, they had higher consumption, and were younger, more likely to be female, and had a non-manual rather than manual occupation. In total, 18.9% (95% CI 16.7-21.1) were recorded as being abstinent from smoking for 28 days or longer. The mean number of logins was 8.5 (SD 9.0). The proportion recording abstinence for 28 days or longer was higher in users who were older, in a non-manual occupation, and in those using a smoking cessation medication.

CONCLUSIONS

The recorded 28-day abstinence rates from the mobile app, SF28, suggest that it may help some smokers to stop smoking. Further evaluation by means of a randomized trial appears to be warranted.

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.

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.

Do counselor techniques predict quitting during smoking cessation treatment? A component analysis of telephone-delivered Acceptance and Commitment Therapy

No studies to date have examined the effect of counselor techniques on smoking cessation over the course of treatment. To address this gap, we examined the degree to which the use of specific Acceptance and Commitment Therapy (ACT) counseling techniques in a given session predicted smoking cessation reported at the next session. The data came from the ACT arm of a randomized controlled trial of a telephone-delivered smoking cessation intervention. Trained raters coded 139 counseling sessions across 44 participants. The openness, awareness and activation components of the ACT model were rated for each telephone counseling session. Multilevel logistic regression models were used to estimate the predictive relationship between each component during any given telephone session and smoking cessation at the following telephone session. For every 1-unit increase in counselors' use of openness and awareness techniques there were 42% and 52% decreases in the odds of smoking at the next counseling session, respectively. However, there was no significant predictive relationship between counselors' use of activation techniques and smoking cessation. Overall, results highlight the theoretical and clinical value of examining therapists' techniques as predictors of outcome during the course of treatment.

Randomized, controlled pilot trial of a smartphone app for smoking cessation using acceptance and commitment therapy

BACKGROUND

There is a dual need for (1) innovative theory-based smartphone applications for smoking cessation and (2) controlled trials to evaluate their efficacy. Accordingly, this study tested the feasibility, acceptability, preliminary efficacy, and mechanism of behavioral change of an innovative smartphone-delivered acceptance and commitment therapy (ACT) application for smoking cessation vs. an application following US Clinical Practice Guidelines.

METHOD

Adult participants were recruited nationally into the double-blind randomized controlled pilot trial (n=196) that compared smartphone-delivered ACT for smoking cessation application (SmartQuit) with the National Cancer Institute's application for smoking cessation (QuitGuide).

RESULTS

We recruited 196 participants in two months. SmartQuit participants opened their application an average of 37.2 times, as compared to 15.2 times for QuitGuide participants (p<0001). The overall quit rates were 13% in SmartQuit vs. 8% in QuitGuide (OR=2.7; 95% CI=0.8-10.3). Consistent with ACT's theory of change, among those scoring low (below the median) on acceptance of cravings at baseline (n=88), the quit rates were 15% in SmartQuit vs. 8% in QuitGuide (OR=2.9; 95% CI=0.6-20.7).

CONCLUSIONS

ACT is feasible to deliver by smartphone application and shows higher engagement and promising quit rates compared to an application that follows US Clinical Practice Guidelines. As results were limited by the pilot design (e.g., small sample), a full-scale efficacy trial is now needed.

Distinguishing adult-onset asthma from COPD: a review and a new approach

Adult-onset asthma and chronic obstructive pulmonary disease (COPD) are major public health burdens. This review presents a comprehensive synopsis of their epidemiology, pathophysiology, and clinical presentations; describes how they can be distinguished; and considers both established and proposed new approaches to their management. Both adult-onset asthma and COPD are complex diseases arising from gene-environment interactions. Early life exposures such as childhood infections, smoke, obesity, and allergy influence adult-onset asthma. While the established environmental risk factors for COPD are adult tobacco and biomass smoke, there is emerging evidence that some childhood exposures such as maternal smoking and infections may cause COPD. Asthma has been characterized predominantly by Type 2 helper T cell (Th2) cytokine-mediated eosinophilic airway inflammation associated with airway hyperresponsiveness. In established COPD, the inflammatory cell infiltrate in small airways comprises predominantly neutrophils and cytotoxic T cells (CD8 positive lymphocytes). Parenchymal destruction (emphysema) in COPD is associated with loss of lung tissue elasticity, and small airways collapse during exhalation. The precise definition of chronic airflow limitation is affected by age; a fixed cut-off of forced expiratory volume in 1 second/forced vital capacity leads to overdiagnosis of COPD in the elderly. Traditional approaches to distinguishing between asthma and COPD have highlighted age of onset, variability of symptoms, reversibility of airflow limitation, and atopy. Each of these is associated with error due to overlap and convergence of clinical characteristics. The management of chronic stable asthma and COPD is similarly convergent. New approaches to the management of obstructive airway diseases in adults have been proposed based on inflammometry and also multidimensional assessment, which focuses on the four domains of the airways, comorbidity, self-management, and risk factors. Short-acting beta-agonists provide effective symptom relief in airway diseases. Inhalers combining a long-acting beta-agonist and corticosteroid are now widely used for both asthma and COPD. Written action plans are a cornerstone of asthma management although evidence for self-management in COPD is less compelling. The current management of chronic asthma in adults is based on achieving and maintaining control through step-up and step-down approaches, but further trials of back-titration in COPD are required before a similar approach can be endorsed. Long-acting inhaled anticholinergic medications are particularly useful in COPD. Other distinctive features of management include pulmonary rehabilitation, home oxygen, and end of life care.

Self-efficacy and acceptance of cravings to smoke underlie the effectiveness of quitline counseling for smoking cessation

BACKGROUND

Few studies have examined why smoking cessation interventions are effective. The aim of this study was to examine the mediating processes underlying the effectiveness of cessation counseling administered by the Dutch national quitline.

METHODS

Data were used of a two-arm randomized controlled trial in which smoking parents, who were recruited through primary schools in The Netherlands, received either quitline cessation counseling (n=256) or a self-help brochure (n=256). The endpoint was 6-months prolonged abstinence at 12-months follow-up, with 86.7% outcome data retention. Putative psychological mediators of treatment effectiveness included smoking-related cognitions (positive smoking outcome expectancies, self-efficacy), emotions (negative affect, perceived stress, depressive symptoms), and smoking cue coping methods (avoidance coping, acceptance coping) assessed at 3-months post-measurement.

RESULTS

Quitline cessation counseling significantly decreased positive smoking outcome expectancies and negative affect and increased self-efficacy to refrain from smoking, avoidance of external cues to smoking, and acceptance of internal cues to smoking compared to self-help material. Increased self-efficacy to refrain from smoking in stressful and tempting situations (p<.001) and increased acceptance of cravings to smoke (p<.001) significantly mediated the effect of quitline cessation counseling on prolonged abstinence at 12-months follow-up (explained variance: 25.1%).

CONCLUSIONS

Self-efficacy to refrain from smoking and acceptance of cravings represent an important source of therapeutic change in smoking cessation counseling.

Efficacy and experiences of telephone counselling for informal carers of people with dementia

BACKGROUND

Informal carers of people with dementia can suffer from depressive symptoms, emotional distress and other physiological, social and financial consequences.

OBJECTIVES

This review focuses on three main objectives:To:1) produce a quantitative review of the efficacy of telephone counselling for informal carers of people with dementia;2) synthesize qualitative studies to explore carers' experiences of receiving telephone counselling and counsellors' experiences of conducting telephone counselling; and3) integrate 1) and 2) to identify aspects of the intervention that are valued and work well, and those interventional components that should be improved or redesigned.

SEARCH METHODS

The Cochrane Dementia and Cognitive Improvement Group's Specialized Register, The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, PSYNDEX, PsycINFO, Web of Science, DIMDI databases, Springer database, Science direct and trial registers were searched on 3 May 2011 and updated on 25 February 2013. A Forward Citation search was conducted for included studies in Web of Science and Google Scholar. We used the Related Articles service of PubMed for included studies, contacted experts and hand-searched abstracts of five congresses.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or cross-over trials that compared telephone counselling for informal carers of people with dementia against no treatment, usual care or friendly calls for chatting were included evaluation of efficacy. Qualitative studies with qualitative methods of data collection and analysis were also included to address experiences with telephone counselling.

DATA COLLECTION AND ANALYSIS

Two authors independently screened articles for inclusion criteria, extracted data and assessed the quantitative trials with the Cochrane 'Risk of bias' tool and the qualitative studies with the Critical Appraisal Skills Program (CASP) tool. The authors conducted meta-analyses, but reported some results in narrative form due to clinical heterogeneity. The authors synthesised the qualitative data and integrated quantitative RCT data with the qualitative data.

MAIN RESULTS

Nine RCTs and two qualitative studies were included. Six studies investigated telephone counselling without additional intervention, one study combined telephone counselling with video sessions, and two studies combined it with video sessions and a workbook. All quantitative studies had a high risk of bias in terms of blinding of participants and outcome assessment. Most studies provided no information about random sequence generation and allocation concealment. The quality of the qualitative studies ('thin descriptions') was assessed as moderate. Meta-analyses indicated a reduction of depressive symptoms for telephone counselling without additional intervention (three trials, 163 participants: standardised mean different (SMD) 0.32, 95% confidence interval (CI) 0.01 to 0.63, P value 0.04; moderate quality evidence). The estimated effects on other outcomes (burden, distress, anxiety, quality of life, self-efficacy, satisfaction and social support) were uncertain and differences could not be excluded (burden: four trials, 165 participants: SMD 0.45, 95% CI -0.01 to 0.90, P value 0.05; moderate quality evidence; support: two trials, 67 participants: SMD 0.25, 95% CI -0.24 to 0.73, P value 0.32; low quality evidence). None of the quantitative studies included reported adverse effects or harm due to telephone counselling. Three analytical themes (barriers and facilitators for successful implementation of telephone counselling, counsellor's emotional attitude and content of telephone counselling) and 16 descriptive themes that present the carers' needs for telephone counselling were identified in the thematic synthesis. Integration of quantitative and qualitative data shows potential for improvement. For example, no RCT reported that the counsellor provided 24-hour availability or that there was debriefing of the counsellor. Also, the qualitative studies covered a limited range of ways of performing telephone counselling.

AUTHORS' CONCLUSIONS

There is evidence that telephone counselling can reduce depressive symptoms for carers of people with dementia and that telephone counselling meets important needs of the carer. This result needs to be confirmed in future studies that evaluate efficacy through robust RCTs and the experience aspect through qualitative studies with rich data.

Efficacy of interventions to combat tobacco addiction: Cochrane update of 2013 reviews

AIMS

The Cochrane Collaboration is an international not-for profit organization which produces and disseminates systematic reviews. This paper is the second in a series of annual updates of Cochrane reviews on tobacco addiction interventions, covering new and updated reviews from 2013.

METHODS

In 2013, the Group published two new reviews and updated 11 others. This update summarizes and comments on these reviews as well as on a review of psychosocial interventions for smoking cessation in pregnant women, and presents pooled results from reviews of cessation interventions.

RESULTS

New reviews in 2013 found: low-quality evidence that behavioural interventions with mood management components could significantly increase long-term quit rates in people with current [risk ratio (RR) = 1.47, 95% confidence interval (CI) = 1.13-1.92) and past (RR = 1.41, 95% CI = 1.13-1.77] depression; evidence from network meta-analysis that varenicline and combined forms of nicotine replacement therapy (NRT) are associated with higher quit rates than bupropion or single-form NRT (varenicline versus single-form NRT odds ratio (OR) = 1.57, 95% credibility interval (CredI) = 1.29-1.91; versus bupropion OR = 1.59, 95% CredI = 1.29-1.96); and no evidence of a significant increase in serious adverse events in trial participants randomized to varenicline or bupropion when compared to placebo controls. New evidence emerging from updated reviews suggests that counselling interventions can increase quit rates in pregnant women and that school-based smoking programmes with social competence curricula can lead to a significant reduction in uptake of smoking at more than a year. Updated reviews also suggested that naltrexone, selective serotonin re-uptake inhibitors and St John's wort do not have a significant effect on long-term smoking cessation.

CONCLUSIONS

Cochrane systematic review evidence from 2013 suggests that adding mood management to behavioural support may improve cessation outcomes in smokers with current or past depression and strengthens evidence for previous conclusions, including the safety of varenicline and bupropion and the benefits of behavioural support for smoking cessation in pregnancy.

Tobacco use and cessation for cancer survivors: an overview for clinicians

Approximately 30% of all cancer deaths in the United States are caused by tobacco use and smoking. Cancers of eighteen sites have been causally linked to smoking, the most common of which are the lung, head and neck, bladder, and esophagus. While quit rates and quit attempt rates are relatively high shortly after a cancer diagnosis, the recidivism rates are also high. Therefore, screening, treating, and preventing relapse to tobacco use is imperative among patients with and survivors of cancer. To date, research has consistently shown that a combination of pharmacologic and behavioral interventions is needed to achieve the highest smoking cessation rates, with a recent emphasis on individualized treatment as a most promising approach. Challenges in health care systems, including the lack of appropriate resources and provider training, have slowed the progress in addition to important clinical considerations relevant to the treatment of tobacco dependence (eg, a high degree of comorbidity with psychiatric disorders and other substance use disorders). However, continued tobacco use has been shown to limit the effectiveness of major cancer treatments and to increase the risk of complications and of developing secondary cancers. The authors recommend that oncology providers screen all patients for tobacco use and refer users to specialized treatment when available. Alternatively, oncology clinicians can provide basic advice on tobacco use cessation and pharmacotherapy and/or referral to outside resources (eg, quitlines). Herein, the authors summarize the current knowledge on tobacco use and its treatment, with a focus on the related available evidence for patients with and survivors of cancer.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials giving advice and information may help them and increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine: the effectiveness of different forms of print-based self-help materials, compared with no treatment and with other minimal contact strategies; the effectiveness of adjuncts to print-based self help, such as computer-generated feedback, telephone hotlines and pharmacotherapy; and the effectiveness of approaches tailored to the individual compared with non-tailored materials.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search April 2014.

SELECTION CRITERIA

We included randomized trials of smoking cessation with follow-up of at least six months, where at least one arm tested a print-based self-help intervention. We defined self help as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the nature of the self-help materials, the amount of face-to-face contact given to intervention and to control conditions, outcome measures, method of randomization, and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We identified 74 trials which met the inclusion criteria. Many study reports did not include sufficient detail to judge risk of bias for some domains. Twenty-eight studies (38%) were judged at high risk of bias for one or more domains but the overall risk of bias across all included studies was judged to be moderate, and unlikely to alter the conclusions.Thirty-four trials evaluated the effect of standard, non-tailored self-help materials. Pooling 11 of these trials in which there was no face-to-face contact and provision of structured self-help materials was compared to no intervention gave an estimate of benefit that just reached statistical significance (n = 13,241, risk ratio [RR] 1.19, 95% confidence interval [CI] 1.04 to 1.37). This analysis excluded two trials with strongly positive outcomes that introduced significant heterogeneity. Six further trials without face-to-face contact in which the control group received alternative written materials did not show evidence for an effect of the smoking self-help materials (n = 7023, RR 0.88, 95% CI 0.74 to 1.04). When these two subgroups were pooled, there was no longer evidence for a benefit of standard structured materials (n = 20,264, RR 1.06, 95% CI 0.95 to 1.18). We failed to find evidence of benefit from providing standard self-help materials when there was brief contact with all participants (5 trials, n = 3866, RR 1.17, 95% CI 0.96 to 1.42), or face-to-face advice for all participants (11 trials, n = 5365, RR 0.97, 95% CI 0.80 to 1.18).Thirty-one trials offered materials tailored for the characteristics of individual smokers, with controls receiving either no materials, or stage matched or non-tailored materials. Most of the trials used more than one mailing. Pooling these showed a benefit of tailored materials (n = 40,890, RR 1.28, 95% CI 1.18 to 1.37) with moderate heterogeneity (I² = 32%). The evidence is strongest for the subgroup of nine trials in which tailored materials were compared to no intervention (n = 13,437, RR 1.35, 95% CI 1.19 to 1.53), but also supports tailored materials as more helpful than standard materials. Part of this effect could be due to the additional contact or assessment required to obtain individual data, since the subgroup of 10 trials where the number of contacts was matched did not detect an effect (n = 11,024, RR 1.06, 95% CI 0.94 to 1.20). In two trials including a direct comparison between tailored materials and brief advice from a health care provider, there was no evidence of a difference, but confidence intervals were wide (n = 2992, RR 1.13, 95% CI 0.86 to 1.49).Only four studies evaluated self-help materials as an adjunct to nicotine replacement therapy, with no evidence of additional benefit (n = 2291, RR 1.05, 95% CI 0.88 to 1.25). A small number of other trials failed to detect benefits from using additional materials or targeted materials, or to find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Standard, print-based self-help materials increase quit rates compared to no intervention, but the effect is likely to be small. We did not find evidence that they have an additional benefit when used alongside other interventions such as advice from a healthcare professional, or nicotine replacement therapy. There is evidence that materials that are tailored for individual smokers are more effective than non-tailored materials, although the absolute size of effect is still small. Available evidence tested self-help interventions in high income countries; further research is needed to investigate their effect in contexts where more intensive support is not available.

An evaluation of long-term changes in alcohol use and alcohol problems among clients of the Swedish National Alcohol Helpline

Background

The Swedish National Alcohol Helpline was developed with the intention to provide an easily available, low threshold service to hazardous and harmful alcohol users in the community. The primary aim of this study was to describe the 12-month outcome of a cohort of clients and to evaluate whether these varied as a function of the intensity of exposure to the intervention.

Methods

The alcohol use and alcohol problems of a cohort of 191 clients accessing the service between 1 April 2009 and 1 February 2011 were assessed by telephone survey at the time of the first call and after 12 months. Change in AUDIT score between baseline and follow-up was used as primary outcome. Intensity of exposure was defined by number of counselling sessions.

Results

At 12-month follow-up, respondents had significantly reduced their AUDIT score to half of the baseline values, and one third of the participants were abstinent or consumed alcohol at a low-risk level. Participating in more than one counselling session as compared to one session was associated with a tendency to shift to a lower AUDIT zone at follow-up among women.

Conclusions

The Alcohol Helpline provides a viable community service for harmful and hazardous alcohol users. Future randomized studies including other treatment or control conditions are warranted in order to strengthen our preliminary conclusion of possible effectiveness of the counselling provided at the helpline, as well as to explore further the role of gender in moderating the treatment’s effect.

Effectiveness of proactive and reactive services at the Swedish National Tobacco Quitline in a randomized trial

BACKGROUND

The Swedish National Tobacco Quitline (SNTQ), which has both a proactive and a reactive service, has successfully provided tobacco cessation support since 1998. As there is a demand for an increase in national cessation support, and because the quitline works under funding constraints, it is crucial to identify the most clinically effective and cost-effective service. A randomized controlled trial was performed to compare the effectiveness of the high-intensity proactive service with the low-intensity reactive service at the SNTQ.

METHODS

Those who called the SNTQ for smoking or tobacco cessation from February 2009 to September 2010 were randomized to proactive service (even dates) and reactive service (odd dates). Data were collected through postal questionnaires at baseline and after 12 months. Those who replied to the baseline questionnaire constituted the study base. Outcome measures were self-reported point prevalence and 6-month continuous abstinence at the 12-month follow-up. Intention-to-treat (ITT) and responder-only analyses were performed.

RESULTS

The study base consisted of 586 persons, and 59% completed the 12-month follow-up. Neither ITT- nor responder-only analyses showed any differences in outcome between proactive and reactive service. Point prevalence was 27% and continuous abstinence was 21% in analyses treating non-responders as smokers, and 47% and 35%, respectively, in responder-only analyses.

CONCLUSION

Reactive service may be used as the standard procedure to optimize resource utilization at the SNTQ. However, further research is needed to assess effectiveness in different subgroups of clients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02085616.

Position paper on the importance of psychosocial factors in cardiology: Update 2013

Background: The rapid progress of psychosomatic research in cardiology and also the increasing impact of psychosocial issues in the clinical daily routine have prompted the Clinical Commission of the German Heart Society (DGK) to agree to an update of the first state of the art paper on this issue which was originally released in 2008.

Methods: The circle of experts was increased, general aspects were implemented and the state of the art was updated. Particular emphasis was dedicated to coronary heart diseases (CHD), heart rhythm diseases and heart failure because to date the evidence-based clinical knowledge is most advanced in these particular areas. Differences between men and women and over the life span were considered in the recommendations as were influences of cognitive capability and the interactive and synergistic impact of classical somatic risk factors on the affective comorbidity in heart disease patients.

Results: A IA recommendation (recommendation grade I and evidence grade A) was given for the need to consider psychosocial risk factors in the estimation of coronary risks as etiological and prognostic risk factors. Furthermore, for the recommendation to routinely integrate psychosocial patient management into the care of heart surgery patients because in these patients, comorbid affective disorders (e.g. depression, anxiety and post-traumatic stress disorder) are highly prevalent and often have a malignant prognosis. A IB recommendation was given for the treatment of psychosocial risk factors aiming to prevent the onset of CHD, particularly if the psychosocial risk factor is harmful in itself (e.g. depression) or constrains the treatment of the somatic risk factors. Patients with acute and chronic CHD should be offered anti-depressive medication if these patients suffer from medium to severe states of depression and in this case medication with selective reuptake inhibitors should be given. In the long-term course of treatment with implanted cardioverter defibrillators (ICDs) a subjective health technology assessment is warranted. In particular, the likelihood of affective comorbidities and the onset of psychological crises should be carefully considered.

Conclusions: The present state of the art paper presents an update of current empirical evidence in psychocardiology. The paper provides evidence-based recommendations for the integration of psychosocial factors into cardiological practice and highlights areas of high priority. The evidence for estimating the efficiency for psychotherapeutic and psychopharmacological interventions has increased substantially since the first release of the policy document but is, however, still weak. There remains an urgent need to establish curricula for physician competence in psychodiagnosis, communication and referral to ensure that current psychocardiac knowledge is translated into the daily routine.

Effectiveness of proactive quitline counselling for smoking parents recruited through primary schools: results of a randomized controlled trial

AIMS

To test the effectiveness of tailored quitline (telephone) counselling among smoking parents recruited into cessation support through their children's primary schools.

DESIGN

Two-arm randomized controlled trial with 3- and 12-month follow-up.

SETTING

Proactive telephone counselling was administered by the Dutch national quitline.

PARTICIPANTS

Smoking parents were recruited through their children's primary schools and received either intensive quitline support in combination with tailored supplementary materials (n = 256) or a standard self-help brochure (n = 256).

MEASUREMENTS

The primary outcome was 7-day point-prevalence abstinence at 12-month follow-up. Also measured were baseline characteristics, use of and adherence to nicotine replacement therapy and pharmacotherapy, smoking characteristics and implementation of a home smoking ban.

FINDINGS

Parents who received quitline counselling were more likely to report 7-day point-prevalence abstinence at 12-month assessment [34.0 versus 18.0%, odds ratio (OR) = 2.35, confidence interval (CI) = 1.56-3.54] than those who received a standard self-help brochure. Parents who received quitline counselling were more likely to use nicotine replacement therapy (P < 0.001) than those who received a standard self-help brochure. Among parents who did not achieve abstinence, those who received quitline counselling smoked fewer cigarettes at 3-month (P < 0.001) and 12-month assessment (P < 0.001), were more likely to make a quit attempt (P < 0.001), to achieve 24 hours' abstinence (P < 0.001) and to implement a complete home smoking ban (P < 0.01).

CONCLUSIONS

Intensive quitline support tailored to smoking parents is an effective method for helping parents quit smoking and promoting parenting practices that protect their children from adverse effects of smoking.

Building an Evidence Base Using Qualitative Data for mHealth Development

To be successful mHealth applications must be consistent with the way individuals use technology. Using qualitative methods and an iterative approach that blends consumer-driven and investigator-driven aims can produce paradigm-shifting, novel intervention applications that maximize the likelihood of use by the target audience and their potential impact on health behaviors. In behavioral health the development of mHealth applications often takes a top-down approach driven by the investigators and programmers, with relatively little input from the targeted population. Often user-input is limited to "like/dislike" post-intervention consumer satisfaction ratings or device/application-specific user analytics. To have a lasting effect on health behaviors it is crucial to obtain user input from the start of each project and throughout development. This paper describes the use of qualitative methods in an end-user participatory framework, and demonstrates how this lead to important changes in our approach to health interventions delivered through mobile technologies.

Predictors of abstinence among smokers recruited actively to quitline support

AIMS

Active recruitment of smokers increases the reach of quitlines; however, some quitlines restrict proactive telephone counselling (i.e. counsellor-initiated calls) to smokers ready to quit within 30 days. Identifying characteristics associated with successful quitting by actively recruited smokers could help to distinguish those most likely to benefit from proactive telephone counselling. This study assessed the baseline characteristics of actively recruited smokers associated with prolonged abstinence at 4, 7 and 13 months and the proportion achieving prolonged abstinence that would miss out on proactive telephone counselling if such support was offered only to smokers intending to quit within 30 days at baseline.

DESIGN

Secondary analysis of a randomized controlled trial in which the baseline characteristics associated with prolonged abstinence were examined.

SETTING

New South Wales (NSW) community, Australia.

PARTICIPANTS

A total of 1562 smokers recruited at random from the electronic NSW telephone directory.

MEASUREMENTS

Baseline socio-demographic and smoking-related characteristics associated with prolonged abstinence at 4, 7 and 13 months post-recruitment.

FINDINGS

Waiting more than an hour to smoke after waking and intention to quit within 30 days at baseline predicted five of the six prolonged abstinence measures. If proactive telephone counselling was restricted to smokers who at baseline intended to quit within 30 days, 53.8-65.9% of experimental group participants who achieved prolonged abstinence would miss out on telephone support.

CONCLUSIONS

Less addicted and more motivated smokers who are actively recruited to quitline support are more likely to achieve abstinence. Most actively recruited smokers reported no intention to quit within the next 30 days, but such smokers still achieved long-term abstinence.

Self-reported exposure to policy and environmental influences on smoking cessation and relapse: a 2-year longitudinal population-based study

Although most smokers want to quit, the long-term success rate of quit attempts remains low; research is needed to understand the policy and environmental influences that can increase the success of cessation efforts. This paper uses regression methods to investigate self-reported exposure to policy and environmental influences on quit attempts, maintenance of a quit attempt for at least 6 months, and relapse in a longitudinal population-based sample, the New York Adult Cohort Survey, followed for 12 months (N = 3,261) and 24 months (N = 1,142). When policy or environmental influence variables were assessed independently of other policy or environmental influence variables, many were significant for at least some of the cessation outcomes. In the full models that included a full set of policy or environmental influence variables, many significant associations became nonsignificant. A number of policies may have an influence on multiple cessation outcomes. However, the effect varies by cessation outcome, and statistical significance is influenced by model specification.