Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation

Integrated Nicotine Replacement and Behavioral Support to Reduce Smoking in Opioid Agonist Therapy: A Randomized Clinical Trial

Importance

Approximately 85% of individuals receiving opioid agonist therapy for opioid dependence smoke tobacco. Despite the significant health risks associated with smoking-related diseases, there has been limited evaluation of smoking interventions tailored to this population.

Objective

To determine the effectiveness of an intervention combining nicotine replacement with brief behavioral support in reducing cigarette use.

Design, Setting, and Participants

This multicenter randomized clinical trial was conducted from April 2022 to October 2023 in 7 specialized opioid agonist therapy clinics in Bergen and Stavanger, Norway. The analyst was blinded to patient groupings. Assessors (study nurses) were not fully blinded to participant allocation. Individuals diagnosed with opioid dependency receiving opioid agonist therapy at participating clinics and smoking at least 1 cigarette per day were eligible for participation. Data analysis was performed from December 2023 through October 2024.

Intervention

In addition to standard opioid agonist therapy, participants in the intervention group received a 16-week integrated treatment combining nicotine replacement with brief behavioral support. Participants in the control group received only standard opioid agonist therapy.

Main Outcomes and Measures

The primary outcome was at least a 50% reduction in the number of cigarettes smoked, self-reported as cigarette use in the past 7 days at week 16. The analysis followed intention-to-treat principles. Cigarette use was self-reported as per the timeline-follow-back method.

Results

Among the 259 participants (mean [SD] age, 48.5 [10.4] years; 80 [30.9%] female), 135 were allocated to the intervention group and 124 to the control group. The odds ratio of at least halving the number of cigarettes smoked was 2.07 (95% CI, 1.14-3.75) in the intervention group compared with the control group.

Conclusions and Relevance

Providing integrated nicotine replacement and behavioral support at opioid agonist treatment clinics effectively helped opioid-dependent participants reduce the number of cigarettes smoked.

Trial Registration

ClinicalTrials.gov Identifier: NCT05290025.

Evaluating the Impact of Pharmacotherapy in Augmenting Quit Rates Among Hispanic Adults in an App-Delivered Smoking Cessation Intervention: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Hispanic adults receive less advice to quit smoking and use fewer evidence-based smoking cessation treatments compared to their non-Hispanic counterparts. Digital smoking cessation interventions, such as those delivered via smartphone apps, provide a feasible and within-reach treatment option for Hispanic adults who smoke and want to quit smoking. While the combination of pharmacotherapy and behavioral interventions are considered best practices for smoking cessation, its efficacy among Hispanic adults, especially alongside smartphone app-based interventions, is uncertain.

OBJECTIVE

This secondary analysis used data from a randomized controlled trial that compared the efficacy of 2 smoking cessation apps, iCanQuit (based on acceptance and commitment therapy) and QuitGuide (following US clinical practice guidelines), to explore the association between pharmacotherapy use and smoking cessation outcomes among the subsample of 173 Hispanic participants who reported on pharmacotherapy use. Given the randomized design, we first tested the potential interaction of pharmacotherapy use and intervention arm on 12-month cigarette smoking abstinence. We then examined whether the use of any pharmacotherapy (ie, nicotine replacement therapy [NRT], varenicline, or bupropion) and NRT alone augmented each app-based intervention efficacy.

METHODS

Participants reported using pharmacotherapy on their own during the 3-month follow-up and cigarette smoking abstinence at the 12-month follow-up via web-based surveys. These data were used (1) to test the interaction effect of using pharmacotherapy to aid smoking cessation and intervention arm (iCanQuit vs QuitGuide) on smoking cessation at 12 months and (2) to test whether the use of pharmacotherapy to aid smoking cessation augmented the efficacy of each intervention arm to help participants successfully quit smoking.

RESULTS

The subsample of Hispanic participants was recruited from 30 US states. They were on average 34.5 (SD 9.3) years of age, 50.9% (88/173) were female, and 56.1% (97/173) reported smoking at least 10 cigarettes daily. Approximately 22% (38/173) of participants reported using pharmacotherapy to aid smoking cessation at the 3-month follow-up, including NRT, varenicline, or bupropion, with no difference between intervention arms. There was an interaction between pharmacotherapy use and intervention arm that marginally influenced 12-month quit rates at 12 months (P for interaction=.053). In the iCanQuit arm, 12-month missing-as-smoking quit rates were 43.8% (7/16) for pharmacotherapy users versus 28.8% (19/16) for nonusers (odds ratio 2.21, 95% CI 0.66-7.48; P=.20). In the QuitGuide arm, quit rates were 9.1% (2/22) for pharmacotherapy users versus 21.7% (15/69) for nonusers (odds ratio 0.36, 95% CI 0.07-1.72; P=.20). Results were similar for the use of NRT only.

CONCLUSIONS

Combining pharmacotherapy to aid smoking cessation with a smartphone app-based behavioral intervention that teaches acceptance of cravings to smoke (iCanQuit) shows promise in improving quit rates among Hispanic adults. However, this combined approach was not effective with the US clinical guideline-based app (QuitGuide).

TRIAL REGISTRATION

ClinicalTrials.gov NCT02724462; https://clinicaltrials.gov/study/NCT02724462.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1001/jamainternmed.2020.4055.

Electronic cigarettes for smoking cessation

BACKGROUND

Electronic cigarettes (ECs) are handheld electronic vaping devices that produce an aerosol by heating an e-liquid. People who smoke, healthcare providers, and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review.

OBJECTIVES

To examine the safety, tolerability, and effectiveness of using EC to help people who smoke tobacco achieve long-term smoking abstinence, in comparison to non-nicotine EC, other smoking cessation treatments, and no treatment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 February 2024 and the Cochrane Tobacco Addiction Group's Specialized Register to 1 February 2023, reference-checked, and contacted study authors.

SELECTION CRITERIA

We included trials randomizing people who smoke to an EC or control condition. We included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report an eligible outcome.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. We used the risk of bias tool (RoB 1) and GRADE to assess the certainty of evidence. Critical outcomes were abstinence from smoking after at least six months, adverse events (AEs), and serious adverse events (SAEs). Important outcomes were biomarkers, toxicants/carcinogens, and longer-term EC use. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in pairwise and network meta-analyses (NMA).

MAIN RESULTS

We included 90 completed studies (two new to this update), representing 29,044 participants, of which 49 were randomized controlled trials (RCTs). Of the included studies, we rated 10 (all but one contributing to our main comparisons) at low risk of bias overall, 61 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. Nicotine EC results in increased quit rates compared to nicotine replacement therapy (NRT) (high-certainty evidence) (RR 1.59, 95% CI 1.30 to 1.93; I2 = 0%; 7 studies, 2544 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6 more). The rate of occurrence of AEs is probably similar between groups (moderate-certainty evidence (limited by imprecision)) (RR 1.03, 95% CI 0.91 to 1.17; I2 = 0%; 5 studies, 2052 participants). SAEs were rare, and there is insufficient evidence to determine whether rates differ between groups due to very serious imprecision (RR 1.20, 95% CI 0.90 to 1.60; I2 = 32%; 6 studies, 2761 participants; low-certainty evidence). Nicotine EC probably results in increased quit rates compared to non-nicotine EC (moderate-certainty evidence, limited by imprecision) (RR 1.46, 95% CI 1.09 to 1.96; I2 = 4%; 6 studies, 1613 participants). In absolute terms, this might lead to an additional three quitters per 100 (95% CI 1 to 7 more). There is probably little to no difference in the rate of AEs between these groups (moderate-certainty evidence) (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 840 participants). There is insufficient evidence to determine whether rates of SAEs differ between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 9 studies, 1412 participants; low-certainty evidence). Compared to behavioural support only/no support, quit rates may be higher for participants randomized to nicotine EC (low-certainty evidence due to issues with risk of bias) (RR 1.96, 95% CI 1.66 to 2.32; I2 = 0%; 11 studies, 6819 participants). In absolute terms, this represents an additional four quitters per 100 (95% CI 3 to 5 more). There was some evidence that (non-serious) AEs may be more common in people randomized to nicotine EC (RR 1.18, 95% CI 1.10 to 1.27; I2 = 6%; low-certainty evidence; 6 studies, 2351 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 0.93, 95% CI 0.68 to 1.28; I2 = 0%; 12 studies, 4561 participants; very low-certainty evidence). Results from the NMA were consistent with those from pairwise meta-analyses for all critical outcomes. There was inconsistency in the AE network, which was explained by a single outlying study contributing the only direct evidence for one of the nodes. Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons; hence, evidence for these is limited, with CIs often encompassing both clinically significant harm and benefit.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care or no treatment also suggests benefit, but is less certain due to risk of bias inherent in the study design. Confidence intervals were, for the most part, wide for data on AEs, SAEs, and other safety markers, with no evidence for a difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT, but low-certainty evidence for increased AEs compared with behavioural support/no support. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but longer, larger studies are needed to fully evaluate EC safety. Our included studies tested regulated nicotine-containing EC; illicit products and/or products containing other active substances (e.g. tetrahydrocannabinol (THC)) may have different harm profiles. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

Differences in the effectiveness of individual-level smoking cessation interventions by socioeconomic status

BACKGROUND

People from lower socioeconomic groups are more likely to smoke and less likely to succeed in achieving abstinence, making tobacco smoking a leading driver of health inequalities. Contextual factors affecting subpopulations may moderate the efficacy of individual-level smoking cessation interventions. It is not known whether any intervention performs differently across socioeconomically-diverse populations and contexts.

OBJECTIVES

To assess whether the effects of individual-level smoking cessation interventions on combustible tobacco cigarette use differ by socioeconomic groups, and their potential impact on health equalities.

SEARCH METHODS

We searched the Cochrane Database of Systematic Reviews from inception to 1 May 2023 for Cochrane reviews investigating individual-level smoking cessation interventions. We selected studies included in these reviews that met our criteria. We contacted study authors to identify further eligible studies.

SELECTION CRITERIA

We included parallel, cluster or factorial randomised controlled trials (RCTs) investigating any individual-level smoking cessation intervention which encouraged complete cessation of combustible tobacco cigarette use compared to no intervention, placebo, or another intervention in adults. Studies must have assessed or reported smoking quit rates, split by any measure of socioeconomic status (SES) at longest follow-up (≥ six months), and been published in 2000 or later.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening, data extraction, and risk of bias assessment. We assessed the availability of smoking abstinence data by SES in lieu of selective reporting. The primary outcome was smoking cessation quit rates, split by lower and higher SES, at the longest follow-up (≥ six months). Where possible, we calculated ratios of odds ratios (ROR) with 95% confidence intervals (CIs) for each study, comparing lower to higher SES. We pooled RORs by intervention type in random-effects meta-analyses, using the generic inverse-variance method. We subgrouped by type of SES indicator and economic classification of the study country. We summarised all evidence in effect direction plots and categorised the intervention impact on health equality as: positive (evidence that the relative effect of the intervention on quit rates was greater in lower rather than higher SES groups), possibly positive, neutral, possibly neutral, possibly negative, negative, no reported statistically significant difference, or unclear. We evaluated certainty using GRADE.

MAIN RESULTS

We included 77 studies (73 from high-income countries), representing 127,791 participants. We deemed 12 studies at low overall risk of bias, 13 at unclear risk, and the remaining 52 at high risk. Included studies investigated a range of pharmacological interventions, behavioural support, or combinations of these. Pharmacological interventions We found very low-certainty evidence for all the main pharmacological interventions compared to control. Evidence on cytisine (ROR 1.13, 95% CI 0.73 to 1.74; 1 study, 2472 participants) and nicotine electronic cigarettes (ROR 4.57, 95% CI 0.88 to 23.72; 1 study, 989 participants) compared to control indicated a greater relative effect of these interventions on quit rates in lower compared to higher SES groups, suggesting a possibly positive impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring higher SES groups. There was a lower relative effect of bupropion versus placebo on quit rates in lower compared to higher SES groups, indicating a possibly negative impact on health equality (ROR 0.05, 95% CI 0.00 to 1.00; from 1 of 2 studies, 354 participants; 1 study reported no difference); however, the CI included the possibility of no clinically important difference. We could not determine the intervention impact of combination or single-form nicotine replacement therapy on relative quit rates by SES. No studies on varenicline versus control were included. Behavioural interventions We found low-certainty evidence of lower quit rates in lower compared to higher SES groups for print-based self-help (ROR 0.85, 95% CI 0.52 to 1.38; 3 studies, 4440 participants) and text-messaging (ROR 0.76, 95% CI 0.47 to 1.23; from 3 of 4 studies, 5339 participants; 1 study reported no difference) versus control, indicating a possibly negative impact on health equality. CIs for both estimates included the possibility of no clinically important difference and of favouring lower SES groups. There was very low-certainty evidence of quit rates favouring higher SES groups for financial incentives compared to balanced intervention components. However, the CI included the possibility of no clinically important difference and of favouring lower SES groups (ROR 0.91, 95% CI 0.45 to 1.85; from 5 of 6 studies, 3018 participants; 1 study reported no difference). This indicates a possibly negative impact on health equality. There was very low-certainty evidence of no difference in quit rates by SES for face-to-face counselling compared to less intensive counselling, balanced components, or usual care. However, the CI included the possibility of favouring lower and higher SES groups (ROR 1.26, 95% CI 0.18 to 8.93; from 1 of 6 studies, 294 participants; 5 studies reported no difference), indicating a possibly neutral impact. We found very low-certainty evidence of a greater relative effect of telephone counselling (ROR 4.31, 95% CI 1.28 to 14.51; from 1 of 7 studies, 903 participants; 5 studies reported no difference, 1 unclear) and internet interventions (ROR 1.49, 95% CI 0.99 to 2.25; from 1 of 5 studies, 4613 participants; 4 studies reported no difference) versus control on quit rates in lower versus higher SES groups, suggesting a possibly positive impact on health equality. The CI for the internet intervention estimate included the possibility of no difference. Although the CI for the telephone counselling estimate only favoured lower SES groups, most studies narratively reported no clear evidence of interaction effects.

AUTHORS' CONCLUSIONS

Currently, there is no clear evidence to support the use of differential individual-level smoking cessation interventions for people from lower or higher SES groups, or that any one intervention would have an effect on health inequalities. This conclusion may change as further data become available. Many studies did not report sufficient data to be included in a meta-analysis, despite having tested the association of interest. Further RCTs should collect, analyse, and report quit rates by measures of SES, to inform intervention development and ensure recommended interventions do not exacerbate but help reduce health inequalities caused by smoking.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Interventions for smoking cessation: An overview of Cochrane reviews

INTRODUCTION

Evidence of different smoking cessation interventions varies and has been assessed in many Cochrane reviews. We conducted an overview of these Cochrane reviews to summarize the effects of current interventions for smoking cessation.

METHODS

Nine databases were searched from their inception to October 2024, with no restrictions on language. Two authors independently extracted data from the same studies simultaneously, double checking after extraction. A second round of examination was conducted on all the extracted contents by another author. We employed a measurement tool to assess systematic reviews (AMSTAR-2) to evaluate the methodological rigor of the included systematic reviews (SRs), synthesized the GRADE results as reported, and conducted a narrative synthesis. The research protocol was registered on PROSPERO (CRD42023388884).

RESULTS

Seventy-one Cochrane reviews involving 3022 trials were included in this comprehensive analysis. The two predominant smoking cessation interventions were pharmacotherapy (24 SRs) and non-pharmacological therapy (31SRs). Overall, the methodological quality of all the reviews was good. Compared with placebo, the point effect size for each Cochrane review on relative risk (RR) regarding pharmacotherapies for prolonged abstinence rate ranged from 1.11 to 3.34, demonstrating high- or moderate-certainty evidence; whereas for non-pharmacological therapies, it varied from 0.79 to 25.38, but substantial heterogeneity was observed in most meta-analysis (I2>50%). Four studies investigating pharmacotherapies as interventions, adverse events were reported but no significant differences in outcomes were observed.

CONCLUSIONS

Pharmacotherapy demonstrated some efficacy in promoting prolonged abstinence rate, while the effectiveness of different non-pharmacological interventions for smoking cessation varied widely, highlighting the need for further research on the integration of pharmacotherapy and non-pharmacological therapies.

Understanding use of e-cigarettes for smoking cessation among a sample of US adults

INTRODUCTION

Many adults who smoke cigarettes report trying e-cigarettes to quit smoking. Understanding the use of e-cigarettes for smoking cessation and the type of support that adults desire when trying to quit smoking is important for supporting cessation attempts and maximizing smoking abstinence.

METHODS

In summer 2021, an online survey of 857 adults who reported a history of regular cigarette smoking and endorsed using e-cigarettes in a recent smoking cessation attempt was conducted. Survey items assessed reasons for using e-cigarettes to quit smoking, what was helpful about e-cigarettes, and what information participants desired when using e-cigarettes to quit smoking.

RESULTS

Common reasons for using e-cigarettes to quit smoking included beliefs that vaping would be helpful for quitting (53.6%), vaping is safer than smoking (50.5%), and favorable comparisons relative to other nicotine replacement treatment (NRT) like nicotine patches and gum (24.7%). 23.8% selected e-cigarettes because they were cheaper than other smoking cessation aids. 89% of participants reported still smoking cigarettes at the time of survey. The most common information people wanted when quitting was advice on how to gradually reduce nicotine over time to become nicotine-free (46.3%), how different vaping devices work (39.7%), and what nicotine concentration to start with (37.7%).

CONCLUSIONS

Findings identified common beliefs about e-cigarettes as a smoking cessation aid and how they compare to other treatments including NRT. Understanding factors that support cessation are critical especially due to high relapse rates. Results may help to inform support programs, especially for individuals who are interested in using e-cigarettes to quit smoking.

IMPLICATIONS

Despite greater reporting, there is a limited understanding of e-cigarette use for quitting among those who smoke cigarettes.Our study highlights the reasons for using e-cigarettes among those who have recently tried e-cigarettes for quitting smoking, and the components of e-cigarette that were helpful.We also examined the desired support in a program designed to use e-cigarettes for quitting smoking. Majority of participants who attempted to quit smoking using an e-cigarette relapsed to smoking, indicating the gap in cessation support that can be filled with greater understanding of the desired support.

Long-Term Effectiveness of a Quitline for Smoking Cessation: Results of a Randomized Controlled Trial

INTRODUCTION

Smoking remains a significant global public health issue, leading to numerous preventable deaths and disabilities annually. Telephone counselling is a recommended intervention for smoking cessation, offering accessible support to a wide range of people who smoke. This study aimed to evaluate the long-term effectiveness of the German quitline for smoking cessation.

METHODS

A parallel-group, two-arm, superiority, randomized controlled trial was conducted between October 2021 and November 2023. People who smoked daily and were willing to quit received either up to six telephone counselling calls (intervention group) or a self-help brochure (control group). Seven-day point prevalence abstinence from cigarettes and tobacco at 12 months and prolonged cigarette and tobacco abstinence from 3 to 12 months after the start of the intervention were assessed. Further, the use of additional cessation aids was assessed.

RESULTS

A total of n = 905 participants were randomized (intention-to-treat sample). The intervention group (n = 477) exhibited higher rates of prolonged cigarette abstinence (31.7% vs. 17.8%) and prolonged tobacco abstinence (30.8% vs. 15.2%) compared to the control group (n = 428) at 12-month follow-up with corresponding odds ratios of 2.2 (95% CI [1.6, 3.0]) and 2.5 (95% CI [1.8, 3.5]). Seven-day point-prevalence cigarette abstinence was not statistically significant (OR = 1.3, 95% CI [1.0, 1.7]). E-cigarettes were the most commonly used additional cessation aid (46.0%), followed by electronic media (31.0%) and nicotine replacement therapy (26.2%).

CONCLUSIONS

Telephone counselling provided by the national German quitline for smoking cessation demonstrates effectiveness in promoting long-term abstinence from cigarettes and tobacco. Increased awareness and use of the quitline could promote cessation rates in Germany. Given the rising popularity of novel nicotine consumer products, counselling protocols should incorporate information on their risks and potential as cessation tools.

Effectiveness of residential versus outpatient therapy for smoking cessation: The START randomized clinical trial

BACKGROUND AND AIMS

Tobacco smoking represents a major cause for preventable death and morbidity. Results from non-randomized studies suggest that smoking cessation therapy in a residential setting might be a new viable way to facilitate smoking abstinence. We aimed to test the effects of residential multicomponent group therapy for smoking cessation compared with outpatient group therapy.

DESIGN

Prospective parallel-group open-label randomized superiority trial, with assessments at baseline, 6 and 12 months.

SETTING

Recruitment throughout Germany via media advertisements.

PARTICIPANTS

Adult smokers (≥10 cigarettes/day) randomly assigned to residential (n = 157) or outpatient (n = 158) therapy. 51.8% female; mean age 53.2 years; mean years of smoking 34.4.

INTERVENTION AND COMPARATOR

Residential 9-day smoking cessation group therapy comprising six daily therapy sessions and supportive interventions for cessation and daily structure embedded in the routines of a somatic rehabilitation center, compared with weekly outpatient smoking cessation group therapy (3-7 weeks) provided in routine care courses close to the participants' places of residence, both including at least 9 h of behavioral therapy.

MEASUREMENTS

Co-primary outcomes were self-reported continuous 6- and 12-month abstinence (hierarchically ordered). Primary analyses were conducted in the therapy-uptake population including participants who started therapy with sensitivity analyses in the intention-to-treat population of all randomized participants.

FINDINGS

Intervention uptake rates were 87.3% (n = 137) in the residential and 60.1% (n = 95) in the outpatient group. In the therapy-uptake population, abstinence rates were 46.7% in the residential versus 26.3% in the outpatient group at 6 months (odds ratio [OR] = 2.46, 95% confidence interval [CI] = 1.39-4.33, P = 0.0019) and 39.4% versus 24.2% at 12 months (OR = 2.04, 95% CI = 1.14-3.64, P = 0.017). Biochemically validated abstinence rates at 12 months were 33.1% in the residential versus 17.4% in the outpatient group (OR = 2.35, 95% CI = 1.22-4.51, P = 0.011). In the intention-to-treat population, self-reported and biochemically validated abstinence rates at 12 months were 34.4% in the residential versus 14.6% in the outpatient group (OR = 3.08, 95% CI = 1.77-5.34, P < 0.0001) and 28.6% versus 10.3% (OR = 3.48, 95% CI = 1.85-6.52, P = 0.0001), respectively.

CONCLUSIONS

Residential therapy exclusively for smoking cessation is feasible and effective and could be a beneficial new treatment for smokers.

Systematic review and meta-analyses of cytisine to support tobacco cessation

BACKGROUND AND AIMS

Cytisine (also known as cytisinicline) is a low-cost partial agonist of nicotinic acetylcholine receptors used to assist tobacco cessation. We aimed to review the effectiveness of cytisine for tobacco cessation and the effects of dose and co-use of behavioural or other pharmacological interventions on cessation outcomes.

METHODS

We searched seven databases, Google Scholar, and reference lists of included publications for randomised controlled trials investigating use of cytisine as a tobacco cessation aid. Studies were eligible if participants were ≥15 years old and used tobacco upon study enrolment. We conducted four random effects meta-analyses and sensitivity analyses with fixed effects models. We used the Cochrane risk-of-bias tool for randomised trials version 2 to assess risk of bias in included studies, with adjustments recommended by the Cochrane Tobacco Addiction Group.

RESULTS

Participants using cytisine were significantly more likely to quit tobacco than participants who received placebo/no intervention/usual care (risk ratio [RR] = 2.65, 95% confidence interval [CI] = 1.50-4.67, 6 trials, 5194 participants) or nicotine replacement therapy (RR = 1.36, 95% CI = 1.06-1.73, p = 0.0152, 2 trials, 1511 participants). The difference in cessation rates among participants receiving cytisine versus varenicline was not statistically significant (RR = 0.96, 95% CI 0.63-1.45, P = 0.8464, 3 trials, 2508 participants). Two trials examined longer versus shorter treatment duration, finding higher abstinence rates with longer treatment (RR = 1.29, 95% CI = 1.02-1.63, 2 trials, 1009 participants). The differences in the number of adverse events reported by participants who received cytisine versus placebo (RR = 1.19, 95% CI = 0.99-1.41, P = 0.0624; 6 trials; 4578 participants) or cytisine versus varenicline (RR = 1.37, 95% CI = 0.57-3.33, P = 0.4835; 2 trials; 1345 participants) were not statistically significant. Most adverse events were mild (e.g. abnormal dreams, nausea, headaches).

CONCLUSIONS

Cytisine is an effective aid for tobacco cessation and appears to be more effective for tobacco cessation than placebo, no intervention, usual care and nicotine replacement therapy.

Co-Designing a Smoking Cessation Chatbot: Focus Group Study of End Users and Smoking Cessation Professionals

BACKGROUND

Our prototype smoking cessation chatbot, Quin, provides evidence-based, personalized support delivered via a smartphone app to help people quit smoking. We developed Quin using a multiphase program of co-design research, part of which included focus group evaluation of Quin among stakeholders prior to clinical testing.

OBJECTIVE

This study aimed to gather and compare feedback on the user experience of the Quin prototype from end users and smoking cessation professionals (SCPs) via a beta testing process to inform ongoing chatbot iterations and refinements.

METHODS

Following active and passive recruitment, we conducted web-based focus groups with SCPs and end users from Queensland, Australia. Participants tested the app for 1-2 weeks prior to focus group discussion and could also log conversation feedback within the app. Focus groups of SCPs were completed first to review the breadth and accuracy of information, and feedback was prioritized and implemented as major updates using Agile processes prior to end user focus groups. We categorized logged in-app feedback using content analysis and thematically analyzed focus group transcripts.

RESULTS

In total, 6 focus groups were completed between August 2022 and June 2023; 3 for SCPs (n=9 participants) and 3 for end users (n=7 participants). Four SCPs had previously smoked, and most end users currently smoked cigarettes (n=5), and 2 had quit smoking. The mean duration of focus groups was 58 (SD 10.9; range 46-74) minutes. We identified four major themes from focus group feedback: (1) conversation design, (2) functionality, (3) relationality and anthropomorphism, and (4) role as a smoking cessation support tool. In response to SCPs' feedback, we made two major updates to Quin between cohorts: (1) improvements to conversation flow and (2) addition of the "Moments of Crisis" conversation tree. Participant feedback also informed 17 recommendations for future smoking cessation chatbot developments.

CONCLUSIONS

Feedback from end users and SCPs highlighted the importance of chatbot functionality, as this underpinned Quin's conversation design and relationality. The ready accessibility of accurate cessation information and impartial support that Quin provided was recognized as a key benefit for end users, the latter of which contributed to a feeling of accountability to the chatbot. Findings will inform the ongoing development of a mature prototype for clinical testing.

Interventions for tobacco use cessation in people living with HIV

BACKGROUND

The prevalence of tobacco use among people living with HIV (PLWH) is up to four times higher than in the general population. Unfortunately, tobacco use increases the risk of progression to AIDS and death. Individual- and group-level interventions, and system-change interventions that are effective in helping PLWH stop using tobacco can markedly improve the health and quality of life of this population. However, clear evidence to guide policy and practice is lacking, which hinders the integration of tobacco use cessation interventions into routine HIV care. This is an update of a review that was published in 2016. We include 11 new studies.

OBJECTIVES

To assess the benefits, harms and tolerability of interventions for tobacco use cessation among people living with HIV. To compare the benefits, harms and tolerability of interventions for tobacco use cessation that are tailored to the needs of people living with HIV with that of non-tailored cessation interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, Embase, and PsycINFO in December 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of individual-/group-level behavioural or pharmacological interventions, or both, for tobacco use cessation, delivered directly to PLWH aged 18 years and over, who use tobacco. We also included RCTs, quasi-RCTs, other non-randomised controlled studies (e.g. controlled before and after studies), and interrupted time series studies of system-change interventions for tobacco use cessation among PLWH. For system-change interventions, participants could be PLWH receiving care, or staff working in healthcare settings and providing care to PLWH; but studies where intervention delivery was by research personnel were excluded. For both individual-/group-level interventions, and system-change interventions, any comparator was eligible.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods, and used GRADE to assess certainty of the evidence. The primary measure of benefit was tobacco use cessation at a minimum of six months. Primary measures for harm were adverse events (AEs) and serious adverse events (SAEs). We also measured quit attempts or quit episodes, the receipt of a tobacco use cessation intervention, quality of life, HIV viral load, CD4 count, and the incidence of opportunistic infections.

MAIN RESULTS

We identified 17 studies (16 RCTs and one non-randomised study) with a total of 9959 participants; 11 studies are new to this update. Nine studies contributed to meta-analyses (2741 participants). Fifteen studies evaluated individual-/group-level interventions, and two evaluated system-change interventions. Twelve studies were from the USA, two from Switzerland, and there were single studies for France, Russia and South Africa. All studies focused on cigarette smoking cessation. All studies received funding from independent national- or institutional-level funding. Three studies received study medication free of charge from a pharmaceutical company. Of the 16 RCTs, three were at low risk of bias overall, five were at high risk, and eight were at unclear risk. Behavioural support or system-change interventions versus no or less intensive behavioural support Low-certainty evidence (7 studies, 2314 participants) did not demonstrate a clear benefit for tobacco use cessation rates in PLWH randomised to receive behavioural support compared with brief advice or no intervention: risk ratio (RR) 1.11, 95% confidence interval (CI) 0.87 to 1.42, with no evidence of heterogeneity. Abstinence at six months or more was 10% (n = 108/1121) in the control group and 11% (n = 127/1193) in the intervention group. There was no evidence of an effect on tobacco use cessation on system-change interventions: calling the quitline and transferring the call to the patient whilst they are still in hospital ('warm handoff') versus fax referral (RR 3.18, 95% CI 0.76 to 13.99; 1 study, 25 participants; very low-certainty evidence). None of the studies in this comparison assessed SAE. Pharmacological interventions versus placebo, no intervention, or another pharmacotherapy Moderate-certainty evidence (2 studies, 427 participants) suggested that varenicline may help more PLWH to quit smoking than placebo (RR 1.95, 95% CI 1.05 to 3.62) with no evidence of heterogeneity. Abstinence at six months or more was 7% (n = 14/215) in the placebo control group and 13% (n = 27/212) in the varenicline group. There was no evidence of intervention effects from individual studies on behavioural support plus nicotine replacement therapy (NRT) versus brief advice (RR 8.00, 95% CI 0.51 to 126.67; 15 participants; very low-certainty evidence), behavioural support plus NRT versus behavioural support alone (RR 1.47, 95% CI 0.92 to 2.36; 560 participants; low-certainty evidence), varenicline versus NRT (RR 0.93, 95% CI 0.48 to 1.83; 200 participants; very low-certainty evidence), and cytisine versus NRT (RR 1.18, 95% CI 0.66 to 2.11; 200 participants; very low-certainty evidence). Low-certainty evidence (2 studies, 427 participants) did not detect a difference between varenicline and placebo in the proportion of participants experiencing SAEs (8% (n = 17/212) versus 7% (n = 15/215), respectively; RR 1.14, 95% CI 0.58 to 2.22) with no evidence of heterogeneity. Low-certainty evidence from one study indicated similar SAE rates between behavioural support plus NRT and behavioural support only (1.8% (n = 5/279) versus 1.4% (n = 4/281), respectively; RR 1.26, 95% CI 0.34 to 4.64). No studies assessed SAEs for the following: behavioural support plus NRT versus brief advice; varenicline versus NRT and cytisine versus NRT.

AUTHORS' CONCLUSIONS

There is no clear evidence to support or refute the use of behavioural support over brief advice, one type of behavioural support over another, behavioural support plus NRT over behavioural support alone or brief advice, varenicline over NRT, or cytisine over NRT for tobacco use cessation for six months or more among PLWH. Nor is there clear evidence to support or refute the use of system-change interventions such as warm handoff over fax referral, to increase tobacco use cessation or receipt of cessation interventions among PLWH who use tobacco. However, the results must be considered in the context of the small number of studies included. Varenicline likely helps PLWH to quit smoking for six months or more compared to control. We did not find evidence of difference in SAE rates between varenicline and placebo, although the certainty of the evidence is low.

Effectiveness of culturally tailoring smoking cessation interventions for reducing or quitting combustible tobacco: A systematic review and meta-analyses

BACKGROUND AND AIMS

Standard approaches to smoking cessation may not be as effective for certain populations, and tailoring on cultural factors could improve their effectiveness. This systematic review measured the effectiveness of culturally tailoring smoking cessation interventions on quitting or reducing smoking combustible tobacco.

METHOD

We searched MEDLINE, PsychInfo, Embase and Cochrane Central Register from inception to 21 June 2023 for randomized controlled trials (RCTs) of community-based, primary care or web-based interventions for smoking cessation in adults who smoked tobacco, with measurement of smoking abstinence or reduction at least 3 months following baseline. We examined comparisons between either an intensity-matched culturally tailored intervention and a non-tailored intervention or a standard non-tailored intervention and the same intervention plus a culturally tailored adjunct. We sub-grouped studies according to the level of tailoring and performed subgroup analyses where appropriate. We assessed risk of bias and certainty of evidence.

RESULTS

We identified 43 studies, 33 of which were meta-analyzed (n = 12 346 participants). We found moderate certainty evidence, limited by heterogeneity, that intensity-matched culturally tailored cessation interventions increased quit success when compared with non-tailored interventions at 3-month follow-up or longer (n = 5602, risk ratio [RR] = 1.29 95% confidence interval [CI] 1.10, 1.51, I2  = 47%, 14 studies). We found a positive effect of adding a culturally tailored component to a standard intervention compared with the standard intervention alone (n = 6674, RR = 1.47, 95% CI 1.10, 1.95, I2  = 74%, 18 studies), but our certainty in this effect was low due to imprecision and substantial statistical heterogeneity.

CONCLUSION

Culturally tailored smoking cessation interventions may help more people to quit smoking than a non-tailored intervention. Adapting or adding cultural components to smoking cessation interventions originally developed for majority populations could improve cessation rates in populations who do not fully identify with majority cultural norms.

Electronic cigarettes for smoking cessation

BACKGROUND

Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review.

OBJECTIVES

To examine the safety, tolerability and effectiveness of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence, in comparison to non-nicotine EC, other smoking cessation treatments and no treatment.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register to 1 February 2023, and Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2023, and reference-checked and contacted study authors.

SELECTION CRITERIA

We included trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention as these studies have the potential to provide further information on harms and longer-term use. Studies had to report an eligible outcome.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Critical outcomes were abstinence from smoking after at least six months, adverse events (AEs), and serious adverse events (SAEs). We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in pairwise and network meta-analyses (NMA).

MAIN RESULTS

We included 88 completed studies (10 new to this update), representing 27,235 participants, of which 47 were randomized controlled trials (RCTs). Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 58 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There is high certainty that nicotine EC increases quit rates compared to nicotine replacement therapy (NRT) (RR 1.59, 95% CI 1.29 to 1.93; I2 = 0%; 7 studies, 2544 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6 more). There is moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs is similar between groups (RR 1.03, 95% CI 0.91 to 1.17; I2 = 0%; 5 studies, 2052 participants). SAEs were rare, and there is insufficient evidence to determine whether rates differ between groups due to very serious imprecision (RR 1.20, 95% CI 0.90 to 1.60; I2 = 32%; 6 studies, 2761 participants; low-certainty evidence). There is moderate-certainty evidence, limited by imprecision, that nicotine EC increases quit rates compared to non-nicotine EC (RR 1.46, 95% CI 1.09 to 1.96; I2 = 4%; 6 studies, 1613 participants). In absolute terms, this might lead to an additional three quitters per 100 (95% CI 1 to 7 more). There is moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 1840 participants). There is insufficient evidence to determine whether rates of SAEs differ between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 9 studies, 1412 participants; low-certainty evidence). Due to issues with risk of bias, there is low-certainty evidence that, compared to behavioural support only/no support, quit rates may be higher for participants randomized to nicotine EC (RR 1.88, 95% CI 1.56 to 2.25; I2 = 0%; 9 studies, 5024 participants). In absolute terms, this represents an additional four quitters per 100 (95% CI 2 to 5 more). There was some evidence that (non-serious) AEs may be more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low-certainty evidence; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 0.89, 95% CI 0.59 to 1.34; I2 = 23%; 10 studies, 3263 participants; very low-certainty evidence). Results from the NMA were consistent with those from pairwise meta-analyses for all critical outcomes, and there was no indication of inconsistency within the networks. Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence, evidence for these is limited, with CIs often encompassing both clinically significant harm and benefit.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain due to risk of bias inherent in the study design. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but the longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

Effectiveness of the Brief Guided Self-Change Therapy Combined with Varenicline under "Real-Life" Conditions and Mediators for Smoking Cessation

Background: Brief therapies have proven to reduce tobacco cost-effectively, however, unsuccessful quit attempts remain notable in real-life conditions, and the underlying mechanisms of treatment success are still unclear. Objectives: We aimed to analyze the effectiveness of the Guided Self-Change (GSC) therapy combined with varenicline (VAR+T) in public health services against varenicline alone (VAR), and to identify mediators of treatment outcomes. We conducted a two-arm quasi-experimental study with 126 treatment-seeking smokers (age=57.3±9.1 years; 59.5% women). Before treatment, and at weeks 12 and 24, we assessed tobacco use and five potential mediators: withdrawal, craving, motivation to quit, anxiety, and depression. Results: Only 25% of participants adhered to varenicline prescription, and 54% to GSC therapy. VAR+T group showed a greater proportion of abstainers compared to VAR group at week 12 (75% vs 57.4%; φc=0.21) and week 24 (62.9% vs 52.5%; φc=0.10). When controlling for weeks taking varenicline, motivation showed a significant indirect effect over abstinence rates in VAR+T compared with VAR (a1b1=1.34; 95%CI=0.04, 5.03). Conclusions: The GSC effectiveness seems to increase motivation which in turn contributes to reducing tobacco use. The implementation of GSC therapy in public health services could minimize treatment duration and increase smoking abstinence in 'real-life' conditions where varenicline adherence remains low.

Pharmacological and electronic cigarette interventions for smoking cessation in adults: component network meta-analyses

BACKGROUND

Tobacco smoking is the leading preventable cause of death and disease worldwide. Stopping smoking can reduce this harm and many people would like to stop. There are a number of medicines licenced to help people quit globally, and e-cigarettes are used for this purpose in many countries. Typically treatments work by reducing cravings to smoke, thus aiding initial abstinence and preventing relapse. More information on comparative effects of these treatments is needed to inform treatment decisions and policies.

OBJECTIVES

To investigate the comparative benefits, harms and tolerability of different smoking cessation pharmacotherapies and e-cigarettes, when used to help people stop smoking tobacco.

SEARCH METHODS

We identified studies from recent updates of Cochrane Reviews investigating our interventions of interest. We updated the searches for each review using the Cochrane Tobacco Addiction Group (TAG) specialised register to 29 April 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs and factorial RCTs, which measured smoking cessation at six months or longer, recruited adults who smoked combustible cigarettes at enrolment (excluding pregnant people) and randomised them to approved pharmacotherapies and technologies used for smoking cessation worldwide (varenicline, cytisine, nortriptyline, bupropion, nicotine replacement therapy (NRT) and e-cigarettes) versus no pharmacological intervention, placebo (control) or another approved pharmacotherapy. Studies providing co-interventions (e.g. behavioural support) were eligible if the co-intervention was provided equally to study arms.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening, data extraction and risk of bias (RoB) assessment (using the RoB 1 tool). Primary outcome measures were smoking cessation at six months or longer, and the number of people reporting serious adverse events (SAEs). We also measured withdrawals due to treatment. We used Bayesian component network meta-analyses (cNMA) to examine intervention type, delivery mode, dose, duration, timing in relation to quit day and tapering of nicotine dose, using odds ratios (OR) and 95% credibility intervals (CrIs). We calculated an effect estimate for combination NRT using an additive model. We evaluated the influence of population and study characteristics, provision of behavioural support and control arm rates using meta-regression. We evaluated certainty using GRADE.

MAIN RESULTS

Of our 332 eligible RCTs, 319 (835 study arms, 157,179 participants) provided sufficient data to be included in our cNMA. Of these, we judged 51 to be at low risk of bias overall, 104 at high risk and 164 at unclear risk, and 118 reported pharmaceutical or e-cigarette/tobacco industry funding. Removing studies at high risk of bias did not change our interpretation of the results. Benefits We found high-certainty evidence that nicotine e-cigarettes (OR 2.37, 95% CrI 1.73 to 3.24; 16 RCTs, 3828 participants), varenicline (OR 2.33, 95% CrI 2.02 to 2.68; 67 RCTs, 16,430 participants) and cytisine (OR 2.21, 95% CrI 1.66 to 2.97; 7 RCTs, 3848 participants) were associated with higher quit rates than control. In absolute terms, this might lead to an additional eight (95% CrI 4 to 13), eight (95% CrI 6 to 10) and seven additional quitters per 100 (95% CrI 4 to 12), respectively. These interventions appeared to be more effective than the other interventions apart from combination NRT (patch and a fast-acting form of NRT), which had a lower point estimate (calculated additive effect) but overlapping 95% CrIs (OR 1.93, 95% CrI 1.61 to 2.34). There was also high-certainty evidence that nicotine patch alone (OR 1.37, 95% CrI 1.20 to 1.56; 105 RCTs, 37,319 participants), fast-acting NRT alone (OR 1.41, 95% CrI 1.29 to 1.55; 120 RCTs, 31,756 participants) and bupropion (OR 1.43, 95% CrI 1.26 to 1.62; 71 RCTs, 14,759 participants) were more effective than control, resulting in two (95% CrI 1 to 3), three (95% CrI 2 to 3) and three (95% CrI 2 to 4) additional quitters per 100 respectively. Nortriptyline is probably associated with higher quit rates than control (OR 1.35, 95% CrI 1.02 to 1.81; 10 RCTs, 1290 participants; moderate-certainty evidence), resulting in two (CrI 0 to 5) additional quitters per 100. Non-nicotine/placebo e-cigarettes (OR 1.16, 95% CrI 0.74 to 1.80; 8 RCTs, 1094 participants; low-certainty evidence), equating to one additional quitter (95% CrI -2 to 5), had point estimates favouring the intervention over control, but CrIs encompassed the potential for no difference and harm. There was low-certainty evidence that tapering the dose of NRT prior to stopping treatment may improve effectiveness; however, 95% CrIs also incorporated the null (OR 1.14, 95% CrI 1.00 to 1.29; 111 RCTs, 33,156 participants). This might lead to an additional one quitter per 100 (95% CrI 0 to 2). Harms There were insufficient data to include nortriptyline and non-nicotine EC in the final SAE model. Overall rates of SAEs for the remaining treatments were low (average 3%). Low-certainty evidence did not show a clear difference in the number of people reporting SAEs for nicotine e-cigarettes, varenicline, cytisine or NRT when compared to no pharmacotherapy/e-cigarettes or placebo. Bupropion may slightly increase rates of SAEs, although the CrI also incorporated no difference (moderate certainty). In absolute terms bupropion may cause one more person in 100 to experience an SAE (95% CrI 0 to 2).

AUTHORS' CONCLUSIONS

The most effective interventions were nicotine e-cigarettes, varenicline and cytisine (all high certainty), as well as combination NRT (additive effect, certainty not rated). There was also high-certainty evidence for the effectiveness of nicotine patch, fast-acting NRT and bupropion. Less certain evidence of benefit was present for nortriptyline (moderate certainty), non-nicotine e-cigarettes and tapering of nicotine dose (both low certainty). There was moderate-certainty evidence that bupropion may slightly increase the frequency of SAEs, although there was also the possibility of no increased risk. There was no clear evidence that any other tested interventions increased SAEs. Overall, SAE data were sparse with very low numbers of SAEs, and so further evidence may change our interpretation and certainty. Future studies should report SAEs to strengthen certainty in this outcome. More head-to-head comparisons of the most effective interventions are needed, as are tests of combinations of these. Future work should unify data from behavioural and pharmacological interventions to inform approaches to combined support for smoking cessation.

A qualitative study on people with opioid use disorders' perspectives on smoking and smoking cessation interventions

Introduction

Smoking-related diseases are major contributors to disability and shorter life expectancy among opioid-dependent patients. Smoking prevalence is considerably higher for opioid-dependent persons than among the general population, and only a minority quit smoking in treatment settings. Studies show that pharmacological smoking cessation interventions have modest success rates. This study aimed to investigate patients' receiving opioid agonist therapy perspectives on factors affecting behavior and decisions related to smoking cessation, and their experiences with smoking cessation.

Methods

This is a qualitative study using semi-structured individual interviews. The participants were asked, among others, to elaborate on the participants' thoughts about smoking, previous attempts to quit tobacco use, and what could prompt a smoking cessation attempt. We analyzed the transcripts with systematic text condensation. The Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research guidelines were followed. Opioid-dependent patients receiving opioid agonist therapy in outpatient clinics were invited to participate using a purposive sampling method. In total, fourteen individuals participated in this study.

Results

We identified six themes which were: (1) reflections on how smoking affected decisions, (2) smoking and its impact on physical and mental health, (3) the economy as a motivator to stop smoking, (4) emotions, desires, and habits related to smoking, (5) knowledge of smoking, smoking cessation, and quit attempts, and (6) social factors influencing the participants' choices and activities. The participants were well informed about the consequences of smoking and had some knowledge and experience in quitting. The participants' pulmonary health was an important motivational factor for change. Withdrawal symptoms, anxiety, and fear of using other substances discouraged several from attempting to quit smoking. In contrast, social support from partners and access to meaningful activities were considered important factors for success. Few reported being offered help from health professionals to make a smoking cessation attempt.

Discussion

Experiencing social support, being encouraged to quit smoking, and patients' concerns for their physical health were important reasons for wanting to quit smoking. Smoking cessation interventions based on patient preferences and on the behavior change wheel may enable a higher success rate among patients receiving opioid agonist therapy.

Interventions for waterpipe smoking cessation

BACKGROUND

While cigarette smoking has declined globally, waterpipe smoking is rising, especially among youth. The impact of this rise is amplified by mounting evidence of its addictive and harmful nature. Waterpipe smoking is influenced by multiple factors, including appealing flavors, marketing, use in social settings, and misperceptions that waterpipe is less harmful or addictive than cigarettes. People who use waterpipes are interested in quitting, but are often unsuccessful at doing so on their own. Therefore, developing and testing waterpipe cessation interventions to help people quit was identified as a priority for global tobacco control efforts.  OBJECTIVES: To evaluate the effectiveness of tobacco cessation interventions for people who smoke waterpipes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Review Group Specialized Register from database inception to 29 July 2022, using variant terms and spellings ('waterpipe' or 'narghile' or 'arghile' or 'shisha' or 'goza' or 'narkeela' or 'hookah' or 'hubble bubble'). We searched for trials, published or unpublished, in any language.

SELECTION CRITERIA

We sought randomized controlled trials (RCTs), quasi-RCTs, or cluster-RCTs of any smoking cessation interventions for people who use waterpipes, of any age or gender. In order to be included, studies had to measure waterpipe abstinence at a three-month follow-up or longer.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was abstinence from waterpipe use at least three months after baseline. We also collected data on adverse events. Individual study effects and pooled effects were summarized as risk ratios (RR) and 95% confidence intervals (95% CI), using Mantel-Haenszel random-effects models to combine studies, where appropriate. We assessed statistical heterogeneity with the I2 statistic. We summarized secondary outcomes narratively. We used the five GRADE considerations (risk of bias, inconsistency of effect, imprecision, indirectness, and publication bias) to assess the certainty of the body of evidence for our primary outcome in four categories high, moderate, low, or very low.

MAIN RESULTS

This review included nine studies, involving 2841 participants. All studies were conducted in adults, and were carried out in Iran, Vietnam, Syria, Lebanon, Egypt, Pakistan, and the USA. Studies were conducted in several settings, including colleges/universities, community healthcare centers, tuberculosis hospitals, and cancer treatment centers, while two studies tested e-health interventions (online web-based educational intervention, text message intervention). Overall, we judged three studies to be at low risk of bias, and six studies at high risk of bias. We pooled data from five studies (1030 participants) that tested intensive face-to-face behavioral interventions compared with brief behavioral intervention (e.g. one behavioral counseling session), usual care (e.g. self-help materials), or no intervention. In our meta-analysis, we included people who used waterpipe exclusively, or with another form of tobacco. Overall, we found low-certainty evidence of a benefit of behavioral support for waterpipe abstinence (RR 3.19 95% CI 2.17 to 4.69; I2 = 41%; 5 studies, N = 1030). We downgraded the evidence because of imprecision and risk of bias. We pooled data from two studies (N = 662 participants) that tested varenicline combined with behavioral intervention compared with placebo combined with behavioral intervention. Although the point estimate favored varenicline, 95% CIs were imprecise, and incorporated the potential for no difference and lower quit rates in the varenicline groups, as well as a benefit as large as that found in cigarette smoking cessation (RR 1.24, 95% CI 0.69 to 2.24; I2 = 0%; 2 studies, N = 662; low-certainty evidence). We downgraded the evidence because of imprecision. We found no clear evidence of a difference in the number of participants experiencing adverse events (RR 0.98, 95% CI 0.67 to 1.44; I2 = 31%; 2 studies, N = 662). The studies did not report serious adverse events.   One study tested the efficacy of seven weeks of bupropion therapy combined with behavioral intervention. There was no clear evidence of benefit for waterpipe cessation when compared with behavioral support alone (RR 0.77, 95% CI 0.42 to 1.41; 1 study, N = 121; very low-certainty evidence), or with self-help (RR 1.94, 95% CI 0.94 to 4.00; 1 study, N = 86; very low-certainty evidence).  Two studies tested e-health interventions. One study reported higher waterpipe quit rates among participants randomized to either a tailored mobile phone or untailored mobile phone intervention compared with those randomized to no intervention (RR 1.48, 95% CI 1.07 to 2.05; 2 studies, N = 319; very low-certainty evidence). Another study reported higher waterpipe abstinence rates following an intensive online educational intervention compared with a brief online educational intervention (RR 1.86, 95% CI 1.08 to 3.21; 1 study, N = 70; very low-certainty evidence).  AUTHORS' CONCLUSIONS: We found low-certainty evidence that behavioral waterpipe cessation interventions can increase waterpipe quit rates among waterpipe smokers. We found insufficient evidence to assess whether varenicline or bupropion increased waterpipe abstinence; available evidence is compatible with effect sizes similar to those seen for cigarette smoking cessation.  Given e-health interventions' potential reach and effectiveness for waterpipe cessation, trials with large samples and long follow-up periods are needed. Future studies should use biochemical validation of abstinence to prevent the risk of detection bias. Finally, there has been limited attention given to high-risk groups for waterpipe smoking, such as youth, young adults, pregnant women, and dual or poly tobacco users. These groups would benefit from targeted studies.

The World Trade Center Health Program: Smoking cessation

Cigarette smoking can cause and/or worsen a variety of health conditions. The U.S. Preventive Services Task Force (USPSTF) recommends that smoking cessation services be offered to all adults who currently smoke, and governmental and non-governmental professional organizations support providing these interventions to patients who smoke. The World Trade Center (WTC) Health Program, a federal program that provides health monitoring and treatment to those directed exposed to the September 11, 2001 terrorist attacks, provides smoking cessation therapy for eligible members. This paper identifies treatment strategies for smoking cessation and references the treatment coverage policy in the WTC Health Program. In addition, this paper notes the higher smoking prevalence among those with mental health conditions such as posttraumatic stress disorder (PTSD), and the need for heightened cessation efforts given the lower quit success rates among such persons.

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.

Challenges and opportunities associated with e-cigarettes in Australia: A qualitative study

OBJECTIVE

The use of e-cigarettes in Australia has increased significantly in recent years. To assist with identifying policy and practice priorities, this study sought to provide a greater understanding of the population-level challenges and opportunities associated with these products.

METHODS

Semi-structured interviews were conducted with 34 public health experts working in tobacco- and/or nicotine-related policy, practice and research. Interview transcripts were subject to reflexive thematic analysis.

RESULTS

Several challenges associated with e-cigarettes were identified, with uptake of use among youth, the potential for use to lead to smoking and industry interference the most frequently mentioned. Recommended means of addressing these challenges included improved regulation and increased enforcement of existing laws. Most interviewees acknowledged some potential for e-cigarettes to assist with smoking cessation.

CONCLUSIONS

Despite strong restrictions on e-cigarettes in Australia, experts working in this field reported that these products, and the companies behind them, present several challenges to public health.

IMPLICATIONS FOR PUBLIC HEALTH

Tighter regulation and increased enforcement are needed to address the challenges posed by e-cigarettes. Controlled access to liquid nicotine under a pharmaceutical model offers an opportunity for smokers to access the behavioural support that may help them to quit while also restricting e-cigarette availability.

Evaluation of the smoking cessation effects of QuitAction, a smartphone WeChat platform

INTRODUCTION

Many smokers in China desire to quit, though the success rate among adults is low. This study evaluated the effects of QuitAction, a WeChat smoking cessation platform, summarized the intervention experience of the smoking cessation platform, identified aspects of the platform that necessitated improvement, and provided references for further optimization of the smoking cessation platform.

METHODS

This single-arm study was conducted in Hunan, China, from September 2020 to October 2021. Regular smokers, who were aged ≥15 years and willing to quit smoking using QuitAction, were recruited. An in-application questionnaire evaluated participants' baseline smoking status and intention to quit smoking. The QuitAction program included questionnaires regarding the participants' ongoing smoking cessation status at 24 hours, one week, one month and three months after quitting. The smoking cessation procedure was discontinued if the participant had no intention of continuing. The smoking cessation rate, influencing success factors, frequency of use satisfaction, and helpfulness of QuitAction were recorded.

RESULTS

A total of 303 participants registered and logged into the QuitAction program, including 59 with incomplete information and 64 with no intention of quitting. The study finally included 180 participants. The smoking cessation rate was 33.9% at 24 hours, 27.2% at one week, 26.1% at one month, and 25.0% at three months. QuitAction was reported as helpful by 94.9% of participants and 95.7% were satisfied with the program. Participants with a quitting difficulty score of 80-100 were less likely to quit smoking than participants with a difficulty score of 0-60 (OR=0.28; 95% CI: 0.10-0.78; p=0.015). Participants using the platform ≥5 times were more likely to quit smoking than those who used the platform <5 times (OR=3.59; 95% CI: 1.51-8.52; p=0.004).

CONCLUSIONS

The QuitAction platform provides smoking cessation services that can improve smokers' success rate and improve user experience satisfaction.

Barriers and facilitators for smoking cessation in chronic smokers with atherosclerotic cardiovascular disease enrolled in a randomized intervention trial: A qualitative study

Objectives

Smoking is common in patients with cardiovascular disease. Despite strong recommendations for cessation and the existence of efficacious pharmacological and behavioral interventions, cessation rates remain low. Therefore, in this study, we explore perceived facilitators and barriers to smoking cessation in patients with atherosclerotic cardiovascular disease who have participated in a cessation intervention study.

Methods

Participants (N = 10) from the intervention arm of a randomized controlled study with access to free cessation support and pharmacological aids completed a semi-structured, in-depth telephone interview after a 6-monthfollow-up between October 2021 and July 2022. The interviews were audio recorded, transcribed, and analyzed according to principles of thematic analysis.

Results

The mean age was 65.7 (range: 55-79) years, and three of the 10 participants were women. Among the participants, five had quit smoking, three had relapsed, and two were persistent smokers. The themes identified encompassed barriers and facilitators to cessation, both including individual and contextual factors. Barriers included the upsides of smoking, difficult life situations, addiction to smoking, smoking in social circles, perceived lack of support and understanding from health professionals. Facilitators included intrinsic motivation, concerns about the health condition, financial implications, specific behavioral strategies, positive influence from the social environment, and helpful components of the cessation intervention.

Conclusion

Smokers with cardiovascular disease who have attended a cessation intervention study report several facilitators weighted against barriers, interacting with the intention to cease smoking. The most important potentially modifiable factors of significance for cessation identified may be addressed through motivational interviews and focus groups with other smokers.

Smoking quit rates among patients receiving pharmacotherapy who received general practitioner counselling versus intensive counselling: a retrospective cohort study

BACKGROUND

Behavioral treatments can augment the success of pharmacotherapy in smoking cessation. The aim of this study was to compare smoking quit rates between patients receiving individual counseling with their general practitioner during office visits or intensive counselling with behavioral support, both augmented by varenicline.

METHODS

A nationwide retrospective cohort study conducted in a large Healthcare Maintenance Organization in Israel. We selected randomly patients who filled a prescription for varenicline and received either individual consulting by their general practitioner or intensive counselling with behavioural support, and asked them to answer a questionnaire. The outcome variables were smoking cessation 26-52 weeks following the beginning of treatment and satisfaction with the process.

RESULTS

870 patients were contacted and 604 agreed to participate (a response rate of 69%); 301 patients in the general practitioner group, 300 in the intensive counselling group and 3 were excluded due to missing date. The quit rate was 36.5% in the general practitioner group and 42.3% in the intensive counselling group (P = 0.147). In a logistic regression analysis, controlling for age, gender, socioeconomic status, ischemic heart disease, chronic obstructive pulmonary disease, pack years and duration of varenicline consumption, the adjusted OR for quitting in the general practitioner group was 0.79 (95% CI 0.56,1.13). The adjusted OR was higher in the group with the highest socioeconomic status at 2.06 (1.39,3.07) and a longer period of varenicline consumption at 1.30 (1.15,1.47). Age, gender and cigarette pack-years were not associated with quit rate. In the general practitioner group 68% were satisfied with the process, while 19% were not. In the intensive counselling group 64% were satisfied and 14% were not (P = 0.007).

CONCLUSION

We did not detect a statistically significant difference in smoking quit rates, though there was a trend towards higher quit rates with intensive counselling.

Feasibility and Acceptability of a Telephone-Based Smoking Cessation Intervention for Qatari Residents

The steady increase in smoking rates has led to a call for wide-reaching and scalable interventions for smoking cessation in Qatar. This study examined the feasibility and acceptability of an evidence-based smoking cessation program delivered by telephone for Qatari residents. A total of 248 participants were recruited through primary care centers and received five weekly scheduled proactive behavioral counseling calls from personnel trained in tobacco cessation and navigation to obtain cessation pharmacotherapy from clinics. Outcomes were assessed at end of treatment (EOT), and 1- and-3-month follow up. The Mann-Whitney test was used to compare the average number of participants recruited per month pre- and post-COVID. We recruited 16 participants/month, the majority (85.5%) attended at least one counselling session, and 95.4% used some of pharmacotherapy. Retention rates were 70% at EOT, 64.4% and 71.7% at 1- and 3-month follow up, respectively; 86% reported being 'extremely satisfied' by the program. Our ITT 7-day point prevalence abstinence was 41.6% at EOT, 38.4% and 39.3% at 1-and 3-month, respectively. The average number of participants recruited per month was significantly higher for pre vs. post-COVID (18.9 vs. 10.0, p-value = 0.02). Average number of participants retained at EOT per recruitment month showed a slight decrease from 8.6 pre- to 8.2 post-COVID; average number who quit smoking at EOT per recruitment month also showed a decrease from 6 to 4.6. The study results indicated that our telephone-based intervention is feasible and acceptable in this population and presents a new treatment model which can be easily disseminated to a broad population of Qatari smokers.

Electronic cigarettes for smoking cessation

BACKGROUND

Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, although some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review.

OBJECTIVES

To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 July 2022, and reference-checked and contacted study authors.  SELECTION CRITERIA: We included randomized controlled trials (RCTs) and randomized cross-over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants, or both. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta-analyses.

MAIN RESULTS

We included 78 completed studies, representing 22,052 participants, of which 40 were RCTs. Seventeen of the 78 included studies were new to this review update. Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 50 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There was high certainty that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (RR 1.63, 95% CI 1.30 to 2.04; I2 = 10%; 6 studies, 2378 participants). In absolute terms, this might translate to an additional four quitters per 100 (95% CI 2 to 6). There was moderate-certainty evidence (limited by imprecision) that the rate of occurrence of AEs was similar between groups (RR 1.02, 95% CI 0.88 to 1.19; I2 = 0%; 4 studies, 1702 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.12, 95% CI 0.82 to 1.52; I2 = 34%; 5 studies, 2411 participants). There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 5 studies, 1840 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 1.00, 95% CI 0.56 to 1.79; I2 = 0%; 8 studies, 1272 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.66, 95% CI 1.52 to 4.65; I2 = 0%; 7 studies, 3126 participants). In absolute terms, this represents an additional two quitters per 100 (95% CI 1 to 3). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that (non-serious) AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants) and, again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.03, 95% CI 0.54 to 1.97; I2 = 38%; 9 studies, 1993 participants).  Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued EC use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit.

AUTHORS' CONCLUSIONS

There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

Spirometry and Smoking Cessation in Primary Care: The ESPIROTAB STUDY, A Randomized Clinical Trial

This study aims to evaluate the effect of regularly reporting spirometry results during smoking cessation counseling from a primary care physician on the quit rate in adult smokers.

METHODS

A randomized, two-arm intervention study was conducted at six primary care centers. A total of 350 smokers, ≥18 years of age, who consulted their primary care physician, participated in the study. At the selection visit, smokers who gave their consent to participate underwent spirometry. Subsequently, an appointment (visit 0) was scheduled to complete a nicotine dependence test, a smoking cessation motivation questionnaire, and a sociodemographic questionnaire. Participants were also offered brief, structured advice on how to quit smoking, as well as detailed information on spirometry results. Patients were then randomized and scheduled for follow-up visits at 3, 6, 12, and 24 months. Both arms received brief, structured advice and detailed information on spirometry results at visit 0. At consecutive follow-up visits, the control group only received brief, structured smoking cessation advice, while the intervention group also received information on initial spirometry results at visits 3 and 6, and a spirometry retest at visit 12. Exhaled carbon monoxide testing was used to check smoking cessation.

RESULTS

The study included 350 smokers; 179 were assigned to the control group and 171 to the intervention group. Smoking cessation at one year was 24.0% in the intervention group compared to 16.2% in the control group. At two years, it was 25.2% in the intervention group and 18.4% in the control group. Overall, the adjusted odds of quitting smoking in the intervention group were 42% higher than in the control group (p = 0.018).

CONCLUSIONS

Regular and detailed feedback of spirometry results with smokers increases smoking cessation. Specifically, the likelihood of quitting smoking in the intervention group is 1.42 times higher than in the control group (p = 0.018).

Medium- and longer-term cardiovascular effects of e-cigarettes in adults making a stop-smoking attempt: a randomized controlled trial

BACKGROUND

Smoking is a major risk factor for cardiovascular disease and smoking cessation reduces excess risk. E-cigarettes are popular for smoking cessation but there is little evidence on their cardiovascular health effect. Our objective was to compare the medium- and longer-term cardiovascular effects in smokers attempting to quit smoking using e-cigarettes with or without nicotine or prescription nicotine replacement therapy (NRT).

METHODS

This was a single-center, pragmatic three-arm randomized (1:1:1) controlled trial, which recruited adult smokers (≥ 10 cigarettes/day), who were willing to attempt to stop smoking with support (n = 248). Participants were randomized to receive behavioral support with either (a) e-cigarettes with 18 mg/ml nicotine, (b) e-cigarettes without nicotine, and (c) NRT. Flow-mediated dilation (%FMD) and peak cutaneous vascular conductance (CVCmax) responses to acetylcholine (ACh) and sodium nitroprusside (SNP), mean arterial pressure (MAP), and other outcomes were recorded at baseline, 3, and 6 months after stopping smoking. Data were analyzed using generalized estimating equations (GEE).

RESULTS

At 3- and 6-month follow-up, %FMD showed an improvement over baseline in all three groups (e.g., p < 0.0001 at 6 months). Similarly, ACh, SNP, and MAP improved significantly over baseline in all groups both at 3 and 6 months (e.g., ACh: p = 0.004, at 6 months).

CONCLUSIONS

Smokers attempting to quit experienced positive cardiovascular impact after both a 3- and 6-month period. None of the groups (i.e., nicotine-containing and nicotine-free e-cigarettes or NRT) offered superior cardiovascular benefits to the others.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03061253 . Registered on 17 February 2017.

Patient experiences with tobacco use during substance use disorder treatment and early recovery: a mixed method analysis of phone interview responses

Tobacco use and related mortality remain disproportionately high among individuals with substance use disorders (SUDs). Though engagement in tobacco cessation interventions is associated with improved long-term recovery, many individuals in SUD treatment do not participate. The goal of the present study was to better understand patient views regarding tobacco use/cessation during residential SUD treatment, in order to decrease barriers for this vulnerable population. This study utilized a cross-sectional design and mixed methods analysis. Following discharge from residential SUD treatment, individuals who reported any use of tobacco were invited to participate in a brief phone interview. Forty-one of the 60 who were reached (68%) agreed to participate. Responses were quantified for analysis when appropriate, and descriptive statistics were calculated for quantitative data. Thematic analysis was used to analyze qualitative responses. Most respondents (83%) reported that tobacco cessation was an important goal and were open to tobacco cessation treatment. The vast majority (85%) did not think tobacco use interfered with their recovery from other SUDs. Respondents noted the socially-reinforcing nature of tobacco use in treatment, and indicated a desire for increased access to cessation services. Results suggest increased patient education and changes to treatment center tobacco policies may assist individuals recovering from SUD with tobacco cessation.

Duration of the effectiveness of nicotine electronic cigarettes on smoking cessation and reduction: Systematic review and meta-analysis

Background

The success of pharmacotherapies for smoking cessation in real-life remains limited, with a significant number of long-term relapses. Despite first promising results, the duration of the effectiveness of electronic cigarettes is still unknown. Our objective was to assess the duration of the effectiveness of electronic cigarettes on smoking cessation and reduction in daily smokers.

Methods

The databases EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov and PUBMED were consulted until March 23, 2022. We selected only randomized controlled trials with daily adult smokers. The intervention was the nicotinic electronic cigarette vs. non-nicotine electronic cigarette or other validated pharmacotherapies (varenicline, bupropion and nicotine replacement therapy). The minimum duration of the intervention was 3 months, with a follow-up of at least 6 months. Two independent reviewers used the PRISMA guidelines. The primary endpoint was smoking cessation at the end of the intervention and follow-up periods confirmed by a reduction in expired CO < 10 ppm. The reduction was defined as at least 50% of the initial consumption or by a decrease of daily mean cigarette consumption at the end of the intervention and follow-up periods.

Results

Abstinence at the end of the intervention and follow-up periods was significantly higher in the nicotine electronic cigarette group, compared to nicotine replacement therapy (NRT) [respectively: RR: 1.37 (CI 95%: 1.32-2.93) and RR: 1.49 (CI 95%: 1.14-1.95)] and to the non-nicotine electronic cigarette condition [respectively: RR: 1.97 (CI 95%: 1.18-2.68) and RR: 1.66 (CI 95%: 1.01-2.73)]. With regard to smoking reduction, the electronic cigarette with nicotine is significantly more effective than NRT at the end of the intervention and follow-up periods [respectively RR: 1.48 (CI 95%: 1.04-2.10) and RR: 1.47 (CI 95%: 1.18-1.82)] and non-nicotine electronic cigarette in the long term [RR: 1.31 (CI 95%: 1.02-1.68)].

Conclusions

This meta-analysis shows the duration of the effectiveness of the nicotine electronic cigarette vs. non-nicotine electronic cigarette and NRT on smoking cessation and reduction. There are still uncertainties about the risks of its long-term use and its potential role as a gateway into smoking, particularly among young people.

Behavioural programmes for cigarette smoking cessation: investigating interactions between behavioural, motivational and delivery components in a systematic review and component network meta-analysis

AIMS

To investigate the comparative and combined effectiveness of four types of components of behavioural interventions for cigarette smoking cessation: behavioural (e.g. counselling), motivational (e.g. focus on reasons to quit), delivery mode (e.g. phone) and provider (e.g. nurse).

DESIGN

Systematic review and component network meta-analysis of randomised controlled trials identified from Cochrane reviews. Interventions included behavioural interventions for smoking cessation (including all non-pharmacological interventions, e.g. counselling, exercise, hypnotherapy, self-help materials), compared with another behavioural intervention or no support. Building on a 2021 review (CD013229), we conducted three analyses, investigating: comparative effectiveness of the components, whether models that allowed interactions between components gave different results to models assuming additivity, and predicted effect estimates for combined effects of components that had showed promise but where there were few trials.

SETTING

Community and health-care settings.

PARTICIPANTS

Adults who smoke tobacco.

MEASUREMENTS

Smoking cessation at ≥6 months, preferring sustained, biochemically validated outcomes where available.

FINDINGS

Three hundred and twelve trials (250 563 participants) were included. Fifty were at high risk of bias using Cochrane risk of bias tool, V1 (ROB1); excluding these studies did not change findings. Head-to-head comparisons of components suggested that support via text message (SMS) compared with telephone (OR 1.48, 95% CrI 1.13-1.94) or print materials (OR 1.44, 95% CrI 1.14-1.83) was more effective, and individual delivery was less effective than delivery as part of a group (OR 0.78, 95% CrI 0.64-0.95). There was no conclusive evidence of synergistic or antagonistic interactions when combining components that were commonly used together. Adding multiple components that are commonly used in behavioural counselling suggested clinically relevant and statistically conclusive evidence of benefit. Components with the largest effects that could be combined, but rarely have been, were estimated to increase the odds of quitting between two and threefold. For example, financial incentives delivered via SMS, with tailoring and a focus on how to quit, had an estimated OR of 2.94 (95% CrI 1.91-4.52).

CONCLUSIONS

Among the components of behavioural support for smoking cessation, behavioural counselling and guaranteed financial incentives are associated with the greatest success. Incorporating additional components associated with effectiveness may further increase benefit, with delivery via text message showing particular promise.

The effectiveness of smoking cessation interventions in rural and remote populations: Systematic review and meta-analyses

BACKGROUND

Rural and remote residents are more likely to smoke tobacco than those in major cities. However, they may experience unique systemic, provider, and individual barriers to accessing smoking cessation treatments, including distance and limited resources. Understanding the effectiveness of smoking cessation interventions in this population is important due to higher smoking-related disease burden and death compared to those in major cities.

METHODS

Medline, EMBASE, Scopus, PsychINFO, and Cochrane Library were searched until 19-02/2021. Inclusion criteria were randomised controlled trials (RCTs), cluster RCTs, randomised trials, or cluster randomised trials investigating behavioural interventions and pharmacotherapies for smoking cessation in rural and remote populations compared with a control or another smoking cessation treatment; and published in English. Given there is no internationally-standardised rurality index, definitions of 'rural' and 'remote' used by authors of studies were applied to reflect their country. Exclusion criteria were studies of non-combustible smoking cessation; and studies with urban participants in the sample. Two reviewers independently screened records for eligibility, extracted data from studies utilising a modified Cochrane Effective Practice and Organisation of Care Group form, and rated methodological quality using the Quality Assessment Tool for Quantitative Studies.

RESULTS

Sixteen studies were included. Meta-analysis revealed a statistically significant treatment effect of individual face-to-face counselling on smoking cessation (RR 2.35, 95% CI 1.16-4.76, I²=0%) in rural and remote populations. There was no statistically significant treatment effect for nicotine replacement therapy (RR 2.97, 95% CI 0.84-10.53, I²=47%), telephone-counselling (RR 1.69, 95% CI 0.56-5.06, I²=62%), and community-based multiple-interventions (RR:1.57, 95% CI 0.89-2.78, I²=85%). Certainty of evidence was rated very low for each meta-analysis.

CONCLUSION

Despite limited resources in rural and remote settings, individual face-to-face counselling for smoking cessation appears promising. Given the limited number of studies, further research about the effectiveness of smoking cessation interventions in rural and remote populations is warranted.

Characterizing Participant Perceptions about Smoking-Cessation Pharmacotherapy and E-Cigarettes from Facebook Smoking-Cessation Support Groups

The prevalence of smoking among young adults aged 19-28 years old in the United States persists at rates of 14.3%. Young adults underutilize pharmacotherapy for smoking cessation, and the use of e-cigarettes has increased. We analyzed comments from online smoking-cessation support groups to understand young-adult smokers' views of pharmacotherapy and e-cigarettes, to provide a more in-depth insight into the underutilization of pharmacotherapy. A qualitative analysis was performed on comments about pharmacotherapy and e-cigarettes from participants enrolled in online smoking-cessation support groups in 2016-2020. A codebook was developed with a deductive approach to code the comments, followed by thematic analysis. Eighteen themes were identified, with four dominant themes: interest, benefit, knowledge, and flavor. Participants expressed less interest in both nicotine-replacement therapy and e-cigarettes; moreover, they expressed unfamiliarity with and misconceptions about pharmacotherapy, and recognized the enticing flavors of e-cigarettes. Participants often felt e-cigarettes were not useful for smoking cessation, but the flavors of e-cigarettes were appealing for use. Participants had mixed opinions about the use of e-cigarettes for smoking cessation, but predominantly felt e-cigarettes were not useful for smoking cessation. The use of social media may be an effective way to address misconceptions about pharmacotherapy for smoking cessation and increase willingness to accept assistance.

The effectiveness of smoking cessation interventions for socio-economically disadvantaged women: a systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis assessed the effectiveness of smoking cessation interventions among women smokers in low socio-economic status (SES) groups or women living in disadvantaged areas who are historically underserved by smoking cessation services.

METHODS

A systematic literature search was conducted using MEDLINE (OVID), EMBASE, Cochrane, CINAHL, PsychINFO and Web of Science databases. Eligibility criteria included randomised controlled trials of any smoking cessation intervention among women in low SES groups or living in socio-economically disadvantaged areas. A random effects meta-analysis assessed effectiveness of interventions on smoking cessation. Risk of bias was assessed with the Cochrane Risk of Bias tool. The GRADE approach established certainty of evidence.

RESULTS

A total of 396 studies were screened for eligibility and 11 (6153 female participants) were included. Seven studies targeted women-only. 5/11 tested a form of face-to-face support. A pooled effect size was estimated in 10/11 studies. At end of treatment, two-thirds more low SES women who received a smoking cessation intervention were more likely to stop smoking than women in control groups (risk ratio (RR) 1.68, 95% CI 1.36-2.08, I2= 34%). The effect was reduced but remained significant when longest available follow-up periods were pooled (RR 1.23, 95% CI 1.04-1.48, I2 = 0%). There was moderate-to-high risk of bias in most studies. Certainty of evidence was low.

CONCLUSIONS

Behavioural and behavioural + pharmacotherapy interventions for smoking cessation targeting women in low SES groups or women living in areas of disadvantage were effective in the short term. However, longer follow-up periods indicated reduced effectiveness. Future studies to explore ways to prevent smoking relapse in this population are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42019130160.

One-month alcohol abstinence national campaigns: a scoping review of the harm reduction benefits

Over the last decade, one-month alcohol abstinence campaigns (OMACs) have been implemented within the general population in an increasing number of countries. We identified the published studies reporting data on OMACs to explore the following aspects: profile of participants, rates and factors associated with the completion of the abstinence challenge, and outcomes and harm reduction benefits in participating in the challenges. We screened 322 records, including those found in the grey literature, and reviewed 6 studies and 7 Dry July Annual Reports. Compared to non-participating alcohol users, participants were more likely to be female, have a higher income, and a higher level of education. They were heavier drinkers and were more concerned by the consequences of alcohol on health and by their health in general. Participants who achieved the one-month abstinence challenge were lower drinkers and more likely to have registered on the campaign-related Internet communities. Both successful and unsuccessful participants frequently reported health benefits, including sleep improvement and weight loss. Successful participants were more likely to durably change their alcohol drinking habits. Overall, OMACs provide short- or mid-term harm reduction benefits for both successful and unsuccessful participants. Findings were limited by the paucity of studies, their observational nature, and heterogeneity in the features of the different national campaigns, which would probably gain in enhanced internationalization.

Visualising health risks with medical imaging for changing recipients' health behaviours and risk factors: Systematic review with meta-analysis

BACKGROUND

There is ongoing clinical and research interest in determining whether providing personalised risk information could motivate risk-reducing health behaviours. We aimed to assess the impact on behaviours and risk factors of feeding back to individuals' images of their bodies generated via medical imaging technologies in assessing their current disease status or risk.

METHODS AND FINDINGS

A systematic review with meta-analysis was conducted using Cochrane methods. MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched up to July 28, 2021, with backward and forward citation searches up to July 29, 2021. Eligible studies were randomised controlled trials including adults who underwent medical imaging procedures assessing current health status or risk of disease, for which personal risk may be reduced by modifying behaviour. Trials included an intervention group that received the imaging procedure plus feedback of visualised results and assessed subsequent risk-reducing health behaviour. We examined 12,620 abstracts and included 21 studies, involving 9,248 randomised participants. Studies reported on 10 risk-reducing behaviours, with most data for smoking (8 studies; n = 4,308), medication use (6 studies; n = 4,539), and physical activity (4 studies; n = 1,877). Meta-analysis revealed beneficial effects of feedback of visualised medical imaging results on reduced smoking (risk ratio 1.11, 95% confidence interval [CI] 1.01 to 1.23, p = 0.04), healthier diet (standardised mean difference [SMD] 0.30, 95% CI 0.11 to 0.50, p = 0.003), increased physical activity (SMD 0.11, 95% CI 0.003 to 0.21, p = 0.04), and increased oral hygiene behaviours (SMD 0.35, 95% CI 0.13 to 0.57, p = 0.002). In addition, single studies reported increased skin self-examination and increased foot care. For other behavioural outcomes (medication use, sun protection, tanning booth use, and blood glucose testing) estimates favoured the intervention but were not statistically significant. Regarding secondary risk factor outcomes, there was clear evidence for reduced systolic blood pressure, waist circumference, and improved oral health, and some indication of reduced Framingham risk score. There was no evidence of any adverse effects, including anxiety, depression, or stress, although these were rarely assessed. A key limitation is that there were some concerns about risk of bias for all studies, with evidence for most outcomes being of low certainty. In particular, valid and precise measures of behaviour were rarely used, and there were few instances of preregistered protocols and analysis plans, increasing the likelihood of selective outcome reporting.

CONCLUSIONS

In this study, we observed that feedback of medical images to individuals has the potential to motivate risk-reducing behaviours and reduce risk factors. Should this promise be corroborated through further adequately powered trials that better mitigate against risk of bias, such interventions could usefully capitalise upon the widespread and growing use of medical imaging technologies in healthcare.

A population-level analysis of changes in Australian smokers' preferences for smoking cessation support over two decades - from 1998 to 2017

Background

Encouraging and assisting smokers to quit remains a key public health goal. Government and commercial initiatives have nudged smokers towards supported cessation. We tracked long-term trends in Australian smokers’ quit attempt methods across 20 years.

Methods

Data from 11,917 smokers were collected from an annual, cross-sectional, face-to-face, random and representative population survey. The survey measured demographic characteristics, tobacco use, recent quit attempts, nicotine dependence, quit intentions, and recent methods used when attempting to quit. Quit attempt preferences were analysed over time and by smoker characteristics.

Findings

Each year, more smokers attempted to quit than remained quit, with a stable trend over time. Socioeconomic disadvantage and mental health conditions are more likely among smokers, but there was no difference in quit attempts by these characteristics. Quit attempts have risen among those aged 60 years and over whereas other age groups have remained stable. Although trending downwards, unassisted quitting remained the most common method: 1998: 61% and 2017: 40%. Asking a doctor for help/advice (34%) was the most common assisted method in 2017, increasing from 18% in 1998. Methods of quitting varied by smoker characteristics, with supported methods used more often by older, more dependent, socio-economically disadvantaged smokers and those with a mental health condition.

Interpretation

The relative stability of recent quit attempts, persistence in unassisted quitting, and fluctuating preferences for supported cessation methods indicate that it is important for clinicians and policy makers to continue to support quit attempts through a variety of options, tailored to smoker's needs.

Heated tobacco products for smoking cessation and reducing smoking prevalence

BACKGROUND

Heated tobacco products (HTPs) are designed to heat tobacco to a high enough temperature to release aerosol, without burning it or producing smoke. They differ from e-cigarettes because they heat tobacco leaf/sheet rather than a liquid. Companies who make HTPs claim they produce fewer harmful chemicals than conventional cigarettes. Some people report stopping smoking cigarettes entirely by switching to using HTPs, so clinicians need to know whether they are effective for this purpose and relatively safe. Also, to regulate HTPs appropriately, policymakers should understand their impact on health and on cigarette smoking prevalence.

OBJECTIVES

To evaluate the effectiveness and safety of HTPs for smoking cessation and the impact of HTPs on smoking prevalence.  SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, and six other databases for relevant records to January 2021, together with reference-checking and contact with study authors and relevant groups.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which people who smoked cigarettes were randomised to switch to exclusive HTP use or a control condition. Eligible outcomes were smoking cessation, adverse events, and selected biomarkers.  RCTs conducted in clinic or in an ambulatory setting were deemed eligible when assessing safety, including those randomising participants to exclusively use HTPs, smoke cigarettes, or attempt abstinence from all tobacco. Time-series studies were also eligible for inclusion if they examined the population-level impact of heated tobacco on smoking prevalence or cigarette sales as an indirect measure.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking at the longest follow-up point available, adverse events, serious adverse events, and changes in smoking prevalence or cigarette sales. Other outcomes included biomarkers of harm and exposure to toxicants/carcinogens (e.g. NNAL and carboxyhaemoglobin (COHb)). We used a random-effects Mantel-Haenszel model to calculate risk ratios (RR) with 95% confidence intervals (CIs) for dichotomous outcomes. For continuous outcomes, we calculated mean differences on the log-transformed scale (LMD) with 95% CIs. We pooled data across studies using meta-analysis where possible.

MAIN RESULTS

We included 13 completed studies, of which 11 were RCTs assessing safety (2666 participants) and two were time-series studies. We judged eight RCTs to be at unclear risk of bias and three at high risk. All RCTs were funded by tobacco companies. Median length of follow-up was 13 weeks. No studies reported smoking cessation outcomes.  There was insufficient evidence for a difference in risk of adverse events between smokers randomised to switch to heated tobacco or continue smoking cigarettes, limited by imprecision and risk of bias (RR 1.03, 95% CI 0.92 to 1.15; I2 = 0%; 6 studies, 1713 participants). There was insufficient evidence to determine whether risk of serious adverse events differed between groups due to very serious imprecision and risk of bias (RR 0.79, 95% CI 0.33 to 1.94; I2 = 0%; 4 studies, 1472 participants). There was moderate-certainty evidence for lower NNAL and COHb at follow-up in heated tobacco than cigarette smoking groups, limited by risk of bias (NNAL: LMD -0.81, 95% CI -1.07 to -0.55; I2 = 92%; 10 studies, 1959 participants; COHb: LMD -0.74, 95% CI -0.92 to -0.52; I2 = 96%; 9 studies, 1807 participants). Evidence for additional biomarkers of exposure are reported in the main body of the review. There was insufficient evidence for a difference in risk of adverse events in smokers randomised to switch to heated tobacco or attempt abstinence from all tobacco, limited by risk of bias and imprecision (RR 1.12, 95% CI 0.86 to 1.46; I2 = 0%; 2 studies, 237 participants). Five studies reported that no serious adverse events occurred in either group (533 participants). There was moderate-certainty evidence, limited by risk of bias, that urine concentrations of NNAL at follow-up were higher in the heated tobacco use compared with abstinence group (LMD 0.50, 95% CI 0.34 to 0.66; I2 = 0%; 5 studies, 382 participants). In addition, there was very low-certainty evidence, limited by risk of bias, inconsistency, and imprecision, for higher COHb in the heated tobacco use compared with abstinence group for intention-to-treat analyses (LMD 0.69, 95% CI 0.07 to 1.31; 3 studies, 212 participants), but lower COHb in per-protocol analyses (LMD -0.32, 95% CI -1.04 to 0.39; 2 studies, 170 participants). Evidence concerning additional biomarkers is reported in the main body of the review. Data from two time-series studies showed that the rate of decline in cigarette sales accelerated following the introduction of heated tobacco to market in Japan. This evidence was of very low-certainty as there was risk of bias, including possible confounding, and cigarette sales are an indirect measure of smoking prevalence.

AUTHORS' CONCLUSIONS

No studies reported on cigarette smoking cessation, so the effectiveness of heated tobacco for this purpose remains uncertain. There was insufficient evidence for differences in risk of adverse or serious adverse events between people randomised to switch to heated tobacco, smoke cigarettes, or attempt tobacco abstinence in the short-term. There was moderate-certainty evidence that heated tobacco users have lower exposure to toxicants/carcinogens than cigarette smokers and very low- to moderate-certainty evidence of higher exposure than those attempting abstinence from  all tobacco. Independently funded research on the effectiveness and safety of HTPs is needed.  The rate of decline in cigarette sales accelerated after the introduction of heated tobacco to market in Japan but, as data were observational, it is possible other factors caused these changes. Moreover, falls in cigarette sales may not translate to declining smoking prevalence, and changes in Japan may not generalise elsewhere. To clarify the impact of rising heated tobacco use on smoking prevalence, there is a need for time-series studies that examine this association.

An Overview of the Obese-Asthma Phenotype in Children

Asthma is the most common chronic disease in childhood. Overweight and obesity are included among the comorbidities considered in patients with difficult-to-treat asthma, suggesting a specific phenotype of the disease. Therefore, the constant increase in obesity prevalence in children and adolescents raises concerns about the parallel increase of obesity-associated asthma. The possible correlation between obesity and asthma has been investigated over the last decade by different authors, who suggest a complex multifactorial relationship. Although the particular non-eosinophilic endotype of obesity-related asthma supports the concept that high body weight precedes asthma development, there is ongoing debate about the direct causality of these two entities. A number of mechanisms may be involved in asthma in combination with obesity disease in children, including reduced physical activity, abnormal ventilation, chronic systemic inflammation, hormonal influences, genetics and additional comorbidities, such as gastroesophageal reflux and dysfunctional breathing. The identification of the obesity-related asthma phenotype is crucial to initiate specific therapeutic management. Besides the cornerstones of asthma treatment, lifestyle should be optimized, with interventions aiming to promote physical exercise, healthy diet, and comorbidities. Future studies should clarify the exact association between asthma and obesity and the mechanisms underlying the pathogenesis of these two related conditions with the aim to define personalized therapeutic strategies for asthma management in this population.

Smoking Cessation

Tobacco smoking is the leading cause of preventable death in the United States, and its harms are well established. Physicians have more evidence-based resources than ever before to effectively treat smoking, including new uses and combinations of U.S. Food and Drug Administration-approved pharmacotherapies and expanded community programs. In addition, electronic nicotine delivery systems are potential treatment tools, but their safety and efficacy need to be established. Finally, high-priority groups, such as persons with cancer diagnoses or hospitalized patients, may benefit from particular attention to their tobacco use.

Documentation of the patient's smoking status in common chronic diseases - analysis of medical narrative reports using the ULMFiT based text classification

INTRODUCTION

Smoking cessation is essential part of a successful treatment in many chronic diseases. Our aim was to analyse how actively clinicians discuss and document patients' smoking status into electronic health records (EHR) and deliver smoking cessation assistance.

METHODS

We analysed the results using a combination of rule and deep learning-based algorithms. Narrative reports of all adult patients, whose treatment started between years 2010 and 2016 for one of seven common chronic diseases, were followed for two years. Smoking related sentences were first extracted with a rule-based algorithm. Subsequently, pre-trained ULMFiT-based algorithm classified each patient's smoking status as a current smoker, ex-smoker, or never smoker. A rule-based algorithm was then again used to analyse the physician-patient discussions on smoking cessation among current smokers.

RESULTS

A total of 35,650 patients were studied. Of all patients, 60% were found to have a smoking status in EHR and the documentation improved over time. Smoking status was documented more actively among COPD (86%) and sleep apnoea (83%) patients compared to patients with asthma, type 1&2 diabetes, cerebral infarction and ischemic heart disease (range 44-61%). Of the current smokers (N=7,105), 49% had discussed smoking cessation with their physician. The performance of ULMFiT-based classifier was good with F-scores 79-92.

CONCLUSION

Ee found that smoking status was documented in 60% of patients with chronic disease and that the clinician had discussed smoking cessation in 49% of patients who were current smokers. ULMFiT-based classifier showed good/excellent performance and allowed us to efficiently study a large number of patients' medical narratives.

Short-Term Cardiovascular Effects of E-Cigarettes in Adults Making a Stop-Smoking Attempt: A Randomized Controlled Trial

Simple Summary

E-cigarettes are popular for smoking cessation but knowledge of their effect on cardiovascular health is limited. We compared the short-term cardiovascular effects in 248 smokers who quit smoking using e-cigarettes with or without nicotine or prescription nicotine replacement therapy (NRT). All participants received behavioural support. We assessed the cardiovascular effects of these stop smoking methods 3 days following quit date. Our work suggests that e-cigarettes offer similar vascular health benefits to that of NRT. This happens at a very early stage in the stop smoking process (3 days).

Abstract

Smoking increases cardiovascular disease (CVD) risk by leading to endothelial injury. E-cigarettes remain a popular way to stop smoking. Evidence on their effect on cardiovascular health is growing but remains limited, particularly in the short-term. The main objective of this study was to compare short-term cardiovascular effects in smokers who quit smoking using e-cigarettes with or without nicotine or prescription nicotine replacement therapy (NRT). This was a single-centre (Sheffield, UK) pragmatic three-arm randomised controlled trial which recruited adult smokers (≥10 cigarettes per day), who were willing to attempt to stop smoking with support (n = 248). Participants were randomised to receive either: (a) behavioral support and e-cigarettes with 18 mg/mL nicotine (n = 84); (b) behavioral support and e-cigarettes without nicotine (n = 82); (c) behavioral support and NRT (n = 82). Flow Mediated Dilation (%FMD), peak cutaneous vascular conductance responses to acetylcholine (ACh) and sodium nitroprusside (SNP) and mean arterial pressure (MAP) were recorded at baseline and three days after stopping smoking. General Linear Models were used to compare changes between groups and changes from follow-up. Adjusting for baseline, at follow-up, all outcomes (for the 208 participants that completed the 3-day assessments) with the exception of SNP had improved significantly over baseline and there were no differences between groups (%FMD F = 1.03, p = 0.360, df = 2,207; ACh F = 0.172, p = 0.84, df = 2,207; SNP F = 0.382, p = 0.68, df = 2,207; MAP F = 0.176, p = 0.84, df = 2,207). For smokers ≥20 cigarettes per day, benefits were also pronounced. Smoking cessation showed positive cardiovascular impact even after a 3-day period and the effects did not differ between nicotine-containing e-cigarettes, nicotine-free e-cigarettes and NRT.

Predictors of smoking reduction among African American and Latinx smokers in a randomized controlled trial of JUUL e-cigarettes

INTRODUCTION

E-cigarette (e-cig) use is widespread and may play an important role in facilitating smoking reduction. Racial/ethnic minorities are less likely than Whites to use e-cigs and suffer disproportionate tobacco-related disease, making them a priority for harm reduction. This paper explores factors associated with smoking reduction among African American (AA) and Latinx smokers enrolled in a trial assessing toxicant exposure in those assigned to e-cigs or smoking as usual.

METHODS

Participants were randomized to receive 6 weeks of JUUL e-cigs or continue smoking cigarettes as usual (N = 187). This analysis focuses on 109 participants randomized to e-cigs. We modeled cigarettes smoked in the past week at baseline and week 6 as a function of a priori selected predictors (number of JUUL pods used throughout the study, baseline cigarette dependence, and baseline cotinine) using a Poisson model fit with generalized estimating equations.

RESULTS

Over the six-week study, cigarette smoking decreased from an average of 82.4 to 15.5 cigarettes per week. Greater numbers of JUUL pods used predicted a greater smoking reduction by week 6 (IRR = 0.94 [0.91, 0.96], p < 0.001). Higher baseline cigarette dependence (IRR = 1.03 [1.01, 1.05], p = 0.004), and baseline cotinine (IRR = 1.18 [1.03, 1.37], p = 0.020) predicted a lesser smoking reduction.

CONCLUSIONS

AA and Latinx smokers reduced their cigarette consumption while using JUUL e-cigs. Higher e-cig use during an intervention to switch to e-cigs to reduce harm may facilitate a transition to smoking fewer cigarettes, offering an opportunity to narrow smoking-related health disparities.

Electronic cigarettes for smoking cessation

BACKGROUND

Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol formed by heating an e-liquid. Some people who smoke use ECs to stop or reduce smoking, but some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit and if they are safe to use for this purpose. This is an update conducted as part of a living systematic review.

OBJECTIVES

To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 May 2021, and reference-checked and contacted study authors. We screened abstracts from the Society for Research on Nicotine and Tobacco (SRNT) 2021 Annual Meeting.   SELECTION CRITERIA: We included randomized controlled trials (RCTs) and randomized cross-over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow-up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants or both. We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta-analyses.

MAIN RESULTS

We included 61 completed studies, representing 16,759 participants, of which 34 were RCTs. Five of the 61 included studies were new to this review update. Of the included studies, we rated seven (all contributing to our main comparisons) at low risk of bias overall, 42 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There was moderate-certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.53, 95% confidence interval (CI) 1.21 to 1.93; I2 = 0%; 4 studies, 1924 participants). In absolute terms, this might translate to an additional three quitters per 100 (95% CI 1 to 6). There was low-certainty evidence (limited by very serious imprecision) that the rate of occurrence of AEs was similar (RR 0.98, 95% CI 0.80 to 1.19; I2 = 0%; 2 studies, 485 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.30, 95% CI 0.89 to 1.90: I2 = 0; 4 studies, 1424 participants). There was moderate-certainty evidence, again limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non-nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate-certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 3 studies, 601 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 1.06, 95% CI 0.47 to 2.38; I2 = 0; 5 studies, 792 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.61, 95% CI 1.44 to 4.74; I2 = 0%; 6 studies, 2886 participants). In absolute terms this represents an additional six quitters per 100 (95% CI 2 to 15). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that non-serious AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants), and again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.51, 95% CI 0.70 to 3.24; I2 = 0%; 7 studies, 1303 participants).  Data from non-randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that ECs with nicotine increase quit rates compared to NRT and compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs. Overall incidence of SAEs was low across all study arms. We did not detect  evidence of harm from nicotine EC, but longest follow-up was two years and the  number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up-to-date information to decision-makers, this review is now a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

Strategies to improve smoking cessation rates in primary care

BACKGROUND

Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials).

OBJECTIVES

To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs).

MAIN RESULTS

We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.

The impact of a regional smoking cessation program on referrals and use of Quitline services in Queensland, Australia: a controlled interrupted time series analysis

BACKGROUND

The prevalence of smoking in Central Queensland (CQ), Australia was higher than the state and national averages. A regional smoking cessation initiative ("10,000 Lives") was launched to promote available interventions (e.g., Quitline). We investigated the impact of "10,000 Lives" on referral to and use of Quitline services.

METHODS

We conducted an interrupted time series analysis using a segmented Poisson regression model to measure the impact of "10,000 Lives" on monthly referrals to, and use of Quitline services (counselling sessions and nicotine replacement therapy (NRT) dispatched by Quitline), in CQ compared to other areas in the state (control population). The control population included all regional areas in Queensland with a comparable smoking prevalence to CQ and similar access to Quitline's Intensive Quit Support Program. We calculated the changes in level and trend of outcomes in CQ relative to the change in the control area during the post-launch period of "10,000 Lives". The models were checked for autocorrelation and seasonality and adjusted accordingly.

FINDINGS

After the introduction of "10,000 Lives", the mean monthly rate per 1,000 smoking population increased in the intervention area for each outcome; e.g., from 3.3 to 10.8 for referrals to Quitline, from 1.6 to 4.4 for initial counselling session completed. These results were validated by the controlled interrupted time series analysis which showed relative increases for each of these outcomes (238•5% for monthly rate of referral to Quitline per 1,000 smoking population and 248•6% for monthly rate of initial counselling sessions completed per 1,000 smoking population).

INTERPRETATION

Our study demonstrates a locally coordinated health promotion initiative can promote and boost the referral to, and use of Quitline smoking cessation services.

FUNDING

The research is funded by a collaborative research grant between School of Public Health at University of Queensland and Central Queensland Public Health Unit which is awarded by the Central Queensland Hospital and Health Service (CQHHS93907). The lead author (AK) is supported by a University of Queensland Research Training Scholarship and a Research Higher Degree Top-up Scholarship.

Effectiveness and Safety Profile of Alternative Tobacco and Nicotine Products for Smoking Reduction and Cessation: A Systematic Review

BACKGROUND

Alternative tobacco and nicotine products such as electronic cigarettes (EC), smokeless tobacco, and nicotine replacement therapy (NRT) are currently being assessed as options in tobacco harm reduction due to their potential role in smoking reduction and smoking cessation.

OBJECTIVE

To provide the current evidence on the effectiveness and safety of various alternative tobacco and nicotine products for smoking reduction and cessation.

METHODS

A systematic review using databases from MEDLINE (PubMed), EMBASE, and The Cochrane Library was conducted up to December 2020 to identify eligible experimental and observational studies assessing the use of alternative tobacco and nicotine products on smoking reduction and smoking cessation and the safety of these products. The Cochrane Risk of Bias 2 (RoB 2) and ROBINS-I tools were used to assess the risk of bias of the included studies. Results were described through a narrative synthesis of the evidence.

RESULTS

From 1955 retrieved references, 44 studies (31 randomized controlled trials/RCTs and 13 prospective cohort studies) met the inclusion criteria and were included in the review. Twenty-nine studies were assessing EC, one study evaluated heat-not-burn (HNB) product, five studies were focused on snus, and nine studies assessed NRT in the form of nicotine patch, gum, etc. The overall results suggested that alternative tobacco and nicotine products in the form of EC, snus, and NRT can moderately reduce daily cigarette consumption and has potential to assist smoking cessation attempts, with fewer adverse events.

CONCLUSION

The findings suggested that alternative tobacco and nicotine products have a potential role in assisting smoking reduction and cessation, highlighting their role in the tobacco harm reduction approach. Further studies should focus on investigating long-term outcomes, safety, and effectiveness of alternative tobacco and nicotine products to better inform smoking reduction/cessation policy.

PROSPERO REGISTRATION NUMBER

CRD42020205830.

Readiness to Provide Medications for Addiction Treatment in HIV Clinics: A Multisite Mixed-Methods Formative Evaluation

BACKGROUND

We sought to characterize readiness, barriers to, and facilitators of providing medications for addiction treatment (MAT) in HIV clinics.

SETTING

Four HIV clinics in the northeastern United States.

METHODS

Mixed-methods formative evaluation conducted June 2017-February 2019. Surveys assessed readiness [visual analog scale, less ready (0-<7) vs. more ready (≥7-10)]; evidence and context ratings for MAT provision; and preferred addiction treatment model. A subset (n = 37) participated in focus groups.

RESULTS

Among 71 survey respondents (48% prescribers), the proportion more ready to provide addiction treatment medications varied across substances [tobacco (76%), opioid (61%), and alcohol (49%) treatment medications (P values < 0.05)]. Evidence subscale scores were higher for those more ready to provide tobacco [median (interquartile range) = 4.0 (4.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.008] treatment medications, but not significantly different for opioid [5.0 (4.0, 5.0) vs. 4.0 (4.0, 5.0), P = 0.11] and alcohol [4.0 (3.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.42] treatment medications. Median context subscale scores ranged from 3.3 to 4.0 and generally did not vary by readiness status (P values > 0.05). Most favored integrating MAT into HIV care but preferred models differed across substances. Barriers to MAT included identification of treatment-eligible patients, variable experiences with MAT and perceived medication complexity, perceived need for robust behavioral services, and inconsistent availability of on-site specialists. Facilitators included knowledge of adverse health consequences of opioid and tobacco use, local champions, focus on quality improvement, and multidisciplinary teamwork.

CONCLUSIONS

Efforts to implement MAT in HIV clinics should address both gaps in perspectives regarding the evidence for MAT and contextual factors and may require substance-specific models.