Interventions to reduce harm from continued tobacco use

How do people quit smoking using e-cigarettes? A mixed-methods exploration of participant smoking pathways following receiving an opportunistic e-cigarette-based smoking cessation intervention

BACKGROUND AND AIMS

Pathways of transitioning from tobacco smoking to vaping after receiving an e-cigarette-based smoking cessation intervention have been minimally explored.

STUDY AIMS

1) identify pathways between intervention delivery and final follow-up; 2) describe baseline and post-intervention statistical data in relation to smoking/vaping behaviour of the different pathway groups; 3) explore qualitative participant perspectives contextualising pathway groups.

DESIGN

Embedded mixed-methods analysis of data collected for the Cessation of Smoking Trial in the Emergency Department (COSTED) randomised controlled trial.

SETTING

Recruitment from 6 Emergency Departments (5 in England and 1 in Scotland) between January and August 2022.

PARTICIPANTS

366 adult smokers who were randomised to receive the COSTED intervention and provided data at 6-month follow-up. Qualitative subsample of 24 participants interviewed after follow-up.

INTERVENTIONS

Brief smoking cessation advice, provision of an e-cigarette starter kit and referral to the local Stop Smoking Service.

MEASUREMENTS

Descriptive statistical reporting of identified pathways and smoking/vaping behaviour at baseline and 6-month follow-up. Semi-structured phone/video interviews analysed thematically.

FINDINGS

13.4% (n = 49) of participants quit smoking within 1 month of receiving the intervention, 19.1% (n = 70) quit between 1 and 6 months, 24.9% (n = 91) reduced cigarettes per day (CPD) by at least 50%, and 42.6% did not experience a significant smoking reduction. Approximately a third of participants who quit reported not vaping at follow-up. Reporting dual use was associated with a reduction in CPD. Appoximately a third reported experimenting with a different device to the one provided as part of the intervention. Quitters reported themes of satisfaction with vaping, changes in environment facilitating quitting and motivation to quit.

CONCLUSIONS

Dual use of cigarettes and e-cigarettes can result in a reduction of smoking and may preclude quitting smoking. Sustained e-cigarette use is not always necessary for quitting success. Success depends on personal context as well satisfaction with vaping.

Effectiveness of smoking cessation interventions among adults: an overview of systematic reviews

BACKGROUND

This overview of reviews aims to identify evidence on the benefits (i.e. tobacco use abstinence and reduction in smoking frequency) and harms (i.e. possible adverse events/outcomes) of smoking cessation interventions among adults aged 18 years and older.

METHODS

We searched Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, the CADTH Health Technology Assessment Database and several other websites for grey literature. Searches were conducted on November 12, 2018, updated on September 24, 2020, with publication years 2008 to 2020. Two reviewers independently performed title-abstract and full-text screening considering pre-determined inclusion criteria. Data extraction and quality assessments were initially completed by two reviewers independently (i.e. 73% of included studies (n = 22)) using A Measurement Tool to Assess Systematic Reviews-2 (AMSTAR 2), and the remainder done by one reviewer and verified by another due to resources and feasibility. The application of Grading of Recommendations Assessment, Development and Evaluation (GRADE) was performed by one independent reviewer and verified by another.

RESULTS

A total of 22 Cochrane systematic reviews evaluating the impact of smoking cessation interventions on outcomes such as tobacco use abstinence, reduction in smoking frequency, quality of life and possible adverse events were included. Pharmaceutical (i.e. varenicline, cytisine, nicotine replacement therapy (NRT), bupropion) and behavioural interventions (i.e. physician advice, non-tailored print-based self-help materials, stage-based individual counselling, etc.) showed to have increased smoking cessation; whereas, data for mobile phone-based interventions including text messaging, hypnotherapy, acupuncture, continuous auricular stimulation, laser therapy, electrostimulation, acupressure, St John's wort, S-adenosyl-L-methionine (SAMe), interactive voice response systems and other combination treatments were unclear. Considering harms related to smoking cessation interventions, small/mild harms (i.e. increased palpitations, chest pain, nausea, insomnia, headache) were observed following NRT, varenicline and cytisine use. There were no data on harms related to behavioural therapies (i.e. individual or group counselling self-help materials, internet interventions), combination therapies or other therapies (i.e. laser therapy, electrostimulation, acupressure, St John's wort, SAMe).

CONCLUSION

Results suggest that pharmacological and behavioural interventions may help the general smoking population quit smoking with observed small/mild harms following NRT or varenicline. Consequently, evidence regarding ideal intervention strategies and the long-term impact of these interventions for preventing smoking was unclear.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018099691.

Effectiveness of e-cigarettes as a stop smoking intervention in adults: a systematic review

BACKGROUND

This systematic review aims to identify the benefits and harms of electronic cigarettes (e-cigarettes) as a smoking cessation aid in adults (aged ≥ 18 years) and to inform the development of the Canadian Task Force on Preventive Health Care's (CTFPHC) clinical practice guidelines on e-cigarettes.

METHODS

We searched Ovid MEDLINE®, Ovid MEDLINE® Epub Ahead of Print, In-Process & Other Non-Indexed Citations, PsycINFO, Embase Classic + Embase, and the Cochrane Library on Wiley. Searches were conducted from January 2016 to July 2019 and updated on 24 September 2020 and 25 January 2024. Two reviewers independently performed title-abstract and full-text screening according to the pre-determined inclusion criteria. Data extraction, quality assessments, and the application of Grading of Recommendations Assessment, Development and Evaluation (GRADE) were performed by one independent reviewer and verified by another.

RESULTS

We identified 18 studies on 17 randomized controlled trials that compared e-cigarettes with nicotine to e-cigarettes without nicotine and e-cigarettes (with or without nicotine) to other interventions (i.e., no intervention, waitlist, standard/usual care, quit advice, or behavioral support). Considering the benefits of e-cigarettes in terms of smoking abstinence and smoking frequency reduction, 14 studies showed small or moderate benefits of e-cigarettes with or without nicotine compared to other interventions; although, with low, very low or moderate evidence certainty. With a focus on e-cigarettes with nicotine specifically, 12 studies showed benefits in terms of smoking abstinence when compared with usual care or non-nicotine e-cigarettes. In terms of harms following nicotine or non-nicotine e-cigarette use, 15 studies reported mild adverse events with little to no difference between groups and low to very low evidence certainty.

CONCLUSION

The evidence synthesis on the e-cigarette's effectiveness shows data surrounding benefits having low to moderate evidence certainty for some comparisons and very low certainty for others, indicating that e-cigarettes may or probably increase smoking cessation, whereas, for harms, there is low to very low evidence certainty. Since the duration for outcome measurement varied among different studies, it may not be long-term enough for Adverse Events (AEs) to emerge, and there is a need for more research to understand the long-term benefits and potential harms of e-cigarettes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018099692.

Association of smoking cessation patterns and untreated smoking with glaucoma, cataract, and macular degeneration: a population-based retrospective study

This study aims to assess the association between nicotine replacement therapy (NRT), varenicline, and untreated smoking with the risk of developing eye disorders. We employed a new-user design to investigate the association between NRT use and the incidence of eye disorders by the Taiwan National Health Insurance program. This study included 8416 smokers who received NRT and 8416 smokers who did not receive NRT (control group) matched using propensity scores between 2007 and 2018. After adjustment for relevant factors, a multivariable Cox regression analysis revealed that compared with untreated smokers, NRT use was associated with a significantly reduced risk of macular degeneration (hazard ratio [HR]: 0.34; 95% confidence interval [CI]: 0.13-0.87, P = 0.024). When stratified by dose, short-term NRT use (8-28 defined daily doses) was associated with significantly lower risk of glaucoma (HR: 0.35; 95% CI: 0.16-0.80, P = 0.012) and a trend toward reduced risk of cataract (HR: 0.60; 95% CI: 0.36-1.01, P = 0.053) compared to no treatment. However, these associations were not observed with long-term NRT use. The results of this real-world observational study indicate that NRT use, particularly short-term use, was associated with a lower risk of certain eye disorders compared to no treatment for smoking cessation. Long-term NRT use did not demonstrate the same benefits. Thus, short-term NRT may be a beneficial treatment strategy for reducing the risk of eye disorders in smokers attempting to quit. However, further evidence is required to verify these findings and determine the optimal duration of NRT use.

Systematic review and meta-analysis investigating nicotine, cotinine and carbon monoxide exposures in people who both smoke and use nicotine replacement therapy

AIMS

To determine effects of concurrent smoking and nicotine replacement therapy (NRT) use on reported heaviness of smoking, nicotine (cotinine) body fluid and exhaled air carbon monoxide (CO) concentrations.

METHODS

Systematic review and meta-analysis of RCTs, which test interventions permitting concurrent NRT use and smoking and comparing, within participants, outcomes when smoking with those when smoking and using NRT concurrently. Measurements included reported number of cigarettes smoked per day (CPD), body fluid cotinine and expired air CO concentrations.

RESULTS

Twenty-nine studies were included in the review. Meta-analysis of nine showed that, compared with when solely smoking, fewer cigarettes were smoked daily when NRT was used (mean difference during concurrent smoking and NRT use, -2.06 CPD [95% CI = -3.06 to -1.07, P < 0.0001]). Meta-analysis of seven studies revealed a non-significant reduction in exhaled CO during concurrent smoking and NRT use (mean difference, -0.58 ppm [95% CI = -2.18 to 1.03, P = 0.48]), but in the three studies that tested NRT used in the lead-up to quitting (i.e. as preloading), a similar reduction in exhaled CO was statistically significant (mean difference, -2.54 ppm CO [95% CI = -4.14 to -0.95, P = 0.002]). Eleven studies reported cotinine concentrations, but meta-analysis was not possible because of data reporting heterogeneity; of these, seven reported lower cotinine concentrations with concurrent NRT use and smoking, four reported no differences, and none reported higher concentrations.

CONCLUSIONS

People who smoke and also use nicotine replacement therapy report smoking less heavily than people who solely smoke. When nicotine replacement therapy is used in the lead-up to quitting (preloading), this reported smoking reduction has been biochemically confirmed. There is no evidence that concurrent smoking and nicotine replacement therapy use result in greater nicotine exposure than solely smoking.

Awareness, Attitudes, and Concerns Regarding Heated Tobacco Products Among Physicians in Japan

BACKGROUND

New tobacco products, particularly heated tobacco products (HTPs), have been introduced across several international markets as alternatives to combustible products, such as cigarettes. However, there are limited studies on physicians' perceptions of HTPs. This study analyzes the awareness of HTPs among physicians and assesses their concerns and attitudes toward patients using HTPs.

METHODS

A self-administered questionnaire was sent to a sample of 7,500 member physicians (6,000 male and 1,500 female) from the Japan Medical Association (JMA). The smoking status of physicians was categorized as never smokers, ever HTP smokers, current HTP smokers, and ever and current smokers of other products. Physicians' awareness and attitudes toward patients using HTPs were analyzed using descriptive statistics. The correlation between the outcomes was examined using logistic regression models, whereas physicians' concerns about HTPs were analyzed using descriptive statistics.

RESULTS

Data were obtained from 5,492 physicians (21.9% women; aged 60.4; standard deviation, 12.1 years) with a response rate of 74.6%. Overall, 76.7% of the physicians had awareness of HTP, and about half of whom asked patients about using HTPs. Physicians who took longer to discuss cessation were more likely to discourage patient use. Smoking status was associated with discouraging HTP use in patients. Physicians who had experience with HTP use were primarily concerned about the products' long-term safety and less about product regulation.

CONCLUSION

Japanese physicians do not have sufficient information and knowledge about HTPs. Therefore, evidence-based guidelines are required to support physicians in advising patients against HTP use.

Nicotine receptor partial agonists for smoking cessation

Background

Nicotine receptor partial agonists may help people to stop smoking by a combination of maintaining moderate levels of dopamine to counteract withdrawal symptoms (acting as an agonist) and reducing smoking satisfaction (acting as an antagonist). This is an update of a Cochrane Review first published in 2007.

Objectives

To assess the effectiveness of nicotine receptor partial agonists, including varenicline and cytisine, for smoking cessation.

Search methods

We searched the Cochrane Tobacco Addiction Group's Specialised Register in April 2022 for trials, using relevant terms in the title or abstract, or as keywords. The register is compiled from searches of CENTRAL, MEDLINE, Embase, and PsycINFO. 

Selection criteria

We included randomised controlled trials that compared the treatment drug with placebo, another smoking cessation drug, e‐cigarettes, or no medication. We excluded trials that did not report a minimum follow‐up period of six months from baseline.

Data collection and analysis

We followed standard Cochrane methods. Our main outcome was abstinence from smoking at longest follow‐up using the most rigorous definition of abstinence, preferring biochemically validated rates where reported. We pooled risk ratios (RRs), using the Mantel‐Haenszel fixed‐effect model. We also reported the number of people reporting serious adverse events (SAEs).

Main results

We included 75 trials of 45,049 people; 45 were new for this update. We rated 22 at low risk of bias, 18 at high risk, and 35 at unclear risk.

We found moderate‐certainty evidence (limited by heterogeneity) that cytisine helps more people to quit smoking than placebo (RR 1.30, 95% confidence interval (CI) 1.15 to 1.47; I2 = 83%; 4 studies, 4623 participants), and no evidence of a difference in the number reporting SAEs (RR 1.04, 95% CI 0.78 to 1.37; I2 = 0%; 3 studies, 3781 participants; low‐certainty evidence). SAE evidence was limited by imprecision. We found no data on neuropsychiatric or cardiac SAEs.

We found high‐certainty evidence that varenicline helps more people to quit than placebo (RR 2.32, 95% CI 2.15 to 2.51; I2 = 60%, 41 studies, 17,395 participants), and moderate‐certainty evidence that people taking varenicline are more likely to report SAEs than those not taking it (RR 1.23, 95% CI 1.01 to 1.48; I2 = 0%; 26 studies, 14,356 participants). While point estimates suggested increased risk of cardiac SAEs (RR 1.20, 95% CI 0.79 to 1.84; I2 = 0%; 18 studies, 7151 participants; low‐certainty evidence), and decreased risk of neuropsychiatric SAEs (RR 0.89, 95% CI 0.61 to 1.29; I2 = 0%; 22 studies, 7846 participants; low‐certainty evidence), in both cases evidence was limited by imprecision, and confidence intervals were compatible with both benefit and harm.

Pooled results from studies that randomised people to receive cytisine or varenicline found no clear evidence of difference in quit rates (RR 1.00, 95% CI 0.79 to 1.26; I2 = 65%; 2 studies, 2131 participants; low‐certainty evidence) and reported SAEs (RR 0.67, 95% CI 0.44 to 1.03; I2 = 45%; 2 studies, 2017 participants; low‐certainty evidence). However, the evidence was limited by imprecision, and confidence intervals incorporated the potential for benefit from either cytisine or varenicline. We found no data on neuropsychiatric or cardiac SAEs.

We found high‐certainty evidence that varenicline helps more people to quit than bupropion (RR 1.36, 95% CI 1.25 to 1.49; I2 = 0%; 9 studies, 7560 participants), and no clear evidence of difference in rates of SAEs (RR 0.89, 95% CI 0.61 to 1.31; I2 = 0%; 5 studies, 5317 participants), neuropsychiatric SAEs (RR 1.05, 95% CI 0.16 to 7.04; I2 = 10%; 2 studies, 866 participants), or cardiac SAEs (RR 3.17, 95% CI 0.33 to 30.18; I2 = 0%; 2 studies, 866 participants). Evidence of harms was of low certainty, limited by imprecision.

We found high‐certainty evidence that varenicline helps more people to quit than a single form of nicotine replacement therapy (NRT) (RR 1.25, 95% CI 1.14 to 1.37; I2 = 28%; 11 studies, 7572 participants), and low‐certainty evidence, limited by imprecision, of fewer reported SAEs (RR 0.70, 95% CI 0.50 to 0.99; I2 = 24%; 6 studies, 6535 participants). We found no data on neuropsychiatric or cardiac SAEs.

We found no clear evidence of a difference in quit rates between varenicline and dual‐form NRT (RR 1.02, 95% CI 0.87 to 1.20; I2 = 0%; 5 studies, 2344 participants; low‐certainty evidence, downgraded because of imprecision). While pooled point estimates suggested increased risk of SAEs (RR 2.15, 95% CI 0.49 to 9.46; I2 = 0%; 4 studies, 1852 participants) and neuropsychiatric SAEs (RR 4.69, 95% CI 0.23 to 96.50; I2 not estimable as events only in 1 study; 2 studies, 764 participants), and reduced risk of cardiac SAEs (RR 0.32, 95% CI 0.01 to 7.88; I2 not estimable as events only in 1 study; 2 studies, 819 participants), in all three cases evidence was of low certainty and confidence intervals were very wide, encompassing both substantial harm and benefit.

Authors' conclusions

Cytisine and varenicline both help more people to quit smoking than placebo or no medication. Varenicline is more effective at helping people to quit smoking than bupropion, or a single form of NRT, and may be as or more effective than dual‐form NRT. People taking varenicline are probably more likely to experience SAEs than those not taking it, and while there may be increased risk of cardiac SAEs and decreased risk of neuropsychiatric SAEs, evidence was compatible with both benefit and harm. Cytisine may lead to fewer people reporting SAEs than varenicline. Based on studies that directly compared cytisine and varenicline, there may be no difference or a benefit from either medication for quitting smoking.

Future trials should test the effectiveness and safety of cytisine compared with varenicline and other pharmacotherapies, and should also test variations in dose and duration. There is limited benefit to be gained from more trials testing the effect of standard‐dose varenicline compared with placebo for smoking cessation. Further trials on varenicline should test variations in dose and duration, and compare varenicline with e‐cigarettes for smoking cessation.

Can medications like varenicline and cytisine (nicotine receptor partial agonists) help people to stop smoking and do they cause unwanted effects?

Key messages

· Varenicline can help people to stop smoking for at least 6 months. Evidence shows it works better than bupropion and using only one type of nicotine replacement therapy (e.g. only patches). Quit rates might be similar to using more than one type of nicotine replacement therapy at the same time (e.g. patches and gum together).

· Cytisine can help people to stop smoking for at least 6 months. It may work as well as varenicline, but future evidence may show that while it helps, it is not quite as helpful as varenicline.

· Future studies should test the effectiveness and safety of cytisine compared with varenicline and other stop‐smoking medications, and should also  investigate giving cytisine or varenicline at different doses and for different lengths of time.

What are 'nicotine receptor partial agonists'?

Smoking tobacco is extremely bad for people’s health. For people who smoke, quitting is the best thing they can do to improve their health. Many people find it difficult to quit smoking. Nicotine receptor partial agonists (NRPAs) are a type of medication used to help people to stop smoking. They help to reduce the withdrawal symptoms people experience when they stop smoking, like cravings and unpleasant mood changes. They also reduce the pleasure people usually experience when they smoke. The most widely‐available treatment in this drug type is varenicline. Cytisine is another, similar medication. They may cause unwanted effects such as feeling sick (nausea) and other stomach problems, difficulties sleeping, abnormal dreams, and headache. They may also lead to potentially serious unwanted effects, such as suicidal thoughts, heart problems and raised blood pressure.

What did we want to find out?

We wanted to find out if using NRPAs can help people to quit smoking, and if they cause unwanted effects. We wanted to know:

· how many people stopped smoking for at least 6 months; and

· how many people had unwanted effects.

What did we do?

We searched for studies that investigated NRPAs used to help people quit smoking. People in the studies had to be chosen at random to receive an NRPA, or another NRPA, placebo (medication like the NRPA but with no active ingredients) or no treatment. They had to be adult tobacco smokers who wanted to stop smoking.

What did we find?

We found 75 studies that compared NRPAs with:

· placebo or no medicine;

· nicotine replacement therapy, such as patches or gum;

· bupropion (another medicine to help people stop smoking);

· another NRPA;

· e‐cigarettes.

The USA hosted the most studies (28 studies). Other studies took place in a range of countries across the world, some in several countries.

Main results

People are more likely to stop smoking for at least six months using varenicline than using placebo (41 studies, 17,395 people), bupropion (9 studies, 7560 people), or just one type of nicotine replacement therapy, like patches alone (11 studies, 7572 people). They may be just as likely to quit as people using two or more kinds of nicotine replacement therapy, like patches and gum together (5 studies, 2344 people).

Cytisine probably helps more people to stop smoking than placebo (4 studies, 4623 people) and may be just as effective as varenicline (2 studies, 2131 people).

For every 100 people using varenicline to stop smoking, 21 to 25 might successfully stop, compared with only 18 of 100 people using bupropion, 18 of 100 people using a single form of nicotine‐replacement therapy, and 20 of 100 using two or more kinds of nicotine‐replacement therapy. For every 100 people using cytisine to stop smoking, 18 to 23 might successfully stop.

The most common unwanted effect of varenicline is nausea, but this is mostly at mild or moderate levels and usually clears over time. People taking varenicline likely have an increased chance of a more serious unwanted effect that could result in going to hospital, however these are still rare (2.7% to 4% of people on varenicline, compared with 2.7% of people without) and may include many that are unrelated to varenicline. People taking cytisine may also have a slightly increased chance of serious unwanted effects compared with people not taking it, but this may be less likely compared with varenicline.

What are the limitations of the evidence?

The evidence for some of our results is very reliable. We’re very confident that varenicline helps people to quit smoking better than many alternatives. We’re less sure of some other results because fewer or smaller studies provided evidence.

Several results suggest one treatment is better or less harmful than another, but the opposite could still be true.

How up to date is the evidence?

The evidence is up to date to 29 April 2022.

Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation

BACKGROUND

Nicotine replacement therapy (NRT) aims to replace nicotine from cigarettes. This helps to reduce cravings and withdrawal symptoms, and ease the transition from cigarette smoking to complete abstinence. Although there is high-certainty evidence that NRT is effective for achieving long-term smoking abstinence, it is unclear whether different forms, doses, durations of treatment or timing of use impacts its effects.

OBJECTIVES

To determine the effectiveness and safety of different forms, deliveries, doses, durations and schedules of NRT, for achieving long-term smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning NRT in the title, abstract or keywords, most recently in April 2022.

SELECTION CRITERIA

We included randomised trials in people motivated to quit, comparing one type of NRT use with another. We excluded studies that did not assess cessation as an outcome, with follow-up of fewer than six months, and with additional intervention components not matched between arms. Separate reviews cover studies comparing NRT to control, or to other pharmacotherapies.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. We measured smoking abstinence after at least six months, using the most rigorous definition available. We extracted data on cardiac adverse events (AEs), serious adverse events (SAEs) and study withdrawals due to treatment.  MAIN RESULTS: We identified 68 completed studies with 43,327 participants, five of which are new to this update. Most completed studies recruited adults either from the community or from healthcare clinics. We judged 28 of the 68 studies to be at high risk of bias. Restricting the analysis only to those studies at low or unclear risk of bias did not significantly alter results for any comparisons apart from the preloading comparison, which tested the effect of using NRT prior to quit day whilst still smoking.  There is high-certainty evidence that combination NRT (fast-acting form plus patch) results in higher long-term quit rates than single form (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.17 to 1.37; I2 = 12%; 16 studies, 12,169 participants). Moderate-certainty evidence, limited by imprecision, indicates that 42/44 mg patches are as effective as 21/22 mg (24-hour) patches (RR 1.09, 95% CI 0.93 to 1.29; I2 = 38%; 5 studies, 1655 participants), and that 21 mg patches are more effective than 14 mg (24-hour) patches (RR 1.48, 95% CI 1.06 to 2.08; 1 study, 537 participants). Moderate-certainty evidence, again limited by imprecision, also suggests a benefit of 25 mg over 15 mg (16-hour) patches, but the lower limit of the CI encompassed no difference (RR 1.19, 95% CI 1.00 to 1.41; I2 = 0%; 3 studies, 3446 participants). Nine studies tested the effect of using NRT prior to quit day (preloading) in comparison to using it from quit day onward. There was moderate-certainty evidence, limited by risk of bias, of a favourable effect of preloading on abstinence (RR 1.25, 95% CI 1.08 to 1.44; I2 = 0%; 9 studies, 4395 participants). High-certainty evidence from eight studies suggests that using either a form of fast-acting NRT or a nicotine patch results in similar long-term quit rates (RR 0.90, 95% CI 0.77 to 1.05; I2 = 0%; 8 studies, 3319 participants). We found no clear evidence of an effect of duration of nicotine patch use (low-certainty evidence); duration of combination NRT use (low- and very low-certainty evidence); or fast-acting NRT type (very low-certainty evidence). Cardiac AEs, SAEs and withdrawals due to treatment were all measured variably and infrequently across studies, resulting in low- or very low-certainty evidence for all comparisons. Most comparisons found no clear evidence of an effect on these outcomes, and rates were low overall. More withdrawals due to treatment were reported in people using nasal spray compared to patches in one study (RR 3.47, 95% CI 1.15 to 10.46; 1 study, 922 participants; very low-certainty evidence) and in people using 42/44 mg patches in comparison to 21/22 mg patches across two studies (RR 4.99, 95% CI 1.60 to 15.50; I2 = 0%; 2 studies, 544 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that using combination NRT versus single-form NRT and 4 mg versus 2 mg nicotine gum can result in an increase in the chances of successfully stopping smoking. Due to imprecision, evidence was of moderate certainty for patch dose comparisons. There is some indication that the lower-dose nicotine patches and gum may be less effective than higher-dose products. Using a fast-acting form of NRT, such as gum or lozenge, resulted in similar quit rates to nicotine patches. There is moderate-certainty evidence that using NRT before quitting may improve quit rates versus using it from quit date only; however, further research is needed to ensure the robustness of this finding. Evidence for the comparative safety and tolerability of different types of NRT use is limited. New studies should ensure that AEs, SAEs and withdrawals due to treatment are reported.

Antidepressants for smoking cessation

BACKGROUND

The pharmacological profiles and mechanisms of antidepressants are varied. However, there are common reasons why they might help people to stop smoking tobacco: nicotine withdrawal can produce short-term low mood that antidepressants may relieve; and some antidepressants may have a specific effect on neural pathways or receptors that underlie nicotine addiction.

OBJECTIVES

To assess the evidence for the efficacy, harms, and tolerability of medications with antidepressant properties in assisting long-term tobacco smoking cessation in people who smoke cigarettes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, most recently on 29 April 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in people who smoked, comparing antidepressant medications with placebo or no pharmacological treatment, an alternative pharmacotherapy, or the same medication used differently. We excluded trials with fewer than six months of follow-up from efficacy analyses. We included trials with any follow-up length for our analyses of harms.

DATA COLLECTION AND ANALYSIS

We extracted data and assessed risk of bias using standard Cochrane methods. Our primary outcome measure was smoking cessation after at least six months' follow-up. We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Our secondary outcomes were harms and tolerance outcomes, including adverse events (AEs), serious adverse events (SAEs), psychiatric AEs, seizures, overdoses, suicide attempts, death by suicide, all-cause mortality, and trial dropouts due to treatment. We carried out meta-analyses where appropriate.

MAIN RESULTS

We included a total of 124 studies (48,832 participants) in this review, with 10 new studies added to this update version. Most studies recruited adults from the community or from smoking cessation clinics; four studies focused on adolescents (with participants between 12 and 21 years old). We judged 34 studies to be at high risk of bias; however, restricting analyses only to studies at low or unclear risk of bias did not change clinical interpretation of the results.  There was high-certainty evidence that bupropion increased smoking cessation rates when compared to placebo or no pharmacological treatment (RR 1.60, 95% CI 1.49 to 1.72; I2 = 16%; 50 studies, 18,577 participants). There was moderate-certainty evidence that a combination of bupropion and varenicline may have resulted in superior quit rates to varenicline alone (RR 1.21, 95% CI 0.95 to 1.55; I2 = 15%; 3 studies, 1057 participants). However, there was insufficient evidence to establish whether a combination of bupropion and nicotine replacement therapy (NRT) resulted in superior quit rates to NRT alone (RR 1.17, 95% CI 0.95 to 1.44; I2 = 43%; 15 studies, 4117 participants; low-certainty evidence). There was moderate-certainty evidence that participants taking bupropion were more likely to report SAEs than those taking placebo or no pharmacological treatment. However, results were imprecise and the CI also encompassed no difference (RR 1.16, 95% CI 0.90 to 1.48; I2 = 0%; 23 studies, 10,958 participants). Results were also imprecise when comparing SAEs between people randomised to a combination of bupropion and NRT versus NRT alone (RR 1.52, 95% CI 0.26 to 8.89; I2 = 0%; 4 studies, 657 participants) and randomised to bupropion plus varenicline versus varenicline alone (RR 1.23, 95% CI 0.63 to 2.42; I2 = 0%; 5 studies, 1268 participants). In both cases, we judged evidence to be of low certainty. There was high-certainty evidence that bupropion resulted in more trial dropouts due to AEs than placebo or no pharmacological treatment (RR 1.44, 95% CI 1.27 to 1.65; I2 = 2%; 25 studies, 12,346 participants). However, there was insufficient evidence that bupropion combined with NRT versus NRT alone (RR 1.67, 95% CI 0.95 to 2.92; I2 = 0%; 3 studies, 737 participants) or bupropion combined with varenicline versus varenicline alone (RR 0.80, 95% CI 0.45 to 1.45; I2 = 0%; 4 studies, 1230 participants) had an impact on the number of dropouts due to treatment. In both cases, imprecision was substantial (we judged the evidence to be of low certainty for both comparisons). Bupropion resulted in inferior smoking cessation rates to varenicline (RR 0.73, 95% CI 0.67 to 0.80; I2 = 0%; 9 studies, 7564 participants), and to combination NRT (RR 0.74, 95% CI 0.55 to 0.98; I2 = 0%; 2 studies; 720 participants). However, there was no clear evidence of a difference in efficacy between bupropion and single-form NRT (RR 1.03, 95% CI 0.93 to 1.13; I2 = 0%; 10 studies, 7613 participants). We also found evidence that nortriptyline aided smoking cessation when compared with placebo (RR 2.03, 95% CI 1.48 to 2.78; I2 = 16%; 6 studies, 975 participants), and some evidence that bupropion resulted in superior quit rates to nortriptyline (RR 1.30, 95% CI 0.93 to 1.82; I2 = 0%; 3 studies, 417 participants), although this result was subject to imprecision. Findings were sparse and inconsistent as to whether antidepressants, primarily bupropion and nortriptyline, had a particular benefit for people with current or previous depression.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that bupropion can aid long-term smoking cessation. However, bupropion may increase SAEs (moderate-certainty evidence when compared to placebo/no pharmacological treatment). There is high-certainty evidence that people taking bupropion are more likely to discontinue treatment compared with people receiving placebo or no pharmacological treatment. Nortriptyline also appears to have a beneficial effect on smoking quit rates relative to placebo, although bupropion may be more effective. Evidence also suggests that bupropion may be as successful as single-form NRT in helping people to quit smoking, but less effective than combination NRT and varenicline. In most cases, a paucity of data made it difficult to draw conclusions regarding harms and tolerability. Further studies investigating the efficacy of bupropion versus placebo are unlikely to change our interpretation of the effect, providing no clear justification for pursuing bupropion for smoking cessation over other licensed smoking cessation treatments; namely, NRT and varenicline. However, it is important that future studies of antidepressants for smoking cessation measure and report on harms and tolerability.

Cigarette smoking and risk of suicide in bipolar disorder: a systematic review

Objective

Bipolar disorder (BD) is a highly prevalent, chronic and recurrent mental illness. The smoking rates in patients with BD are much higher than those of the general population, and BD is associated with an increased risk of suicide. An association between smoking and suicidal behavior has been found in the general population, this systematic review examines whether there is evidence of an association between smoking and suicide behavior in patients with BD.

Method

A database search was carried out in Medline, Embase, The Cochrane Library, Scopus, and Web of Science, updated until December 31st, 2021, according to the 2020 PRISMA guidelines. We identified prospective and retrospective studies that included patients diagnosed with BD types I, II, and not otherwise specified, and in which smoking and suicidal behavior were correlated. Articles that focused exclusively on other mental disorders were excluded. The Ottawa-Newcastle scale was used to assess the methodological quality of the included articles.

Results

Fifteen articles (n = 7,395) met all the inclusion criteria. In nine of these articles, the authors found an association between smoking and suicidal behavior in BD, while in the remaining six articles, this association was not found. A great deal of variability was observed between articles, particularly in the measurement of suicidal behavior and tobacco consumption. The risk of bias, as assessed by the NOS, was high for most of the included articles, except for two papers, whose risk was low.

Conclusion

It was not possible to establish a clear relationship between tobacco use and the risk of suicide in BD patients due to the heterogeneity of the articles included in this systematic review, which had different sample sizes and methodological issues. However, both conditions are highly prevalent and have a negative impact on the prognosis of BD. Therefore, a systematic approach is needed, based on accurate measurement of a patient's smoking habits and their risk of suicidal behavior, in order to establish an appropriate therapeutic plan.

Additional information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors and was registered on PROSPERO with the CRD42022301570 on January 21th 2022.

Nicotine receptor partial agonists for smoking cessation

BACKGROUND

Nicotine receptor partial agonists may help people to stop smoking by a combination of maintaining moderate levels of dopamine to counteract withdrawal symptoms (acting as an agonist) and reducing smoking satisfaction (acting as an antagonist). This is an update of a Cochrane Review first published in 2007.

OBJECTIVES

To assess the effectiveness of nicotine receptor partial agonists, including varenicline and cytisine, for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register in April 2022 for trials, using relevant terms in the title or abstract, or as keywords. The register is compiled from searches of CENTRAL, MEDLINE, Embase, and PsycINFO.  SELECTION CRITERIA: We included randomised controlled trials that compared the treatment drug with placebo, another smoking cessation drug, e-cigarettes, or no medication. We excluded trials that did not report a minimum follow-up period of six months from baseline.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our main outcome was abstinence from smoking at longest follow-up using the most rigorous definition of abstinence, preferring biochemically validated rates where reported. We pooled risk ratios (RRs), using the Mantel-Haenszel fixed-effect model. We also reported the number of people reporting serious adverse events (SAEs).

MAIN RESULTS

We included 75 trials of 45,049 people; 45 were new for this update. We rated 22 at low risk of bias, 18 at high risk, and 35 at unclear risk. We found moderate-certainty evidence (limited by heterogeneity) that cytisine helps more people to quit smoking than placebo (RR 1.30, 95% confidence interval (CI) 1.15 to 1.47; I2 = 83%; 4 studies, 4623 participants), and no evidence of a difference in the number reporting SAEs (RR 1.04, 95% CI 0.78 to 1.37; I2 = 0%; 3 studies, 3781 participants; low-certainty evidence). SAE evidence was limited by imprecision. We found no data on neuropsychiatric or cardiac SAEs. We found high-certainty evidence that varenicline helps more people to quit than placebo (RR 2.32, 95% CI 2.15 to 2.51; I2 = 60%, 41 studies, 17,395 participants), and moderate-certainty evidence that people taking varenicline are more likely to report SAEs than those not taking it (RR 1.23, 95% CI 1.01 to 1.48; I2 = 0%; 26 studies, 14,356 participants). While point estimates suggested increased risk of cardiac SAEs (RR 1.20, 95% CI 0.79 to 1.84; I2 = 0%; 18 studies, 7151 participants; low-certainty evidence), and decreased risk of neuropsychiatric SAEs (RR 0.89, 95% CI 0.61 to 1.29; I2 = 0%; 22 studies, 7846 participants; low-certainty evidence), in both cases evidence was limited by imprecision, and confidence intervals were compatible with both benefit and harm. Pooled results from studies that randomised people to receive cytisine or varenicline showed that more people in the varenicline arm quit smoking (RR 0.83, 95% CI 0.66 to 1.05; I2 = 0%; 2 studies, 2131 participants; moderate-certainty evidence) and reported SAEs (RR 0.67, 95% CI 0.44 to 1.03; I2 = 45%; 2 studies, 2017 participants; low-certainty evidence). However, the evidence was limited by imprecision, and confidence intervals incorporated the potential for benefit from either cytisine or varenicline. We found no data on neuropsychiatric or cardiac SAEs. We found high-certainty evidence that varenicline helps more people to quit than bupropion (RR 1.36, 95% CI 1.25 to 1.49; I2 = 0%; 9 studies, 7560 participants), and no clear evidence of difference in rates of SAEs (RR 0.89, 95% CI 0.61 to 1.31; I2 = 0%; 5 studies, 5317 participants), neuropsychiatric SAEs (RR 1.05, 95% CI 0.16 to 7.04; I2 = 10%; 2 studies, 866 participants), or cardiac SAEs (RR 3.17, 95% CI 0.33 to 30.18; I2 = 0%; 2 studies, 866 participants). Evidence of harms was of low certainty, limited by imprecision. We found high-certainty evidence that varenicline helps more people to quit than a single form of nicotine replacement therapy (NRT) (RR 1.25, 95% CI 1.14 to 1.37; I2 = 28%; 11 studies, 7572 participants), and low-certainty evidence, limited by imprecision, of fewer reported SAEs (RR 0.70, 95% CI 0.50 to 0.99; I2 = 24%; 6 studies, 6535 participants). We found no data on neuropsychiatric or cardiac SAEs. We found no clear evidence of a difference in quit rates between varenicline and dual-form NRT (RR 1.02, 95% CI 0.87 to 1.20; I2 = 0%; 5 studies, 2344 participants; low-certainty evidence, downgraded because of imprecision). While pooled point estimates suggested increased risk of SAEs (RR 2.15, 95% CI 0.49 to 9.46; I2 = 0%; 4 studies, 1852 participants) and neuropsychiatric SAEs (RR 4.69, 95% CI 0.23 to 96.50; I2 not estimable as events only in 1 study; 2 studies, 764 participants), and reduced risk of cardiac SAEs (RR 0.32, 95% CI 0.01 to 7.88; I2 not estimable as events only in 1 study; 2 studies, 819 participants), in all three cases evidence was of low certainty and confidence intervals were very wide, encompassing both substantial harm and benefit.

AUTHORS' CONCLUSIONS

Cytisine and varenicline both help more people to quit smoking than placebo or no medication. Varenicline is more effective at helping people to quit smoking than bupropion, or a single form of NRT, and may be as or more effective than dual-form NRT. People taking varenicline are probably more likely to experience SAEs than those not taking it, and while there may be increased risk of cardiac SAEs and decreased risk of neuropsychiatric SAEs, evidence was compatible with both benefit and harm. Cytisine may lead to fewer people reporting SAEs than varenicline. Based on studies that directly compared cytisine and varenicline, there may be a benefit from varenicline for quitting smoking, however further evidence could strengthen this finding or demonstrate a benefit from cytisine. Future trials should test the effectiveness and safety of cytisine compared with varenicline and other pharmacotherapies, and should also test variations in dose and duration. There is limited benefit to be gained from more trials testing the effect of standard-dose varenicline compared with placebo for smoking cessation. Further trials on varenicline should test variations in dose and duration, and compare varenicline with e-cigarettes for smoking cessation.

A systematic review and meta-analysis of interventions to induce attempts to quit tobacco among adults not ready to quit

The prevalence of past-year smoking cessation remains below 10% in the U.S. Most who smoke are not ready to quit in the near future. Cessation requires both (a) initiating a quit attempt (QA) and (b) maintaining abstinence. Most research has focused on abstinence among people already motivated to quit. We systematically reviewed interventions to promote QAs among people not motivated to quit tobacco. We searched PubMed, CENTRAL, PsycINFO, Embase, and our personal libraries for randomized trials of tobacco interventions that reported QAs as an outcome among adults not ready to quit. We screened studies and extracted data in duplicate. We pooled findings of the 25 included studies using Mantel-Haenszel random effects meta-analyses when ≥ 2 studies tested the same intervention. Most (24) trials addressed cigarettes and one addressed smokeless tobacco. Substantial heterogeneity among trials resulted in a series of small meta-analyses. Findings indicate varenicline may increase QAs more than no varenicline, n = 320; RR = 1.4, 95% CI [1.1, 1.7]; I² = 0%, and nicotine replacement therapy (NRT) may increase QAs more than no NRT, n = 2,568; RR = 1.1, 95% CI [1.02, 1.3]; I² = 0%. Pooled effects for motivational counseling, reduction counseling, and very low nicotine content cigarettes showed no clear evidence of benefit or harm. The evidence was judged to be of medium to very low certainty due to imprecision, inconsistency, and risk of bias, suggesting that further research is likely to change interpretation of our results. Findings demonstrate the need for more high-quality research on interventions to induce QAs among adults not ready to quit tobacco. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effectiveness and cost-effectiveness of behavioural support for prolonged abstinence for smokers wishing to reduce but not quit: Randomised controlled trial of physical activity assisted reduction of smoking (TARS)

AIMS

For smokers unmotivated to quit, we assessed the effectiveness and cost-effectiveness of behavioural support to reduce smoking and increase physical activity on prolonged abstinence and related outcomes.

DESIGN

A multi-centred pragmatic two-arm parallel randomised controlled trial.

SETTING

Primary care and the community across four United Kingdom sites.

PARTICIPANTS

Nine hundred and fifteen adult smokers (55% female, 85% White), recruited via primary and secondary care and the community, who wished to reduce their smoking but not quit.

INTERVENTIONS

Participants were randomised to support as usual (SAU) (n = 458) versus multi-component community-based behavioural support (n = 457), involving up to eight weekly person-centred face-to-face or phone sessions with additional 6-week support for those wishing to quit.

MEASUREMENTS

Ideally, cessation follows smoking reduction so the primary pre-defined outcome was biochemically verified 6-month prolonged abstinence (from 3-9 months, with a secondary endpoint also considering abstinence between 9 and 15 months). Secondary outcomes included biochemically verified 12-month prolonged abstinence and point prevalent biochemically verified and self-reported abstinence, quit attempts, number of cigarettes smoked, pharmacological aids used, SF12, EQ-5D and moderate-to-vigorous physical activity (MVPA) at 3 and 9 months. Intervention costs were assessed for a cost-effectiveness analysis.

FINDINGS

Assuming missing data at follow-up implied continued smoking, nine (2.0%) intervention participants and four (0.9%) SAU participants achieved the primary outcome (adjusted odds ratio, 2.30; 95% confidence interval [CI] = 0.70-7.56, P = 0.169). At 3 and 9 months, the proportions self-reporting reducing cigarettes smoked from baseline by ≥50%, for intervention versus SAU, were 18.9% versus 10.5% (P = 0.009) and 14.4% versus 10% (P = 0.044), respectively. Mean difference in weekly MVPA at 3 months was 81.6 minutes in favour of the intervention group (95% CI = 28.75, 134.47: P = 0.003), but there was no significant difference at 9 months (23.70, 95% CI = -33.07, 80.47: P = 0.143). Changes in MVPA did not mediate changes in smoking outcomes. The intervention cost was £239.18 per person, with no evidence of cost-effectiveness.

CONCLUSIONS

For United Kingdom smokers wanting to reduce but not quit smoking, behavioural support to reduce smoking and increase physical activity improved some short-term smoking cessation and reduction outcomes and moderate-to-vigorous physical activity, but had no long-term effects on smoking cessation or physical activity.

Motivational support intervention to reduce smoking and increase physical activity in smokers not ready to quit: the TARS RCT

Background

Physical activity can support smoking cessation for smokers wanting to quit, but there have been no studies on supporting smokers wanting only to reduce. More broadly, the effect of motivational support for such smokers is unclear.

Objectives

The objectives were to determine if motivational support to increase physical activity and reduce smoking for smokers not wanting to immediately quit helps reduce smoking and increase abstinence and physical activity, and to determine if this intervention is cost-effective.

Design

This was a multicentred, two-arm, parallel-group, randomised (1 : 1) controlled superiority trial with accompanying trial-based and model-based economic evaluations, and a process evaluation.

Setting and participants

Participants from health and other community settings in four English cities received either the intervention (n = 457) or usual support (n = 458).

Intervention

The intervention consisted of up to eight face-to-face or telephone behavioural support sessions to reduce smoking and increase physical activity.

Main outcome measures

The main outcome measures were carbon monoxide-verified 6- and 12-month floating prolonged abstinence (primary outcome), self-reported number of cigarettes smoked per day, number of quit attempts and carbon monoxide-verified abstinence at 3 and 9 months. Furthermore, self-reported (3 and 9 months) and accelerometer-recorded (3 months) physical activity data were gathered. Process items, intervention costs and cost-effectiveness were also assessed.

Results

The average age of the sample was 49.8 years, and participants were predominantly from areas with socioeconomic deprivation and were moderately heavy smokers. The intervention was delivered with good fidelity. Few participants achieved carbon monoxide-verified 6-month prolonged abstinence [nine (2.0%) in the intervention group and four (0.9%) in the control group; adjusted odds ratio 2.30 (95% confidence interval 0.70 to 7.56)] or 12-month prolonged abstinence [six (1.3%) in the intervention group and one (0.2%) in the control group; adjusted odds ratio 6.33 (95% confidence interval 0.76 to 53.10)]. At 3 months, the intervention participants smoked fewer cigarettes than the control participants (21.1 vs. 26.8 per day). Intervention participants were more likely to reduce cigarettes by ≥ 50% by 3 months [18.9% vs. 10.5%; adjusted odds ratio 1.98 (95% confidence interval 1.35 to 2.90] and 9 months [14.4% vs. 10.0%; adjusted odds ratio 1.52 (95% confidence interval 1.01 to 2.29)], and reported more moderate-to-vigorous physical activity at 3 months [adjusted weekly mean difference of 81.61 minutes (95% confidence interval 28.75 to 134.47 minutes)], but not at 9 months. Increased physical activity did not mediate intervention effects on smoking. The intervention positively influenced most smoking and physical activity beliefs, with some intervention effects mediating changes in smoking and physical activity outcomes. The average intervention cost was estimated to be £239.18 per person, with an overall additional cost of £173.50 (95% confidence interval -£353.82 to £513.77) when considering intervention and health-care costs. The 1.1% absolute between-group difference in carbon monoxide-verified 6-month prolonged abstinence provided a small gain in lifetime quality-adjusted life-years (0.006), and a minimal saving in lifetime health-care costs (net saving £236).

Conclusions

There was no evidence that behavioural support for smoking reduction and increased physical activity led to meaningful increases in prolonged abstinence among smokers with no immediate plans to quit smoking. The intervention is not cost-effective.

Limitations

Prolonged abstinence rates were much lower than expected, meaning that the trial was underpowered to provide confidence that the intervention doubled prolonged abstinence.

Future work

Further research should explore the effects of the present intervention to support smokers who want to reduce prior to quitting, and/or extend the support available for prolonged reduction and abstinence.

Trial registration

This trial is registered as ISRCTN47776579.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 4. See the NIHR Journals Library website for further project information.

Smoking Intervention Practices in Texas Healthcare Centers with Sexual and Gender Minority Patients

Objectives

This study evaluated the use of evidence-based practices (EBPs) for smoking cessation in centers providing behavioral healthcare for patient populations that included some proportion of sexual and gender minorities (SGMs).

Methods

Healthcare providers from 75 healthcare centers across Texas serving SGMs with behavioral health needs participated in a survey assessing their center's tobacco control policies and practices.

Results

Nearly half (N = 36) of participating centers had a comprehensive tobacco-free workplace policy, 30.67% employed ≥1 tobacco treatment specialist, 73.91% employed ≥1 prescriber, 80.82% mandated screening for patient tobacco use at intake, and 57.53% provided a template for tobacco use assessments. Overall, 70.67% of providers asked patients about smoking status, 69.33% advised patients to quit, 64.00% assessed patients' interest in quitting, 58.67% assisted patients with quit attempts, and 36.00% arranged follow-up. Providers' ability to tailor interventions for special populations like SGMs ranged from very low/0 to very high/10 (M = 4.63 ± 2.59).

Conclusions

There are opportunities to improve policy implementation, standardization and usage of evidence-based interventions, and intervention tailoring within settings providing care to SGM patients in Texas to better address their tobacco use inequities.

Novel Solvent-Free Extraction Method for Analyzing Tobacco Heating Product Aerosols: An Analytical and In Vitro Toxicological Five-Way Product Comparison

Harmful and potentially harmful constituents (HPHCs) in tobacco smoke are thought to be responsible for the increased health risks. Tobacco heating products (THPs) heat tobacco instead of burning it to achieve significantly fewer toxicants than conventional cigarettes. To assess the toxicity of THP aerosols, it is often desirable to extract the main constituents using a solvent method. In this study, we developed a high-speed centrifugal method for extracting the total particulate matter (TPM) from THPs to quantitatively compare the toxicity of different THPs and conventional cigarettes. Its TPM extraction efficiency exceeded 85%, and the primary aerosol components and typical HPHCs were comparable to those of the solvent method. The TPMs extracted from five THPs were subjected to 14 in vitro toxicology assessments, and the results were compared with those of a 3R4F reference cigarette. Physical separation can improve biases from solvent selectivity and potential interactions between solvent and aerosol constituents. By eliminating solvent influence, the extraction method could achieve high-dose exposures, enabling the toxicity comparison of different THPs. The relative toxicity of the THPs differed under different dosage units, including the TPM concentration, nicotine equivalent, and puff number.

Harm reduction for smokers living with HIV

Tobacco use is now a leading cause of death in people living with HIV in the USA. Increasing cessation rates in this group is a public health priority, yet the results of clinical trials aimed at optimising tobacco treatment strategies have been largely disappointing. Combinations of behavioural and pharmacological cessation therapies in people living with HIV have yielded increases in short-term quit rates, but few have shown long-term efficacy. Even with aggressive therapy combining intensive behavioural treatment with pharmacological agents, most smokers living with HIV continue to smoke. The generalised approach to tobacco treatment that prevails in guidelines and in clinical practices might do a disservice to these individuals, who represent a sizable segment of the population of people living with HIV. Harm reduction is a sensible and needed approach for smokers living with HIV who are unable or unwilling to quit. In this Viewpoint, we take an expansive view of harm reduction to include not only cutting down on cigarette intake for persistent smokers, but also reducing smoking's downstream health effects by increasing lung cancer screening and by controlling concurrent cardiovascular risk factors, especially hypertension and hyperlipidaemia.

Spatial clusters of daily tobacco consumption before and after a smoke-free policy implementation

This study assessed the spatial dependence of daily tobacco consumption and how it is spatially impacted by individual and neighborhood socioeconomic determinants, and tobacco consumption facilities before and after a smoke-free implementation. Individual data was obtained from the Bus Santé, a cross-sectional survey in Geneva. Spatial clusters of high and low tobacco consumption were assessed using Getis-Ord Gi*. Daily tobacco consumption was not randomly clustered in Geneva and may be impacted by tobacco consumption facilities independently of socioeconomic factors and a smoking ban. Spatial analysis should be considered to highlight the impact of smoke-free policies and guide public health interventions.

Comparison between Acupuncture and Nicotine Replacement Therapies for Smoking Cessation Based on Randomized Controlled Trials: A Systematic Review and Bayesian Network Meta-Analysis

Objectives

To evaluate the efficacy and/or safety of acupuncture therapy (AT) in quitting smoking.

Methods

Randomized controlled trials (RCTs) were searched in PubMed, Cochrane Library, Embase, Web of Science, and Chinese Biomedical Database (CBM). We used Cochrane Collaborative Quality Assessment to assess the risk of bias. Bayesian network meta-analysis was utilized to evaluate the efficacy and safety of different interventions. Data analyses were conducted using WinBUGS 1.4.3, Stata 14, and RevMan 5.3.5 software.

Results

A total of 2706 patients from 23 studies were included, involving 6 treatment arms. Network meta-analysis demonstrated that there was no significant difference in short-term abstinence rates or changes in Fagerstrom test for nicotine dependence (FTND) scores and daily smoking among these groups (AT, sham acupuncture therapy (SAT), auricular acupressure (AA), sham auricular acupressure (SAA), acupuncture plus auricular acupressure (APAA), and nicotine replacement therapy (NRT)). However, there was a significant difference between SAA and AA with risk ratio (RR) of 2.49 (95% CI 1.14, 5.97) in long-term abstinence rate. The probabilistic ranking results showed that APAA and AA were superior to other interventions in the comparison of abstinence rates. There was no obvious inconsistency between the direct comparison and indirect comparison, using the consistency test.

Conclusion

AA was superior to SAA in smoke quitting, but there was no difference among other interventions in long-term truncation rates. There was no difference in short-term abstinence rates among these selected groups. We need large sample RCTs to clarify the advantages of interventions such as APAA and AA. In addition, reporting of adverse events that may occur during treatment also should be enhanced to complement evidence-based medicine. The trial is registered with PROSPERO CRD42020164712.

An adapted smoking-cessation intervention for Turkish-speaking migrants in Switzerland: Predictors of smoking outcomes at one-year follow-up

BACKGROUND

Migrant populations usually report higher smoking rates. Among those migrant populations, Turkish- and Kurdish-speaking migrants are often overrepresented. Providing equal access to health services is one of the major challenges of our time. The need for adapted smoking-cessation treatments for Turkish-speaking populations to achieve equity in health led, in 2006, to the development and implementation of the Tiryaki-Kukla smoking-cessation program. The aims of the current study were to evaluate one-year quit rates for smoking-cessation courses held from 2006-2018 and investigate whether certain characteristics predict long-term smoking cessation or reduction.

METHODS

Program evaluation included a pre/post questionnaire (session 1/ 3 months after the quit day) and a follow-up telephone call twelve months after the quit day. To elucidate factors associated with long-term smoking cessation and reduction, Cox regression analysis and Weighted Generalized Equation Models were used.

RESULTS

Of the 478 who participated in smoking-cessation courses, 45.4% declared themselves non-smokers at one-year follow-up. This quit rate is higher than that achieved during the preliminary evaluation of the program involving 61 participants (37.7%). Predictors of long-term smoking cessation were course length (eight vs. six sessions) (95% CI = 1.04-1.36, p = .01), adherence to the course (95% CI = 0.98-0.99, p<0.01), use of pharmacotherapy or nicotine replacement therapy products (95% CI = 0.74-0.98, p = .02), and time passed in the morning until the first cigarette is smoked (95% CI5min = 1.17-1.77, p<0.001; 95% CI30min = 1.09-1.65, p<0.01). Predictors of change in cigarettes smoked per day among smokers were-the time passed until the first cigarette in the morning (5min p < .001; 30min p < .001; 60min p < .01)-, gender (p < .001), and level of motivation to quit at baseline (p = .04).

CONCLUSIONS

Our findings are consistent with existing evidence supporting adapted smoking cessation interventions to reduce health inequity in migrant populations. However, achieving harm reduction in smokers with higher dependence scores remains challenging.

Effect of nicotine exposure on the rate of orthodontic tooth movement: A meta-analysis based on animal studies

Background

Nicotine exposure has been reported to modify bone cell function and the osseous metabolism with potential effects on the rate of orthodontic tooth movement.

Objectives

To systematically investigate and quantitively synthesize the most recent available evidence from animal studies regarding the effect of nicotine exposure on the rate of orthodontic tooth movement.

Search methods

Unrestricted searches in 7 databases and hand searching were performed until July 2020 (PubMed, Central, Cochrane Database of Systematic Reviews, SCOPUS, Web of Science, Arab World Research Source, ProQuest Dissertations and Theses Global).

Selection criteria

We searched for controlled studies on healthy animals investigating the effect of nicotine on the rate of orthodontic tooth movement.

Data collection and analysis

Following study retrieval and selection, relevant data was extracted and the risk of bias was assessed using the SYRCLE’s Risk of Bias Tool. Exploratory synthesis and meta-regression were carried out using the random effects model.

Results

From the initially identified records, 5 articles meeting the inclusion criteria were selected and no specific concerns regarding bias were identified. Quantitative data synthesis showed that the rate of orthodontic tooth movement in the nicotine exposed rats was higher than in the control group animals (2 weeks of force application; 0.317 mm more movement in nicotine exposed rats; 95% Confidence Interval: 0.179–0.454; p = 0.000). No effect of the concentration or the duration force application was demonstrated following exploratory meta-regression.

Conclusion

Rats administered with nicotine showed accelerated rates of orthodontic tooth movement. Although, information from animal studies cannot be fully translated to human clinical scenarios, safe practice would suggest that the orthodontist should be able to identify patients exposed to nicotine and consider the possible implications for everyday clinical practice.

A review of tobacco abuse and its epidemiological consequences

Aim

The economic burden caused by death and disease in the world is credited mainly to tobacco use—currently linked to approximately 8,000,000 deaths per year with approximately 80% of these faralities reported in low and middle income economies. The World Health Organization (WHO) estimates that nearly 7,000,000 deaths are attributed to direct tobacco use, while approximately 1,200,000 non-smokers exposed to second hand cigarette smoke die every year. Accordingly, tobacco use is a major threat to the public health infrastructure; therefore, proper cessation interventions must be put in place to curb tobacco abuse and ease economic and social burdens caused by the tobacco epidemic.

Methods

A systematic review was conducted to investigate how scientific efforts have been advanced towards harm reduction among smokers and non-smokers. Relevant articles published during the period 2010–2020 in PubMed, Crossref, Google scholar, and Web of Science were used in this study. The articles were selected based on health impacts of cigarette smoking, tobacco cessation and emerging diseases, including Covid−19. Various cessation strategies have been identified although their efficiency is yet to match the desired results.

Results

A series of carcinogenic chemicals are generated during cigarette smoking resulting in serious health complications such as cancer and mutagenesis. The precursors for tobacco induced diseases are toxic and carcinogenic chemicals of the nitrosamine type, aldehydes, polonium-210 and benzo[a]pyrene, which bio-accumulate in the body system during cigarette smoking to cause disease. Rehabilitation facilities, use of drugs to diminish the desire to smoke, heavy taxation of tobacco products and warning labels on cigarettes are some of the cessation strategies employed towards curbing tobacco abuse.

Conclusion

The need for further research to develop better methods and research based policies for safe cigarette smoking and workable cessation strategies must be a priority in order to deal with the tobacco epidemic. Campaigns to promote tobacco cessation and abstinence are recommended in this review as a sure measure to mitigate against the deleterious impacts caused by cigarette smoking and tobacco abuse.

Randomised controlled trial of tailored support to increase physical activity and reduce smoking in smokers not immediately ready to quit: protocol for the Trial of physical Activity-assisted Reduction of Smoking (TARS) Study

INTRODUCTION

Smoking reduction can lead to increased success in quitting. This study aims to determine if a client-focused motivational support package for smoking reduction (and quitting) and increasing (or otherwise using) physical activity (PA) can help smokers who do not wish to quit immediately to reduce the amount they smoke, and ultimately quit. This paper reports the study design and methods.

METHODS AND ANALYSIS

A pragmatic, multicentred, parallel, two group, randomised controlled superiority clinical trial, with embedded process evaluation and economics evaluation. Participants who wished to reduce smoking with no immediate plans to quit were randomised 1:1 to receive either (1) tailored individual health trainer face-to-face and/or telephone support to reduce smoking and increase PA as an aid to smoking reduction (intervention) or (2) brief written/electronic advice to reduce or quit smoking (control). Participants in both arms of the trial were also signposted to usual local support for smoking reduction and quitting. The primary outcome measure is 6-month carbon monoxide-confirmed floating prolonged abstinence following participant self-reported quitting on a mailed questionnaire at 3 and 9 months post-baseline. Participants confirmed as abstinent at 9 months will be followed up at 15 months.

ETHICS AND DISSEMINATION

Approved by SW Bristol National Health Service Research Committee (17/SW/0223). Dissemination will include publication of findings for the stated outcomes, parallel process evaluation and economic evaluation in peer-reviewed journals. Results will be disseminated to trial participants and healthcare providers.

TRIAL REGISTRATION NUMBER

ISRCTN47776579; Pre-results.

Role of e-cigarettes and pharmacotherapy during attempts to quit cigarette smoking: The PATH Study 2013-16

BACKGROUND

More smokers report using e-cigarettes to help them quit than FDA-approved pharmacotherapy.

OBJECTIVE

To assess the association of e-cigarettes with future abstinence from cigarette and tobacco use.

DESIGN

Cohort study of US sample, with annual follow-up.

PARTICIPANTS

US adult (ages 18+) daily cigarette smokers identified at Wave 1 (W1; 2013-14) of the PATH Study, who reported a quit attempt before W2 and completed W3 (n = 2443).

EXPOSURES

Use of e-cigarettes, pharmacotherapy (including nicotine replacement therapy), or no product for last quit attempt (LQA), and current daily e-cigarette use at W2.

ANALYSIS

Propensity score matching (PSM) of groups using different methods to quit.

OUTCOME MEASURES

12+ months abstinence at W3 from cigarettes and from all tobacco (including e-cigarettes). 30+ days abstinence at W3 was a secondary outcome.

RESULTS

Among daily smokers with an LQA, 23.5% used e-cigarettes, 19.3% used pharmacotherapy only (including NRT) and 57.2% used no product. Cigarette abstinence for 12+ months at W3 was ~10% in each group. Half of the cigarette abstainers in the e-cigarette group were using e-cigarettes at W3. Different methods to help quitting had statistically comparable 12+ month cigarette abstinence at W3 (e-cigarettes vs no product: Risk Difference (RD) = 0.01, 95% CI: -0.04 to 0.06; e-cigarettes vs pharmacotherapy: RD = 0.02, 95% CI:-0.04 to 0.09). Likewise, daily e-cigarette users at W2 did not show a cessation benefit over comparable no-e-cigarette users and this finding was robust to sensitivity analyses. Abstinence for 30+ days at W3 was also similar across products.

LIMITATIONS

The frequency of e-cigarette use during the LQA was not assessed, nor was it possible to assess continuous abstinence from the LQA.

CONCLUSION

Among US daily smokers who quit cigarettes in 2014-15, use of e-cigarettes in that attempt compared to approved cessation aids or no products showed similar abstinence rates 1-2 years later.

Five-Day Changes in Biomarkers of Exposure Among Adult Smokers After Completely Switching From Combustible Cigarettes to a Nicotine-Salt Pod System

INTRODUCTION

This study examined changes in biomarkers of exposure (BoE) after 5 days of nicotine-salt pod system (NSPS) use, compared with continuation of usual-cigarette smoking and cigarette abstinence, among adult combustible cigarette smokers.

AIMS AND METHODS

A randomized, open-label, parallel-cohort, confinement study of healthy adult smokers, naive to NSPS use, was conducted. Participants (N = 90) were randomized to six cohorts (n = 15 each): exclusive ad libitum use of NSPS (four flavors: Virginia Tobacco, Mint, Mango, Creme), continuation of usual-brand cigarette smoking, or cigarette abstinence. Total nicotine equivalents and BoE (NNN, NNAL, 3-HPMA, MHBMA, S-PMA, HMPMA, CEMA, 1-OHP, and COHb) were measured.

RESULTS

Eight non-nicotine BoEs, measured in urine, were reduced by an aggregate of 85.0% in the pooled NSPS cohort; increased by 14.4% in the cigarette cohort (p < .001 for pooled NSPS vs. cigarette); and reduced by 85.3% in the abstinence cohort (p > .05; 99.6% relative reduction between pooled NSPS vs. abstinence). Similar changes in individual BoEs were also observed (p < .001 for each BoE between pooled NSPS vs. cigarettes; and abstinence vs. pooled NSPS; p > .05 for each BoE between pooled NSPS vs. abstinence). Blood COHb decreased by 71.8% in the pooled NSPS cohort and 69.1% in the abstinence cohort (p > .05) and increased by 13.3% in the cigarette cohort (p < .001). Mean total urine nicotine equivalents increased in the pooled NSPS and cigarette cohorts by 9% and 26%, respectively, and did not significantly differ (p > .05).

CONCLUSION

Complete switching from cigarettes to NSPS produced significant reductions in key non-nicotine BoEs associated with cigarette smoking.

IMPLICATIONS

The results of this study concorded with evidence that complete switching from combustible cigarettes to tobacco and nontobacco-flavored vapor products may reduce exposure to key carcinogens and other toxicants known to be associated with tobacco-related diseases. Future research is needed to assess the long-term health effects of NSPS use. These results should not be interpreted to mean that the use of NSPS is without any risk, particularly for nonusers of tobacco products.

Smokers who have not tried alternative nicotine products: a 2019 survey of adults in Great Britain

Aims

Switching from smoking to using nicotine replacement therapy (NRT), electronic cigarettes (e-cigarettes) or heated tobacco products can reduce tobacco-related health risks. However, not all smokers in Great Britain have tried these products. This study aimed to identify and describe smokers who have never tried alternative nicotine products.

Methods

We analysed cross-sectional survey data of smokers (n = 1777) from a representative adult sample from Great Britain. The online survey was run in March 2019. The proportion of smokers who had never used alternative nicotine products was measured. A multivariate logistic regression assessed the association between never having used alternative nicotine products and sociodemographic and smoking characteristics and motivation to stop smoking.

Results

One in four smokers (27.8%, 95% CI 25.8–29.9%) had never tried NRT, e-cigarettes or heated tobacco products. These smokers were more commonly from Black and Minority than White ethnic groups (AOR = 1.55; 95% CI 1.02–2.31), were more likely to smoke up to 10 versus more cigarettes per day (AOR = 1.52; 95% CI 1.14–2.03) and to report low versus moderate or high motivation to stop smoking (AOR = 1.79; 95% CI 1.20–2.74).

Conclusion

Light smokers, those unmotivated to stop and smokers from Black and Minority ethnic groups are less likely to have ever tried alternative nicotine products. Different approaches are needed to facilitate harm reduction and smoking cessation among these groups of smokers.

'Very brief advice' (VBA) on smoking in family practice: a qualitative evaluation of the tobacco user's perspective

BACKGROUND

Very Brief Advice on smoking (VBA) is an evidence-based intervention designed to increase quit attempts among patients who smoke. VBA has been widely disseminated in general practice settings in the United Kingdom, however its transferability to Southern European settings is not well established. This study sought to document the perspectives of Greek general practice patients in terms of the acceptability and satisfaction with receiving VBA from their general practitioner (GP) and its influence on patients' motivation to make a quit attempt. We also examine patient identified barriers and facilitators to acting on VBA.

METHODS

Semi-structured interviews were conducted with 50 patients who reported current tobacco use recruited from five general practices in Crete, Greece. All patients received VBA from their GP and interviews were conducted immediately after the GP appointment. Thematic analysis was used to analyze data.

RESULTS

The majority of patients were satisfied with the VBA intervention. Approximately one quarter of patients reported they were motivated to make an attempt to quit smoking after receiving VBA from their GP. Patients identified a clear preference for VBA to be delivered in a supportive manner, which communicated genuine concern versus fear-based approaches. Patients with an existing smoking-related illness were more likely to report plans to act on their GP's VBA. Patients not ready to quit smoking indicated they would be likely to seek the support of their GP for future quit attempts as a result of VBA. Many patients reported low self-efficacy with quitting and apprehension about available quit smoking supports.

CONCLUSIONS

VBA was positively received by the majority of smokers interviewed. Participating patients confirmed the motivational role of advice when delivered in a supportive and caring manner. Personal health status, beliefs about quit smoking supports, and low self-efficacy appear to influence patient's motivation to make an aided quit attempt.

Effect of Sodium Bicarbonate Mouth Wash on Salivary pH and Interleukin-1β Levels among Smokers

Objective  Smoking induces changes in salivary pH and inflammatory biomarker levels associated with oral diseases. This study examined the effect of alkaline oral rinse to modify this effect of smoking on salivary study parameters.

Materials and Methods  A double-blind randomized controlled trial (RCT) on systemically healthy smokers was conducted. A total of 78 smokers, aged 18 to 40 years, were enrolled as per exclusion/inclusion criteria. An alkaline mouthwash was provided to the intervention group and a placebo to control group. Salivary pH and inflammatory biomarker interleukin (IL)-1β levels were evaluated at baseline and at follow-up (14 ± 2 days).

Statistical Analysis  Chi-squared test, independaent t -test, and paired t -test were used to observe the changes in parameters among and between groups before and after intervention using SPSS v16 with a significance level of p ≤0.050.

Results  Sixty eight salivary samples were analyzed. All study parameters of the study sample were statistically insignificant between both intervention and control groups at baseline. pH level was 6.56 ± 0.53 at baseline and 6.62 ± 0.45 at follow-up in the intervention group; respective values for control group were 6.70 ± 0.36 and 6.83 ± 0.44 and the changes were not significant ( p ≥0.071). IL-1β level was 9.39 ± 10.23 pg/µL at baseline and 5.40 ± 6.62 pg/µL at a follow-up in the intervention group and the change was significant ( p = 0.001); respective values for the control group were 10.63 ± 11.50, and 9.33 ± 11.73 and the difference was nonsignificant ( p = 0.076).

Conclusion  This randomized trial indicated that sodium bicarbonate mouth rinse is effective in decreasing IL-1β levels and increasing salivary pH favorable for prevention of oral diseases.

Antidepressants for smoking cessation

BACKGROUND

Whilst the pharmacological profiles and mechanisms of antidepressants are varied, there are common reasons why they might help people to stop smoking tobacco. Firstly, nicotine withdrawal may produce depressive symptoms and antidepressants may relieve these. Additionally, some antidepressants may have a specific effect on neural pathways or receptors that underlie nicotine addiction.

OBJECTIVES

To assess the evidence for the efficacy, safety and tolerability of medications with antidepressant properties in assisting long-term tobacco smoking cessation in people who smoke cigarettes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Specialized Register, which includes reports of trials indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO, clinicaltrials.gov, the ICTRP, and other reviews and meeting abstracts, in May 2019.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that recruited smokers, and compared antidepressant medications with placebo or no treatment, an alternative pharmacotherapy, or the same medication used in a different way. We excluded trials with less than six months follow-up from efficacy analyses. We included trials with any follow-up length in safety analyses.

DATA COLLECTION AND ANALYSIS

We extracted data and assessed risk of bias using standard Cochrane methods. We also used GRADE to assess the certainty of the evidence. The primary outcome measure was smoking cessation after at least six months follow-up, expressed as a risk ratio (RR) and 95% confidence intervals (CIs). We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed-effect model. Similarly, we presented incidence of safety and tolerance outcomes, including adverse events (AEs), serious adverse events (SAEs), psychiatric AEs, seizures, overdoses, suicide attempts, death by suicide, all-cause mortality, and trial dropout due to drug, as RRs (95% CIs).

MAIN RESULTS

We included 115 studies (33 new to this update) in this review; most recruited adult participants from the community or from smoking cessation clinics. We judged 28 of the studies to be at high risk of bias; however, restricting analyses only to studies at low or unclear risk did not change clinical interpretation of the results. There was high-certainty evidence that bupropion increased long-term smoking cessation rates (RR 1.64, 95% CI 1.52 to 1.77; I2 = 15%; 45 studies, 17,866 participants). There was insufficient evidence to establish whether participants taking bupropion were more likely to report SAEs compared to those taking placebo. Results were imprecise and CIs encompassed no difference (RR 1.16, 95% CI 0.90 to 1.48; I2 = 0%; 21 studies, 10,625 participants; moderate-certainty evidence, downgraded one level due to imprecision). We found high-certainty evidence that use of bupropion resulted in more trial dropouts due to adverse events of the drug than placebo (RR 1.37, 95% CI 1.21 to 1.56; I2 = 19%; 25 studies, 12,340 participants). Participants randomized to bupropion were also more likely to report psychiatric AEs compared with those randomized to placebo (RR 1.25, 95% CI 1.15 to 1.37; I2 = 15%; 6 studies, 4439 participants). We also looked at the safety and efficacy of bupropion when combined with other non-antidepressant smoking cessation therapies. There was insufficient evidence to establish whether combination bupropion and nicotine replacement therapy (NRT) resulted in superior quit rates to NRT alone (RR 1.19, 95% CI 0.94 to 1.51; I2 = 52%; 12 studies, 3487 participants), or whether combination bupropion and varenicline resulted in superior quit rates to varenicline alone (RR 1.21, 95% CI 0.95 to 1.55; I2 = 15%; 3 studies, 1057 participants). We judged the certainty of evidence to be low and moderate, respectively; in both cases due to imprecision, and also due to inconsistency in the former. Safety data were sparse for these comparisons, making it difficult to draw clear conclusions. A meta-analysis of six studies provided evidence that bupropion resulted in inferior smoking cessation rates to varenicline (RR 0.71, 95% CI 0.64 to 0.79; I2 = 0%; 6 studies, 6286 participants), whilst there was no evidence of a difference in efficacy between bupropion and NRT (RR 0.99, 95% CI 0.91 to 1.09; I2 = 18%; 10 studies, 8230 participants). We also found some evidence that nortriptyline aided smoking cessation when compared with placebo (RR 2.03, 95% CI 1.48 to 2.78; I2 = 16%; 6 studies, 975 participants), whilst there was insufficient evidence to determine whether bupropion or nortriptyline were more effective when compared with one another (RR 1.30 (favouring bupropion), 95% CI 0.93 to 1.82; I2 = 0%; 3 studies, 417 participants). There was no evidence that any of the other antidepressants tested (including St John's Wort, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs)) had a beneficial effect on smoking cessation. Findings were sparse and inconsistent as to whether antidepressants, primarily bupropion and nortriptyline, had a particular benefit for people with current or previous depression.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that bupropion can aid long-term smoking cessation. However, bupropion also increases the number of adverse events, including psychiatric AEs, and there is high-certainty evidence that people taking bupropion are more likely to discontinue treatment compared with placebo. However, there is no clear evidence to suggest whether people taking bupropion experience more or fewer SAEs than those taking placebo (moderate certainty). Nortriptyline also appears to have a beneficial effect on smoking quit rates relative to placebo. Evidence suggests that bupropion may be as successful as NRT and nortriptyline in helping people to quit smoking, but that it is less effective than varenicline. There is insufficient evidence to determine whether the other antidepressants tested, such as SSRIs, aid smoking cessation, and when looking at safety and tolerance outcomes, in most cases, paucity of data made it difficult to draw conclusions. Due to the high-certainty evidence, further studies investigating the efficacy of bupropion versus placebo are unlikely to change our interpretation of the effect, providing no clear justification for pursuing bupropion for smoking cessation over front-line smoking cessation aids already available. However, it is important that where studies of antidepressants for smoking cessation are carried out they measure and report safety and tolerability clearly.

Use of Potentially Reduced Exposure Tobacco Products Among American Indian Smokeless Tobacco Users: Associations With Cessation Behaviors and Cotinine Levels

OBJECTIVES

American Indian/Alaska Native (AI/AN) adults use smokeless tobacco products (eg, chewing and dip tobacco) more often than other racial/ethnic groups do. Although US adults increasingly use potentially reduced exposure tobacco products (PREPs), such as electronic cigarettes and snus, no studies have examined the use of PREPs among AI/AN smokeless tobacco users. We examined associations between current PREPs use and smokeless tobacco-related measures, including cessation attempts and cotinine levels, in a sample of American Indian adults who currently use smokeless tobacco.

METHODS

We collected survey and tobacco biomarker data from 299 adult American Indian smokeless tobacco users at Cherokee Nation health care facilities and events in 2016 and 2017. We used multivariable analyses to determine associations between current PREPs use and smokeless tobacco-related characteristics.

RESULTS

Current PREPs users were younger, less likely to be married or living with a partner, less likely to report a chronic medical condition, and more likely to report other tobacco use than PREPs nonusers. Among participants with annual household incomes ≤$30 000, current PREPs users were less likely than PREPs nonusers to report a definite desire to quit smokeless tobacco (P = .02). PREPs use was not associated with planning to quit smokeless tobacco, past 12-month smokeless tobacco quit attempts, amount of smokeless tobacco used per week, cotinine levels, or scores on the Fagerström Test for Nicotine Dependence-Smokeless Tobacco.

CONCLUSIONS

Our study suggests that American Indian smokeless tobacco users may not be using PREPs as a smokeless tobacco cessation aid. Future studies should take this finding into consideration when evaluating the role of PREPs use in smokeless tobacco cessation and in total tobacco cessation in this population.

Snus: a compelling harm reduction alternative to cigarettes

Snus is an oral smokeless tobacco product which is usually placed behind the upper lip, either in a loose form or in portioned sachets, and is primarily used in Sweden and Norway. The purpose of this review is to examine the reported effects of snus use in relation to specified health effects, namely lung cancer, cardiovascular disease, pancreatic cancer, diabetes, oral cancer and non-neoplastic oral disease. The review also examines the harm reduction potential of snus as an alternative to cigarettes by comparing the prevalence of snus use and cigarette smoking, and the reported incidence of tobacco-related diseases across European Union countries. The scientific literature generally indicates that the use of snus is not a significant risk factor for developing lung cancer, cardiovascular disease, pancreatic cancer or oral cancer. Studies investigating snus use and diabetes have reported that high consumption of snus (estimated as being four or more cans per week) may be associated with a higher risk of developing diabetes or components of metabolic syndrome; however, overall results are not conclusive. Snus use is associated with the presence of non-neoplastic oral mucosal lesions which are reported to heal rapidly once use has stopped. The most recent Eurobarometer data from 2017 reported that Sweden had the lowest prevalence of daily cigarette use in the European Union at 5% whilst daily "oral tobacco" use was reported to be 20%. European data published by the World Health Organisation in 2018 indicated that Sweden had the lowest rate of tobacco-related mortality and the lowest incidence of male lung cancer. Overall, prevalence statistics and epidemiological data indicate that the use of snus confers a significant harm reduction benefit which is reflected in the comparatively low levels of tobacco-related disease in Sweden when compared with the rest of Europe. The available scientific data, including long-term population studies conducted by independent bodies, demonstrates that the health risks associated with snus are considerably lower than those associated with cigarette smoking.

Patterns of tobacco use among smokers prior to hospitalization for an acute cardiac event: Use of combusted and non-combusted products

Use of tobacco products before or after a cardiac event increases risk of morbidity and mortality. Unlike cigarette smoking, which is generally screened in the healthcare system, identifying the use of other tobacco products remains virtually unexplored. This study aimed at characterizing the use of other non-combusted tobacco products in addition to combusted products among cardiac patients and identifying a profile of patients who are more likely to use non-combusted products. Patients (N = 168) hospitalized for a coronary event who reported being current cigarette smokers completed a survey querying sociodemographics, cardiac diagnoses, use of other tobacco products, and perceptions towards these products. Classification and regression tree (CART) analysis was used to identify which interrelationships of participants characteristics led to profiles of smoking cardiac patients more likely to also be using non-combusted tobacco products. Results showed that non-combusted tobacco product use ranged from 0% to 47% depending on patient characteristic combinations. Younger age and lower perception that cigarette smoking is responsible for their cardiac condition were the strongest predictive factors for use of non-combusted products. Tobacco product use among cardiac patients extends beyond combusted products (13.7% non-combusted product use), and consequently, screening in health care settings should be expanded to encompass other tobacco product use. This study also characterizes patients likely to be using non-combusted products in addition to combusted, a group at high-risk due to their multiple product use, but also a group that may be amenable to harm reduction approaches and evidence-based tobacco treatment strategies.

Multimodal Smoking Cessation in a Real-Life Setting: Combining Motivational Interviewing With Official Therapy and Reduced Risk Products

BACKGROUND

Tobacco use is a global pandemic, affecting an estimated 1.2 billion people and resulting in substantial health burdens and associated costs.

OBJECTIVES

The aim of this study was to estimate the efficacy of several treatments for smoking cessation in a real-life setting and to evaluate predictors of smoking abstinence.

METHODS

This research was designed with a sample of 593 cases recorded over the period between 2015 and 2016. Six treatment groups were included: (1) bupropion and motivational interviewing (MI); (2) bupropion, nicotine replacement therapy (NRT), and MI; (3) NRT and MI; (4) varenicline and MI; (5) personal vaporizer electronic cigarette and MI; and (6) electronic cigarette, cigarette like "cigalike," and MI.

RESULTS

Results support the efficacy of all treatment groups when used in a real-life setting. The predictors of smoking abstinence were sex, partner smoking status, previous quit attempts, daily consumption, self-efficacy, and level of nicotine dependence.

CONCLUSIONS

The use of different therapeutic strategies in clinical practice, including pharmacotherapy and nonstandard electronic nicotine delivery systems, such as an electronic cigarette, ensures a greater chance of cessation success and the possibility of tailoring interventions according to patients' resources.

Smoking reduction interventions for smoking cessation

BACKGROUND

The standard way most people are advised to stop smoking is by quitting abruptly on a designated quit day. However, many people who smoke have tried to quit many times and may like to try an alternative method. Reducing smoking behaviour before quitting could be an alternative approach to cessation. However, before this method can be recommended it is important to ensure that abrupt quitting is not more effective than reducing to quit, and to determine whether there are ways to optimise reduction methods to increase the chances of cessation.

OBJECTIVES

To assess the effect of reduction-to-quit interventions on long-term smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, Embase and PsycINFO for studies, using the terms: cold turkey, schedul*, cut* down, cut-down, gradual*, abrupt*, fading, reduc*, taper*, controlled smoking and smoking reduction. We also searched trial registries to identify unpublished studies. Date of the most recent search: 29 October 2018.

SELECTION CRITERIA

Randomised controlled trials in which people who smoked were advised to reduce their smoking consumption before quitting smoking altogether in at least one trial arm. This advice could be delivered using self-help materials or behavioural support, and provided alongside smoking cessation pharmacotherapies or not. We excluded trials that did not assess cessation as an outcome, with follow-up of less than six months, where participants spontaneously reduced without being advised to do so, where the goal of reduction was not to quit altogether, or where participants were advised to switch to cigarettes with lower nicotine levels without reducing the amount of cigarettes smoked or the length of time spent smoking. We also excluded trials carried out in pregnant women.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison (no smoking cessation treatment, abrupt quitting interventions, and other reduction-to-quit interventions) and carried out meta-analyses where appropriate, using a Mantel-Haenszel random-effects model. We also extracted data on quit attempts, pre-quit smoking reduction, adverse events (AEs), serious adverse events (SAEs) and nicotine withdrawal symptoms, and meta-analysed these where sufficient data were available.

MAIN RESULTS

We identified 51 trials with 22,509 participants. Most recruited adults from the community using media or local advertising. People enrolled in the studies typically smoked an average of 23 cigarettes a day. We judged 18 of the studies to be at high risk of bias, but restricting the analysis only to the five studies at low or to the 28 studies at unclear risk of bias did not significantly alter results.We identified very low-certainty evidence, limited by risk of bias, inconsistency and imprecision, comparing the effect of reduction-to-quit interventions with no treatment on cessation rates (RR 1.74, 95% CI 0.90 to 3.38; I2 = 45%; 6 studies, 1599 participants). However, when comparing reduction-to-quit interventions with abrupt quitting (standard care) we found evidence that neither approach resulted in superior quit rates (RR 1. 01, 95% CI 0.87 to 1.17; I2 = 29%; 22 studies, 9219 participants). We judged this estimate to be of moderate certainty, due to imprecision. Subgroup analysis provided some evidence (P = 0.01, I2 = 77%) that reduction-to-quit interventions may result in more favourable quit rates than abrupt quitting if varenicline is used as a reduction aid. Our analysis comparing reduction using pharmacotherapy with reduction alone found low-certainty evidence, limited by inconsistency and imprecision, that reduction aided by pharmacotherapy resulted in higher quit rates (RR 1. 68, 95% CI 1.09 to 2.58; I2 = 78%; 11 studies, 8636 participants). However, a significant subgroup analysis (P < 0.001, I2 = 80% for subgroup differences) suggests that this may only be true when fast-acting NRT or varenicline are used (both moderate-certainty evidence) and not when nicotine patch, combination NRT or bupropion are used as an aid (all low- or very low-quality evidence). More evidence is likely to change the interpretation of the latter effects.Although there was some evidence from within-study comparisons that behavioural support for reduction to quit resulted in higher quit rates than self-help resources alone, the relative efficacy of various other characteristics of reduction-to-quit interventions investigated through within- and between-study comparisons did not provide any evidence that they enhanced the success of reduction-to-quit interventions. Pre-quit AEs, SAEs and nicotine withdrawal symptoms were measured variably and infrequently across studies. There was some evidence that AEs occurred more frequently in studies that compared reduction using pharmacotherapy versus no pharmacotherapy; however, the AEs reported were mild and usual symptoms associated with NRT use. There was no clear evidence that the number of people reporting SAEs, or changes in withdrawal symptoms, differed between trial arms.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that neither reduction-to-quit nor abrupt quitting interventions result in superior long-term quit rates when compared with one another. Evidence comparing the efficacy of reduction-to-quit interventions with no treatment was inconclusive and of low certainty. There is also low-certainty evidence to suggest that reduction-to-quit interventions may be more effective when pharmacotherapy is used as an aid, particularly fast-acting NRT or varenicline (moderate-certainty evidence). Evidence for any adverse effects of reduction-to-quit interventions was sparse, but available data suggested no excess of pre-quit SAEs or withdrawal symptoms. We downgraded the evidence across comparisons due to risk of bias, inconsistency and imprecision. Future research should aim to match any additional components of multicomponent reduction-to-quit interventions across study arms, so that the effect of reduction can be isolated. In particular, well-conducted, adequately-powered studies should focus on investigating the most effective features of reduction-to-quit interventions to maximise cessation rates.

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

OBJECTIVE

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

SETTING

Single centre, open RCT, general population based.

PARTICIPANTS

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

INTERVENTION

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

ISRCTN12951013. Recruitment July 2015-February 2016.

Self-initiated gradual smoking reduction among community correction smokers

INTRODUCTION

Smoking remains the leading cause of preventable death in the United States. Many smoking cessation guidelines advise smokers to quit precipitately; however, most quit attempts involve a more gradual cessation. Characteristics of individuals who tend to reduce prior to quitting and the effectiveness of pre-quit reduction are not well understood. This study examined individual differences and smoking cessation outcomes between individuals who self-initiated gradual reduction in cigarettes per day (CPD) and those who did not reduce prior to quit date.

METHODS

This study is a secondary analysis from a randomized clinical trial of smoking cessation with pharmacotherapy among individuals under community corrections supervision. We compared participants who self-initiated smoking reduction by at least 25% between baseline and the first treatment session (n = 128) to participants who either increased or did not reduce smoking between baseline and the first treatment session (n = 354).

RESULTS

African American race, no previous cigar smoking, no previous use of pharmacotherapy for smoking cessation, less withdrawal symptoms at baseline, and older age at first smoking were associated with being a self-initiated gradual reduction in univariate analyses. Individuals who self-initiated gradual reduction also had a had a greater likelihood of achieving at least one quit during the one-year study period as compared to those who did not reduce prior to the intervention.

CONCLUSIONS

Individuals who self-initiate gradual reduction differ from those who increase or do not change their smoking prior to a quit date. Gradual reduction also increased success in quitting.

Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation

BACKGROUND

Nicotine replacement therapy (NRT) aims to replace nicotine from cigarettes to ease the transition from cigarette smoking to abstinence. It works by reducing the intensity of craving and withdrawal symptoms. Although there is clear evidence that NRT used after smoking cessation is effective, it is unclear whether higher doses, longer durations of treatment, or using NRT before cessation add to its effectiveness.

OBJECTIVES

To determine the effectiveness and safety of different forms, deliveries, doses, durations and schedules of NRT, for achieving long-term smoking cessation, compared to one another.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register, and trial registries for papers mentioning NRT in the title, abstract or keywords. Date of most recent search: April 2018.

SELECTION CRITERIA

Randomized trials in people motivated to quit, comparing one type of NRT use with another. We excluded trials that did not assess cessation as an outcome, with follow-up less than six months, and with additional intervention components not matched between arms. Trials comparing NRT to control, and trials comparing NRT to other pharmacotherapies, are covered elsewhere.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking abstinence was measured after at least six months, using the most rigorous definition available. We extracted data on cardiac adverse events (AEs), serious adverse events (SAEs), and study withdrawals due to treatment. We calculated the risk ratio (RR) and the 95% confidence interval (CI) for each outcome for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate, using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 63 trials with 41,509 participants. Most recruited adults either from the community or from healthcare clinics. People enrolled in the studies typically smoked at least 15 cigarettes a day. We judged 24 of the 63 studies to be at high risk of bias, but restricting the analysis only to those studies at low or unclear risk of bias did not significantly alter results, apart from in the case of the preloading comparison. There is high-certainty evidence that combination NRT (fast-acting form + patch) results in higher long-term quit rates than single form (RR 1.25, 95% CI 1.15 to 1.36, 14 studies, 11,356 participants; I² = 4%). Moderate-certainty evidence, limited by imprecision, indicates that 42/44 mg are as effective as 21/22 mg (24-hour) patches (RR 1.09, 95% CI 0.93 to 1.29, 5 studies, 1655 participants; I² = 38%), and that 21 mg are more effective than 14 mg (24-hour) patches (RR 1.48, 95% CI 1.06 to 2.08, 1 study, 537 participants). Moderate-certainty evidence (again limited by imprecision) also suggests a benefit of 25 mg over 15 mg (16-hour) patches, but the lower limit of the CI encompassed no difference (RR 1.19, 95% CI 1.00 to 1.41, 3 studies, 3446 participants; I² = 0%). Five studies comparing 4 mg gum to 2 mg gum found a benefit of the higher dose (RR 1.43, 95% CI 1.12 to 1.83, 5 studies, 856 participants; I² = 63%); however, results of a subgroup analysis suggest that only smokers who are highly dependent may benefit. Nine studies tested the effect of using NRT prior to quit day (preloading) in comparison to using it from quit day onward; there was moderate-certainty evidence, limited by risk of bias, of a favourable effect of preloading on abstinence (RR 1.25, 95% CI 1.08 to 1.44, 9 studies, 4395 participants; I² = 0%). High-certainty evidence from eight studies suggests that using either a form of fast-acting NRT or a nicotine patch results in similar long-term quit rates (RR 0.90, 95% CI 0.77 to 1.05, 8 studies, 3319 participants; I² = 0%). We found no evidence of an effect of duration of nicotine patch use (low-certainty evidence); 16-hour versus 24-hour daily patch use; duration of combination NRT use (low- and very low-certainty evidence); tapering of patch dose versus abrupt patch cessation; fast-acting NRT type (very low-certainty evidence); duration of nicotine gum use; ad lib versus fixed dosing of fast-acting NRT; free versus purchased NRT; length of provision of free NRT; ceasing versus continuing patch use on lapse; and participant- versus clinician-selected NRT. However, in most cases these findings are based on very low- or low-certainty evidence, and are the findings from single studies.AEs, SAEs and withdrawals due to treatment were all measured variably and infrequently across studies, resulting in low- or very low-certainty evidence for all comparisons. Most comparisons found no evidence of an effect on cardiac AEs, SAEs or withdrawals. Rates of these were low overall. Significantly more withdrawals due to treatment were reported in participants using nasal spray in comparison to patch in one trial (RR 3.47, 95% CI 1.15 to 10.46, 922 participants; very low certainty) and in participants using 42/44 mg patches in comparison to 21/22 mg patches across two trials (RR 4.99, 95% CI 1.60 to 15.50, 2 studies, 544 participants; I² = 0%; low certainty).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that using combination NRT versus single-form NRT, and 4 mg versus 2 mg nicotine gum, can increase the chances of successfully stopping smoking. For patch dose comparisons, evidence was of moderate certainty, due to imprecision. Twenty-one mg patches resulted in higher quit rates than 14 mg (24-hour) patches, and using 25 mg patches resulted in higher quit rates than using 15 mg (16-hour) patches, although in the latter case the CI included one. There was no clear evidence of superiority for 42/44 mg over 21/22 mg (24-hour) patches. Using a fast-acting form of NRT, such as gum or lozenge, resulted in similar quit rates to nicotine patches. There is moderate-certainty evidence that using NRT prior to quitting may improve quit rates versus using it from quit date only; however, further research is needed to ensure the robustness of this finding. Evidence for the comparative safety and tolerability of different types of NRT use is of low and very low certainty. New studies should ensure that AEs, SAEs and withdrawals due to treatment are both measured and reported.

A 'Cut-Down-To-Stop' intervention for smokers who find it hard to quit: a qualitative evaluation

Background

English Stop Smoking Services primarily deliver behavioural interventions to support abrupt quit attempts. Recent evidence suggests an alternative approach could be offered to clients involving a more gradual reduction of cigarettes smoked leading to complete abstinence, known as ‘Cut Down To Stop’ (CDTS). The purpose of this study was to explore the experiences of stop smoking practitioners and service users who participated in a pilot study of a CDTS service.

Methods

The CDTS intervention was pilot tested in a Stop Smoking Service in London, England. As part of the CDTS intervention clients who were still smoking 2 weeks after their quit date were offered tailored advice, medication and support to reduce their current smoking by half, with the aim to stop smoking altogether within a six-month period. A qualitative evaluation was conducted involving a focus group discussion with nine practitioners involved in the delivery of the CDTS intervention and telephone interviews with 18 CDTS service users. Thematic analysis was performed.

Results

Service users and practitioners were very positive about their experience with the CDTS intervention. The intervention was found to be an effective way of keeping clients engaged with the service and was felt to increase the likelihood they might quit and/or re-engage in service for future quit attempts. Elements that contributed to the attractiveness of the CDTS intervention included: 1) the trust and empathetic relationship developed between service users, practitioners and their referring primary care provider; 2) time and flexibility for service users to engage in the quitting process at their own pace; 3) setting progressive goals and building service user confidence; 4) the opportunity to experiment with quit smoking medications; and, 5) the on-going contact with the practitioner/service.

Conclusions

Service users who are not successful with quitting abruptly may benefit from a CDTS intervention. This study highlights the important role of ‘relationships’, time and ‘flexible’ service delivery models in engaging service users who are not initially successful with quitting. The findings of this study have the potential to inform decision-making regarding the value of the CDTS approach for the English Stop Smoking Service and cessation services worldwide.

Mental Illness, Not Obesity Status, is Associated with Food Insecurity Among the Elderly in the Health and Retirement Study

OBJECTIVES

Food insecurity, limited or uncertain access to adequate nutrition, is an increasingly recognized determinant of health outcomes and is often associated with having obesity. It is unclear, however, if this association persists in elderly populations.

METHODS

We conducted a cross-sectional study of 2868 participants' aged 65+ years from the Health and Retirement Study. Multivariate logistic regression was used to assess associations between food insecurity and body mass index, demographic characteristics, psychiatric history, and medical history.

RESULTS

Participants with overweight/obesity had a higher prevalence of food insecurity than leaner counterparts, however, weight status was not a significant predictor of food insecurity after multivariate adjustment. Instead, mental illness, current smoking status, and non-White race were all independently associated with food insecurity.

DISCUSSION

Beyond financial status, health care providers are encouraged to use these characteristics to identify elderly patients that may be at risk of food insecurity.

[Systematic analysis of the scientific literature on heated tobacco]

INTRODUCTION

The tobacco industry (TI) reports that heated tobacco reduces risk of tobacco use and will replace cigarettes. An analysis of the scientific literature was conducted in order to enlighten professionals and decision-makers.

METHOD

After a Medline query in February 2018, a systematic analysis was conducted.

RESULTS

Of the 100 papers published in 2008-2018, 75 have authors affiliated or linked to TI. Emissions contain gases, droplets and solid particles, so are smokes. The main products are: THS2.2 (Iqos®) which heats mini-cigarettes at 340°C, the THP1.0 (Glo®) which heats at 240°C sticks delivering about half as much nicotine, Ploom® which uses reconstituted tobacco microcapsules heated at 180°C. Under the experimental conditions, there is a reduction of toxic emissions and biological effects, but the expected risk reduction is not demonstrated. Symptoms related to passive smoking are described. The 4 epidemiological articles report that heated tobacco is used in 10 to 45% of cases by non-smokers and demonstrate the effectiveness of TI promotion campaigns. Thus, the THS2.2 is more a gateway to smoking (20%) than an exit door (11%); moreover, it is not expected risk reduction among the 69% who are mixed users.

CONCLUSIONS

While reducing emissions is documented, reducing the risk to the smoker who switches to heated-tobacco remains to be demonstrated. On the other hand, the worsening of the global tobacco risk related to the promotion of the products by the TI is anticipated, justifying that the authorities take the appropriate measures to control the promotion of heated tobacco.

Smoking and HIV: what are the risks and what harm reduction strategies do we have at our disposal?

The World Health Organization estimates that smoking poses one of the greatest global health risks in the general population. Rates of current smoking among people living with HIV (PLHIV) are 2–3 times that of the general population, which contributes to the higher incidence of non-AIDS-related morbidity and mortality in PLHIV. Given the benefit of smoking cessation, strategies to assist individuals who smoke to quit should be a primary focus in modern HIV care. Tobacco harm reduction focuses on reducing health risk without necessarily requiring abstinence. However, there remains uncertainty about the safety, policy and familiarity of specific approaches, particularly the use of vaporised nicotine products. Evidence suggests that vaporised nicotine products may help smokers stop smoking and are not associated with any serious side-effects. However, there is the need for further safety and efficacy data surrounding interventions to assist quitting in the general population, as well as in PLHIV specifically. In addition, official support for vaping as a harm reduction strategy varies by jurisdiction and this determines whether medical practitioners can prescribe vaporised products and whether patients can access vaporised nicotine products. When caring for PLHIV who smoke, healthcare workers should follow general guidelines to assist with smoking cessation. These include: asking the patient about their smoking status; assessing the patient’s readiness to quit and their nicotine dependence; advising the patient to stop smoking; assisting the patient in their attempt to stop smoking through referral, counselling, pharmacotherapy, self-help resources and/or health education; and arranging follow-up with the patient to evaluate their progress.

Using the Social-Local-Mobile App for Smoking Cessation in the SmokeFreeBrain Project: Protocol for a Randomized Controlled Trial

Background

Smoking is considered the main cause of preventable illness and early deaths worldwide. The treatment usually prescribed to people who wish to quit smoking is a multidisciplinary intervention, combining both psychological advice and pharmacological therapy, since the application of both strategies significantly increases the chance of success in a quit attempt.

Objective

We present a study protocol of a 12-month randomized open-label parallel-group trial whose primary objective is to analyze the efficacy and efficiency of usual psychopharmacological therapy plus the Social-Local-Mobile app (intervention group) applied to the smoking cessation process compared with usual psychopharmacological therapy alone (control group).

Methods

The target population consists of adult smokers (both male and female) attending the Smoking Cessation Unit at Virgen del Rocío University Hospital, Seville, Spain. Social-Local-Mobile is an innovative intervention based on mobile technologies and their capacity to trigger behavioral changes. The app is a complement to pharmacological therapies to quit smoking by providing personalized motivational messages, physical activity monitoring, lifestyle advice, and distractions (minigames) to help overcome cravings. Usual pharmacological therapy consists of bupropion (Zyntabac 150 mg) or varenicline (Champix 0.5 mg or 1 mg). The main outcomes will be (1) the smoking abstinence rate at 1 year measured by means of exhaled carbon monoxide and urinary cotinine tests, and (2) the result of the cost-effectiveness analysis, which will be expressed in terms of an incremental cost-effectiveness ratio. Secondary outcome measures will be (1) analysis of the safety of pharmacological therapy, (2) analysis of the health-related quality of life of patients, and (3) monitoring of healthy lifestyle and physical exercise habits.

Results

Of 548 patients identified using the hospital’s electronic records system, we excluded 308 patients: 188 declined to participate and 120 did not meet the inclusion criteria. A total of 240 patients were enrolled: the control group (n=120) will receive usual psychopharmacological therapy, while the intervention group (n=120) will receive usual psychopharmacological therapy plus the So-Lo-Mo app. The project was approved for funding in June 2015. Enrollment started in October 2016 and was completed in October 2017. Data gathering was completed in November 2018, and data analysis is under way. The first results are expected to be submitted for publication in early 2019.

Conclusions

Social networks and mobile technologies influence our daily lives and, therefore, may influence our smoking habits as well. As part of the SmokeFreeBrain H2020 European Commission project, this study aims at elucidating the potential role of these technologies when used as an extra aid to quit smoking.

Trial Registration

ClinicalTrials.gov NCT03553173; https://clinicaltrials.gov/ct2/show/record/NCT03553173 (Archived by WebCite at http://www.webcitation.org/74DuHypOW).

International Registered Report Identifier (IRRID)

PRR1-10.2196/12464

Recommendations for the Appropriate Structure, Communication, and Investigation of Tobacco Harm Reduction Claims. An Official American Thoracic Society Policy Statement

RATIONALE

The tobacco harm reduction literature is replete with vague language, far-reaching claims, and unwarranted certainty. The American Thoracic Society has increasingly recognized the need for a framework for reliably making such claims. Evidence-based standards improving the scientific value and transparency of harm reduction claims are expected to improve their trustworthiness, clarity, and consistency.

METHODS

Experts from relevant American Thoracic Society committees identified key topic areas for discussion. Literature search strategy included English language articles across Medline, Google Scholar, and the Cochrane Collaborative databases, with expanded search terms including tobacco, addiction, smoking, cigarettes, nicotine, and harm reduction. Workgroup members synthesized their evidentiary summaries into a list of candidate topics suitable for inclusion in the final report. Breakout groups developed detailed content maps of each topic area, including points to be considered for suggested recommendations. Successive draft recommendations were modified using an iterative consensus process until unanimous approval was achieved. Patient representatives ensured the document's relevance to the lay public.

RESULTS

Fifteen recommendations were identified, organized into four framework elements dealing with: estimating harm reduction among individuals, making claims on the basis of population impact, appropriately careful use of language, and ethical considerations in harm reduction.

DISCUSSION

This statement clarifies important principles guiding valid direct and inferential harm reduction claims. Ideals for effective communication with the lay public and attention to unique ethical concerns are also delineated. The authors call for formal systems of grading harm reduction evidence and regulatory assurances of longitudinal surveillance systems to document the impact of harm reduction policies.

Understanding the implications of the biobehavioral basis of nicotine addiction and its impact on the efficacy of treatment

INTRODUCTION

Tobacco use remains the leading cause of preventable death in the United States. There are efficacious behavioral and pharmacological options for smoking cessation including three FDA approved therapies - nicotine replacement therapy, varenicline and bupropion. Nevertheless, uptake of smoking cessation treatments continues to be poor and there is a need for novel smoking cessation treatments. Areas covered: This article reviews the biobehavioral basis of nicotine addiction, its implications for smoking cessation treatments, the various neurotransmitter systems involved in nicotine addictive effects, and their potential therapeutic value. Included are discussions around the role of genetic factors in predicting response to pharmacotherapy and what we know about appropriate application of pharmacotherapy and behavioral interventions for tobacco use disorder. The evidence for harm reduction measures in individuals who are not willing or able to quit smoking is also reviewed. Expert commentary: Many neurotransmitter system targets have been investigated as a result of our understanding of the underlying neurobiology of tobacco use disorder, and there remain important targets that have yet to be fully explored. rTMS or combination therapies are proposed as possible novel strategies to improve smoking cessation.

Treating Tobacco Use in Patients with Incurable Malignancies: Should We Even Start the Conversation?

BACKGROUND

Clinical practice guidelines recommend that all medical providers address tobacco use with patients, as the long-term health benefits of becoming tobacco free are well documented. What happens, though, when a patient has an incurable malignancy and, therefore, will not reap the long-term benefits? Clinical Consideration: Our case study encourages providers to consider the relevance of tobacco use treatment for those with incurable diseases.

DISCUSSION

Although long-term benefits will not provide realistic motivation, other equally important rewards (e.g., decreased shortness of breath), a sense of accomplishment shared by patients and family, and the ability to exert control over a behavior can be equally motivating for some patients.

Nicotine replacement therapy versus control for smoking cessation

BACKGROUND

Nicotine replacement therapy (NRT) aims to temporarily replace much of the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms, thus easing the transition from cigarette smoking to complete abstinence.

OBJECTIVES

To determine the effectiveness and safety of nicotine replacement therapy (NRT), including gum, transdermal patch, intranasal spray and inhaled and oral preparations, for achieving long-term smoking cessation, compared to placebo or 'no NRT' interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning 'NRT' or any type of nicotine replacement therapy in the title, abstract or keywords. Date of most recent search is July 2017.

SELECTION CRITERIA

Randomized trials in people motivated to quit which compared NRT to placebo or to no treatment. We excluded trials that did not report cessation rates, and those with follow-up of less than six months, except for those in pregnancy (where less than six months, these were excluded from the main analysis). We recorded adverse events from included and excluded studies that compared NRT with placebo. Studies comparing different types, durations, and doses of NRT, and studies comparing NRT to other pharmacotherapies, are covered in separate reviews.

DATA COLLECTION AND ANALYSIS

Screening, data extraction and 'Risk of bias' assessment followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We identified 136 studies; 133 with 64,640 participants contributed to the primary comparison between any type of NRT and a placebo or non-NRT control group. The majority of studies were conducted in adults and had similar numbers of men and women. People enrolled in the studies typically smoked at least 15 cigarettes a day at the start of the studies. We judged the evidence to be of high quality; we judged most studies to be at high or unclear risk of bias but restricting the analysis to only those studies at low risk of bias did not significantly alter the result. The RR of abstinence for any form of NRT relative to control was 1.55 (95% confidence interval (CI) 1.49 to 1.61). The pooled RRs for each type were 1.49 (95% CI 1.40 to 1.60, 56 trials, 22,581 participants) for nicotine gum; 1.64 (95% CI 1.53 to 1.75, 51 trials, 25,754 participants) for nicotine patch; 1.52 (95% CI 1.32 to 1.74, 8 trials, 4439 participants) for oral tablets/lozenges; 1.90 (95% CI 1.36 to 2.67, 4 trials, 976 participants) for nicotine inhalator; and 2.02 (95% CI 1.49 to 2.73, 4 trials, 887 participants) for nicotine nasal spray. The effects were largely independent of the definition of abstinence, the intensity of additional support provided or the setting in which the NRT was offered. A subset of six trials conducted in pregnant women found a statistically significant benefit of NRT on abstinence close to the time of delivery (RR 1.32, 95% CI 1.04 to 1.69; 2129 participants); in the four trials that followed up participants post-partum the result was no longer statistically significant (RR 1.29, 95% CI 0.90 to 1.86; 1675 participants). Adverse events from using NRT were related to the type of product, and include skin irritation from patches and irritation to the inside of the mouth from gum and tablets. Attempts to quantitatively synthesize the incidence of various adverse effects were hindered by extensive variation in reporting the nature, timing and duration of symptoms. The odds ratio (OR) of chest pains or palpitations for any form of NRT relative to control was 1.88 (95% CI 1.37 to 2.57, 15 included and excluded trials, 11,074 participants). However, chest pains and palpitations were rare in both groups and serious adverse events were extremely rare.

AUTHORS' CONCLUSIONS

There is high-quality evidence that all of the licensed forms of NRT (gum, transdermal patch, nasal spray, inhalator and sublingual tablets/lozenges) can help people who make a quit attempt to increase their chances of successfully stopping smoking. NRTs increase the rate of quitting by 50% to 60%, regardless of setting, and further research is very unlikely to change our confidence in the estimate of the effect. The relative effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the individual. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. NRT often causes minor irritation of the site through which it is administered, and in rare cases can cause non-ischaemic chest pain and palpitations.

Evaluation of the cognitive behavioral smoking reduction program "Smoke_less": a randomized controlled trial

The vast majority of smokers are unable or unwilling to quit, but many are open to reducing smoking. No treatment options exist for these smokers besides medication-based therapies. Thus, this study investigated the efficacy of a cognitive behavioral therapy (CBT) smoking reduction program, Smoke_less. A sample of 155 outpatient smokers aged 18-70 years was recruited at the Tobacco Dependence Outpatient Clinic of the Medical Center of the University of Munich, Germany, and randomly assigned to the experimental group (Smoke_less: four weekly CBT group sessions and two telephone calls over 5 weeks, n = 51), active comparator group (one 15-minute counseling session, n = 49), or waiting control group (no intervention during the study, n = 55). The primary endpoint was a ≥50% smoking reduction in the intention-to-treat group 1 week and 6 months after the intervention. We evaluated also abstinence rates at follow-up. Significantly more participants in the Smoke_less group had reduced smoking ≥50% compared to the waiting group at 1 week [OR 7.59 (2.59-22.19)] and 6 months [OR 5.00 (1.68-14.84)] and compared to the active comparison group at 1 week [OR 8.58 (2.67-27.31)] but not at 6 months [OR 1.73 (0.71-4.20)]. We found no significant effects on abstinence rates. The CBT smoking reduction program Smoke_less is effective for smoking reduction but is superior to brief counseling only in the short term. Further research is required to improve its efficacy in long-term smoking reduction to provide a valid, non-medication-based alternative to smokers unable or unwilling to quit.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02337400.

Effects of a Nurse-Led, Stage-Matched, Tailored Program for Smoking Cessation in Health Education Centers: A Prospective, Randomized, Controlled Trial

The purpose of this study was to examine the effectiveness of a stage-matched intervention performed at outpatient clinics. Participants were randomly assigned to an intervention group (IG) or usual care group (UCG). The trial was targeted on smoking patients with coronary heart disease or diabetes. After completing the 3-month intervention, both groups received a telephone follow-up at 6 months. This analysis showed that the outcomes of the IG for the 7-day point prevalence (PP) of abstinence (odds ratio [OR] = 2.00; p = .001) and 30-day PP (OR = 2.27; p = .004) at 6 months were significantly better than the UCG. Stage of change (OR = 4.06; p < .001) and decreased daily cigarette consumption by 50% at 6 months (OR = 2.26; p = .019) outcomes also improved significantly. The preliminary results showed that a nurse-led cessation intervention in clinics may be an effective approach to help outpatients quit smoking.