Five population-based interventions for smoking cessation: a MOST trial

Application of enhanced recovery after surgery based on multiphase optimization strategy in the nursing management of children with snoring disease day surgery

AIMS AND OBJECTIVES

This study aimed to investigate the effectiveness of applying a multiphase optimization strategy (MOST) to enhance recovery after surgery (ERAS) protocols within the nursing management of children undergoing day surgery for snoring disease.

BACKGROUND

While MOST has been applied to behavioral intervention research in smoking cessation, AIDS management, and weight loss by international scholars, its application in constructing nursing intervention projects remains relatively unexplored.

DESIGN

Using convenience sampling, randomised controlled trial.

METHODS

A convenience sampling method was employed. The study recruited 200 preschool children diagnosed with snoring who underwent day surgery at a specific hospital between January 2023 and January 2024. The participants were divided into two groups: a control group receiving standard nursing care and an experimental group receiving MOST-guided, integrated high-quality nursing plans specifically designed for children with snoring undergoing day surgery, adhering to established ERAS guidelines.

RESULTS

Children in the experimental group exhibited significantly lower anxiety levels compared to the control group, both in the preoperative waiting area and upon returning to the ward (p < 0.01). While the quality of discharge teaching scale (QDTS) scores did not reveal a statistically significant difference between the groups (p > 0.01), the content of discharge instructions and the perceived effectiveness and skill of nurse guidance differed significantly between the control and experimental groups(p < 0.01). Notably, the experimental group experienced a demonstrably lower incidence of thirst, hunger, crying, aspiration, pain, and conversion of day ward to routine hospitalization mode compared to the control group (all p < 0.01). There was no significant difference in the incidence of postoperative nausea and vomiting between the groups after rehydration (p > 0.01).

CONCLUSIONS

The implementation of ERAS protocols enhanced by MOST within the nursing management of children with snoring undergoing day surgery demonstrates significant efficacy. This approach can effectively reduce preoperative anxiety in children, improve the quality of discharge guidance provided to parents, and demonstrably decrease the occurrence of postoperative thirst, hunger, crying, aspiration, pain, and the need for unplanned hospitalization transitions within 6 h after surgery.

RELEVANCE TO CLINICAL PRACTICE

It is necessary to provide fast rehabilitation nursing for children with snoring during daytime operation. Nurses should adopt the theory of fast rehabilitation based on multi-stage optimization strategy to promote children's fast rehabilitation after operation.

Multiple Pharmacotherapy Adaptations for Smoking Cessation Based on Treatment Response in Black Adults Who Smoke: A Randomized Clinical Trial

Importance

Adapting to different smoking cessation medications when an individual has not stopped smoking has shown promise, but efficacy has not been tested in racial and ethnic minority individuals who smoke and tend to have less success in quitting and bear a disproportionate share of tobacco-related morbidity and mortality.

Objective

To evaluate efficacy of multiple smoking cessation pharmacotherapy adaptations based on treatment response in Black adults who smoke daily.

Design, Setting, and Participants

This randomized clinical trial of adapted therapy (ADT) or enhanced usual care (UC) included non-Hispanic Black adults who smoke and was conducted from May 2019 to January 2022 at a federally qualified health center in Kansas City, Missouri. Data analysis took place from March 2022 to January 2023.

Interventions

Both groups received 18 weeks of pharmacotherapy with long-term follow-up through week 26. The ADT group consisted of 196 individuals who received a nicotine patch (NP) and up to 2 pharmacotherapy adaptations, with a first switch to varenicline at week 2 and, if needed, a second switch to bupropion plus NP (bupropion + NP) based on carbon monoxide (CO)-verified smoking status (CO ≥6 ppm) at week 6. The UC group consisted of 196 individuals who received NP throughout the duration of treatment.

Main Outcomes and Measures

Anabasine-verified and anatabine-verified point-prevalence abstinence at week 12 (primary end point) and weeks 18 and 26 (secondary end points). The χ2 test was used to compare verified abstinence at week 12 (primary end point) and weeks 18 and 26 (secondary end points) between ADT and UC. A post hoc sensitivity analysis of smoking abstinence at week 12 was performed with multiple imputation using a monotone logistic regression with treatment and gender as covariates to impute the missing data.

Results

Among 392 participants who were enrolled (mean [SD] age, 53 [11.6] years; 224 [57%] female; 186 [47%] ≤ 100% federal poverty level; mean [SD] 13 [12.4] cigarettes per day), 324 (83%) completed the trial. Overall, 196 individuals were randomized to each study group. Using intent-to-treat and imputing missing data as participants who smoke, verified 7-day abstinence was not significantly different by treatment group at 12 weeks (ADT: 34 of 196 [17.4%]; UC: 23 of 196 [11.7%]; odds ratio [OR], 1.58; 95% CI, 0.89-2.80; P = .12), 18 weeks (ADT: 32 of 196 [16.3%]; UC: 31 of 196 [15.8%]; OR, 1.04; 95% CI, 0.61-1.78; P = .89), and 26 weeks (ADT: 24 of 196 [12.2%]; UC: 26 of 196 [13.3%]; OR, 0.91; 95% CI, 0.50-1.65; P = .76). Of the ADT participants who received pharmacotherapy adaptations (135/188 [71.8%]), 11 of 135 (8.1%) were abstinent at week 12. Controlling for treatment, individuals who responded to treatment and had CO-verified abstinence at week 2 had 4.6 times greater odds of being abstinent at week 12 (37 of 129 [28.7%] abstinence) than those who did not respond to treatment (19 of 245 [7.8%] abstinence; OR; 4.6; 95% CI, 2.5-8.6; P < .001).

Conclusions and Relevance

In this randomized clinical trial of adapted vs standard of care pharmacotherapy, adaptation to varenicline and/or bupropion + NP after failure of NP monotherapy did not significantly improve abstinence rates for Black adults who smoke relative to those who continued treatment with NP. Those who achieved abstinence in the first 2 weeks of the study were significantly more likely to achieve later abstinence, highlighting early treatment response as an important area for preemptive intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT03897439.

Successful Optimization of Tobacco Dependence Treatment in the Emergency Department: A Randomized Controlled Trial Using the Multiphase Optimization Strategy

STUDY OBJECTIVE

Tobacco dependence treatment initiated in the hospital emergency department (ED) is effective. However, trials typically use multicomponent interventions, making it difficult to distinguish specific components that are effective. In addition, interactions between components cannot be assessed. The Multiphase Optimization Strategy allows investigators to identify these effects.

METHODS

We conducted a full-factorial, 24 or 16-condition optimization trial in a busy hospital ED to examine the performance of 4 tobacco dependence interventions: a brief negotiation interview; 6 weeks of nicotine replacement therapy with the first dose delivered in the ED; active referral to a telephone quitline; and enrollment in SmokefreeTXT, a free short-messaging service program. Study data were analyzed with a novel mixed methods approach to assess clinical efficacy, cost-effectiveness, and qualitative participant feedback. The primary endpoint was tobacco abstinence at 3 months, verified by exhaled carbon monoxide using a Bedfont Micro+ Smokerlyzer.

RESULTS

Between February 2017 and May 2019, we enrolled 1,056 adult smokers visiting the ED. Odd ratios (95% confidence intervals) from the primary analysis of biochemically confirmed abstinence rates at 3 months for each intervention, versus control, were: brief negotiation interview, 1.8 (1.1, 2.8); nicotine replacement therapy, 2.1 (1.3, 3.2); quitline, 1.4 (0.9, 2.2); SmokefreeTXT, 1.1 (0.7, 1.7). There were no statistically significant interactions among components. Economic and qualitative analyses are in progress.

CONCLUSION

The brief negotiation interview and nicotine replacement therapy were efficacious. This study is the first to identify components of ED-initiated tobacco dependence treatment that are individually effective. Future work will address the scalability of the brief negotiation interview and nicotine replacement therapy by offering provider-delivered brief negotiation interviews and nicotine replacement therapy prescriptions.

The preparation phase in the multiphase optimization strategy (MOST): a systematic review and introduction of a reporting checklist

Multicomponent behavioral interventions developed using the multiphase optimization strategy (MOST) framework offer important advantages over alternative intervention development models by focusing on outcomes within constraints relevant for effective dissemination. MOST consists of three phases: preparation, optimization, and evaluation. The preparation phase is critical to establishing the foundation for the optimization and evaluation phases; thus, detailed reporting is critical to enhancing rigor and reproducibility. A systematic review of published research using the MOST framework was conducted. A structured framework was used to describe and summarize the use of MOST terminology (i.e., preparation phase and optimization objective) and the presentation of preparation work, the conceptual model, and the optimization. Fifty-eight articles were reviewed and the majority focused on either describing the methodology or presenting results of an optimization trial (n = 38, 66%). Although almost all articles identified intervention components (96%), there was considerable variability in the degree to which authors fully described other elements of MOST. In particular, there was less consistency in use of MOST terminology. Reporting on the MOST preparation phase is varied, and there is a need for increased focus on explicit articulation of key design elements and rationale of the preparation phase. The proposed checklist for reporting MOST studies would significantly advance the use of this emerging methodology and improve implementation and dissemination of MOST. Accurate reporting is essential to reproducibility and rigor of scientific trials as it ensures future research fully understands not only the methodology, but the rationale for intervention and optimization decisions.

Barriers to Building More Effective Treatments: Negative Interactions Amongst Smoking Intervention Components

Meaningfully improved mental and behavioral health treatment is an unrealized dream. Across three factorial experiments, inferential tests in prior studies showed a pattern of negative interactions suggesting that better clinical outcomes are obtained when participants receive fewer rather than more intervention components. Further, relatively few significant main effects were found in these experiments. Modeling suggested that negative interactions amongst components may account for these patterns. This paper evaluates factors that may contribute to such declining benefit: increased attentional or effort burden; components that produce their effects via the same capacity limited mechanisms, making their effects subadditive; and a tipping point phenomenon in which those near a hypothesized "tipping point" for change will benefit markedly from weak intervention while those far from the tipping point will benefit little from even strong intervention. New research should explore factors that cause negative interactions amongst components and constrain the development of more effective treatments.

A systematic review of randomized controlled trials and network meta-analysis of e-cigarettes for smoking cessation

AIM

E-cigarettes, or nicotine vaping products, are potential smoking cessation aids that provide both nicotine and behavioural substitution for combustible cigarette smoking. This review aims to compare the effectiveness of nicotine e-cigarettes for smoking cessation with licensed nicotine replacement therapies (NRT) and nicotine-free based control conditions by using network meta-analysis (NMA).

METHODS

We searched PubMed, Web of Science and PsycINFO for randomised controlled trials (RCTs) that allocated individuals to use nicotine e-cigarettes, compared to those that used licensed NRT (e.g., nicotine patches, nicotine gums, etc), or a nicotine-free control condition such as receiving placebo (nicotine-free) e-cigarettes or usual care. We only included studies of healthy individuals who smoked. Furthermore, we identified the latest Cochrane review on NRT and searched NRT trials that were published in similar periods as the e-cigarette trials we identified. NMA was conducted to compare the effect of e-cigarettes on cessation relative to NRT and control condition. Cochrane risk-of-bias tool for randomized trials Version 2 was used to access study bias.

RESULTS

For the e-cigarette trials, our initial search identified 4,717 studies and we included 7 trials for NMA after removal of duplicates, record screening and assessment of eligibility (Total N = 5,674). For NRT trials, our initial search identified 1,014 studies and we included 9 trials that satisfied our inclusion criteria (Total N = 6,080). Results from NMA indicated that participants assigned to use nicotine e-cigarettes were more likely to remain abstinent from smoking than those in the control condition (pooled Risk Ratio (RR) = 2.08, 97.5% CI = [1.39, 3.15]) and those who were assigned to use NRT (pooled RR = 1.49, 97.5% CI = [1.04, 2.14]. There was a moderate heterogeneity between studies (I2 = 42%). Most of the e-cigarette trials has moderate or high risk of bias.

CONCLUSION

Smokers assigned to use nicotine e-cigarettes were more likely to remain abstinent from smoking than those assigned to use licensed NRT, and both were more effective than usual care or placebo conditions. More high quality studies are required to ascertain the effect of e-cigarette on smoking cessation due to risk of bias in the included studies.

Association of Spontaneous and Induced Self-Affirmation With Smoking Cessation in Users of a Mobile App: Randomized Controlled Trial

Background

Most smokers attempt to stop using cigarettes numerous times before successfully quitting. Cigarette cravings may undermine perceived competence to quit and thus constitute psychological threats to the individual’s self-concept. Self-affirmation may promote smoking cessation by offsetting these threats.

Objective

This study examines whether self-affirmation is associated with smoking cessation in the context of a cessation app. Two types of self-affirmation are examined: tendency to spontaneously self-affirm, and self-affirmation inductions added to a publicly available smoking cessation app (Smoke-Free Quit Smoking Now). In addition, this study explores whether optimism and emotional states (happiness, anger, anxiousness, hopefulness, sadness) predict smoking cessation.

Methods

All users who met the inclusion criteria, provided consent to participate, and completed a baseline assessment, including all individual difference measures, were randomized to 1 of 4 conditions. Half of the participants were randomly assigned to complete a self-affirmation induction upon study entry. Orthogonally, half of the participants were randomly assigned to receive self-affirming text notifications during their quit attempt or to receive conventional notifications. The induction and the text notifications were fully automated, and all data were collected through self-assessments in the app. Self-reported smoking cessation was assessed 1 month and 3 months following study entry.

Results

The study enrolled 7899 participants; 647 completed the 1-month follow-up. Using an intent-to-treat analysis at the 1-month follow-up, 7.2% (569/7899) of participants self-reported not smoking in the previous week and 6.4% (503/7899) self-reported not smoking in the previous month. Greater tendency to spontaneously self-affirm predicted a greater likelihood of cessation (P<.001) at 1 month after controlling for smoking-related variables. Neither self-affirmation induction influenced cessation. In addition, spontaneous self-affirmation did not moderate the relationship between self-affirmation inductions and cessation. Greater baseline sadness was associated with a lower likelihood of reporting successful cessation. Optimism predicted past-week cessation at the 1-month follow-up, and both happiness and anger predicted past-month cessation at the 1-month follow-up; however, none of these potential predictors moderated the relationship between self-affirmation conditions and successful cessation.

Conclusions

Spontaneous self-affirmation may be an important psychological resource for managing threats to self-concept during the smoking cessation process. Sadness may hinder quit attempts. Future research can explicate how spontaneous versus induced self-affirmation can promote smoking cessation and examine boundary conditions for the effectiveness of disseminated self-affirmation interventions.

Trial Registration

ISRCTN Registry 56646695; https://www.isrctn.com/ISRCTN56646695

Using Digital Technologies to Reach Tobacco Users Who Want to Quit: Evidence From the National Cancer Institute's Smokefree.gov Initiative

The rapid growth of smartphone ownership and broadband access has created new opportunities to reach smokers with cessation information and support using digital technologies. These technologies can both complement and be integrated with traditional support modalities such as telephone quitlines and 1-on-1 clinical cessation counseling. The National Cancer Institute's Smokefree.gov Initiative provides free, evidence-based cessation support to the public through a multimodal suite of digital interventions, including several mobile-optimized websites, text messaging programs, and 2 mobile applications. In addition to digital resources directed at the general population, the Smokefree.gov Initiative includes population-specific resources targeted to adolescents, women, military veterans, Spanish speakers, older adults, and other populations. This paper describes the reach and use of the Smokefree.gov Initiative's resources over a 5-year period between 2014 and 2018, including how users interact with the program's digital content in ways that facilitate engagement with live counseling support. Use of Smokefree.gov Initiative resources has grown steadily over time; in 2018 alone, approximately 7-8 million people accessed Smokefree.gov Initiative web- and mobile-based resources. Smokefree.gov Initiative utilization data show that people take advantage of the full range of technology tools and options offered as part of the Smokefree.gov Initiative's multiplatform intervention. The Smokefree.gov Initiative experience suggests that offering different, complementary technology options to meet the needs and preferences of smokers has the potential to meaningfully expand the reach of cessation treatment.

Comparing recruitment strategies for a digital smoking cessation intervention: Technology-assisted peer recruitment, social media, ResearchMatch, and smokefree.gov

BACKGROUND

Choosing the right recruitment strategy has implications for the successful conduct of a trial. Our objective was to compare a novel peer recruitment strategy to four other recruitment strategies for a large randomized trial testing a digital tobacco intervention.

METHODS

We compared enrollment rates, demographic and baseline smoking characteristics, and odds of completing the 6-month study by recruitment strategy. Cost of recruitment strategies per retained participant was calculated using staff personnel time and advertisement costs.

FINDINGS

We enrolled 1487 participants between August 2017 and March 2019 from: Peer recruitment n = 273 (18.4%), Facebook Ads n = 505 (34%), Google Ads = 200 (13.4%), ResearchMatch n = 356 (23.9%) and Smokefree.govn = 153 (10.3%). Mean enrollment rate per active recruitment month: 1) Peer recruitment, n = 13.9, 2) Facebook ads, n = 25.3, 3) Google ads, n = 10.51, 4) Research Match, n = 59.3, and 5) Smokefree.gov, n = 13.9. Peer recruitment recruited the greatest number of males (n = 110, 40.3%), young adults (n = 41, 14.7%), participants with a high school degree or less (n = 24, 12.5%) and smokers within one's social network. Compared to peer recruitment (retention rate = 57%), participants from Facebook were less likely (OR 0.46, p < 0.01, retention rate = 40%), and those from ResearchMatch were more likely to complete the study (OR 1.90, p < 0.01, retention rate = 70%). Peer recruitment was moderate in cost per retained participant ($47.18) and substantially less costly than Facebook ($173.60).

CONCLUSIONS

Though peer recruitment had lower enrollment than other strategies, it may provide greater access to harder to reach populations and possibly others who smoke within one's social network while being moderately cost-effective. ClinicalTrials.gov: NCT03224520.

Level of Alcohol Consumption and Successful Smoking Cessation

INTRODUCTION

The negative association between heavy alcohol use and likelihood of successful smoking cessation is well established. However, evidence on the effects of moderate alcohol consumption on smoking cessation is sparse. This analysis evaluated the association between alcohol use and smoking and the interaction of alcohol use and use of pharmacotherapy interventions in relation to smoking cessation.

METHODS

Data from adults (n = 923) recruited through a smoking cessation website between November 2011 and March 2012 were analyzed. Data on past-year alcohol use, tobacco use, and demographics were collected at baseline. Self-reported smoking abstinence and current alcohol use data were collected at 1 and 7 months posttreatment. Chi-square and multivariate logistic regression analyses were conducted.

RESULTS

At 1 month, adjusted odds of continued smoking were 1.54 times greater (95% confidence interval [CI] = 1.05% to 2.23%) for moderate drinkers and 2.59 times greater (95% CI = 1.33% to 4.28%) for heavy drinkers than nondrinkers. At 7 months, adjusted odds of continued smoking were not greater for moderate drinkers than nondrinkers, and were 2.32 times greater (95% CI = 1.35% to 3.96%) among heavy alcohol drinkers than nondrinkers. At 1 month, adjusted odds of smoking cessation were 2.33 times greater (95% CI = 1.04% to 3.09%) for alcohol users assigned to nicotine replacement therapy than for those not assigned to nicotine replacement therapy. This relationship was not observed at 7 months.

CONCLUSIONS

Moderate and heavy drinking might impact smoking cessation efforts. Recent moderate drinking may be associated with short-term continued smoking and heavy drinking associated with relapse in the short and long term.

IMPLICATIONS

This study suggests that moderate drinking may influence the process to quit smoking. Further study is needed to better understand the implications of moderate drinking for smoking cessation. Providing information alone may not be effective in helping people abstain from drinking during smoking cessation, especially if moderate drinkers do not perceive their behavior as reducing their chance for a successful quit attempt. Tailoring smoking cessation interventions to include strategies to reduce moderate-to-heavy alcohol consumption may improve smoking cessation outcomes among alcohol users attempting to quit smoking.

Randomization procedures for multicomponent behavioral intervention factorial trials in the multiphase optimization strategy framework: challenges and recommendations

The multiphase optimization strategy (MOST) is an increasingly popular framework to prepare, optimize, and evaluate multicomponent behavioral health interventions. Within this framework, it is common to use a factorial trial to assemble an optimized multicomponent intervention by simultaneously testing several intervention components. With the possibility of a large number of conditions (unique combinations of components) and a goal to balance conditions on both sample size (for statistical efficiency) and baseline covariates (for internal validity), such trials face additional randomization challenges compared to the standard two-arm trial. The purpose of the current paper is to compare and contrast potential randomization methods for factorial trials in the context of MOST and to provide guidance for the reporting of those methods. We describe the principles, advantages, and disadvantages of several randomization methods in the context of factorial trials. We then provide examples to examine current practice in the MOST-related literature and provide recommendations for reporting of randomization. We identify two key randomization decisions for MOST-related factorial trials: (i) whether to randomize to components or conditions and (ii) whether to use restricted randomization techniques, such as stratification, permuted blocks, and minimization. We also provide a checklist to assist researchers in ensuring complete reporting of randomization methods used. As more investigators use factorial trials within the MOST framework for assembling optimized multicomponent behavioral interventions, appropriate implementation and rigorous reporting of randomization procedures will be essential for ensuring the efficiency and validity of the results.

Mobile phone text messaging and app-based interventions for smoking cessation

BACKGROUND

Mobile phone-based smoking cessation support (mCessation) offers the opportunity to provide behavioural support to those who cannot or do not want face-to-face support. In addition, mCessation can be automated and therefore provided affordably even in resource-poor settings. This is an update of a Cochrane Review first published in 2006, and previously updated in 2009 and 2012.

OBJECTIVES

To determine whether mobile phone-based smoking cessation interventions increase smoking cessation rates in people who smoke.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group's Specialised Register, along with clinicaltrials.gov and the ICTRP. The date of the most recent searches was 29 October 2018.

SELECTION CRITERIA

Participants were smokers of any age. Eligible interventions were those testing any type of predominantly mobile phone-based programme (such as text messages (or smartphone app) for smoking cessation. We included randomised controlled trials with smoking cessation outcomes reported at at least six-month follow-up.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures described in the Cochrane Handbook for Systematic Reviews of Interventions. We performed both study eligibility checks and data extraction in duplicate. We performed meta-analyses of the most stringent measures of abstinence at six months' follow-up or longer, using a Mantel-Haenszel random-effects method, pooling studies with similar interventions and similar comparators to calculate risk ratios (RR) and their corresponding 95% confidence intervals (CI). We conducted analyses including all randomised (with dropouts counted as still smoking) and complete cases only.

MAIN RESULTS

This review includes 26 studies (33,849 participants). Overall, we judged 13 studies to be at low risk of bias, three at high risk, and the remainder at unclear risk. Settings and recruitment procedures varied across studies, but most studies were conducted in high-income countries. There was moderate-certainty evidence, limited by inconsistency, that automated text messaging interventions were more effective than minimal smoking cessation support (RR 1.54, 95% CI 1.19 to 2.00; I² = 71%; 13 studies, 14,133 participants). There was also moderate-certainty evidence, limited by imprecision, that text messaging added to other smoking cessation interventions was more effective than the other smoking cessation interventions alone (RR 1.59, 95% CI 1.09 to 2.33; I² = 0%, 4 studies, 997 participants). Two studies comparing text messaging with other smoking cessation interventions, and three studies comparing high- and low-intensity messaging, did not show significant differences between groups (RR 0.92 95% CI 0.61 to 1.40; I² = 27%; 2 studies, 2238 participants; and RR 1.00, 95% CI 0.95 to 1.06; I² = 0%, 3 studies, 12,985 participants, respectively) but confidence intervals were wide in the former comparison. Five studies compared a smoking cessation smartphone app with lower-intensity smoking cessation support (either a lower-intensity app or non-app minimal support). We pooled the evidence and deemed it to be of very low certainty due to inconsistency and serious imprecision. It provided no evidence that smartphone apps improved the likelihood of smoking cessation (RR 1.00, 95% CI 0.66 to 1.52; I² = 59%; 5 studies, 3079 participants). Other smartphone apps tested differed from the apps included in the analysis, as two used contingency management and one combined text messaging with an app, and so we did not pool them. Using complete case data as opposed to using data from all participants randomised did not substantially alter the findings.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that automated text message-based smoking cessation interventions result in greater quit rates than minimal smoking cessation support. There is moderate-certainty evidence of the benefit of text messaging interventions in addition to other smoking cessation support in comparison with that smoking cessation support alone. The evidence comparing smartphone apps with less intensive support was of very low certainty, and more randomised controlled trials are needed to test these interventions.

Current advances in research in treatment and recovery: Nicotine addiction

The health harms of combusted tobacco use are undeniable. With market and regulatory pressures to reduce the harms of nicotine delivery by combustion, the tobacco product landscape has diversified to include smokeless, heated, and electronic nicotine vaping products. Products of tobacco combustion are the main cause of smoking-induced disease, and nicotine addiction sustains tobacco use. An understanding of the biology and clinical features of nicotine addiction and the conditioning of behavior that occurs via stimuli paired with frequent nicotine dosing, as with a smoked cigarette, is important for informing pharmacologic and behavioral treatment targets. We review current advances in research on nicotine addiction treatment and recovery, with a focus on conventional combustible cigarette use. Our review covers evidence-based methods to treat smoking in adults and policy approaches to prevent nicotine product initiation in youth. In closing, we discuss emerging areas of evidence and consider new directions for advancing the field.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I2 statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I2 = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I2 = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I2 = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials that provide a structured programme for smokers to follow may increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine the effectiveness of different forms of print-based self-help materials that provide a structured programme for smokers to follow, compared with no treatment and with other minimal contact strategies, and to determine the comparative effectiveness of different components and characteristics of print-based self-help, such as computer-generated feedback, additional materials, tailoring of materials to individuals, and targeting of materials at specific groups.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Trials Register, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The date of the most recent search was March 2018.

SELECTION CRITERIA

We included randomised trials of smoking cessation with follow-up of at least six months, where at least one arm tested print-based materials providing self-help compared with minimal print-based self-help (such as a short leaflet) or a lower-intensity control. We defined 'self-help' as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in accordance with standard methodological procedures set out by Cochrane. The main outcome measure was abstinence from smoking after at least six months' follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each study and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a random-effects model.

MAIN RESULTS

We identified 75 studies that met our inclusion criteria. Many study reports did not include sufficient detail to allow judgement of risk of bias for some domains. We judged 30 studies (40%) to be at high risk of bias for one or more domains.Thirty-five studies evaluated the effects of standard, non-tailored self-help materials. Eleven studies compared self-help materials alone with no intervention and found a small effect in favour of the intervention (n = 13,241; risk ratio (RR) 1.19, 95% confidence interval (CI) 1.03 to 1.37; I² = 0%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for indirect relevance to populations in low- and middle-income countries because evidence for this comparison came from studies conducted solely in high-income countries and there is reason to believe the intervention might work differently in low- and middle-income countries. This analysis excluded two studies by the same author team with strongly positive outcomes that were clear outliers and introduced significant heterogeneity. Six further studies of structured self-help compared with brief leaflets did not show evidence of an effect of self-help materials on smoking cessation (n = 7023; RR 0.87, 95% CI 0.71 to 1.07; I² = 21%). We found evidence of benefit from standard self-help materials when there was brief contact that did not include smoking cessation advice (4 studies; n = 2822; RR 1.39, 95% CI 1.03 to 1.88; I² = 0%), but not when self-help was provided as an adjunct to face-to-face smoking cessation advice for all participants (11 studies; n = 5365; RR 0.99, 95% CI 0.76 to 1.28; I² = 32%).Thirty-two studies tested materials tailored for the characteristics of individual smokers, with controls receiving no materials, or stage-matched or non-tailored materials. Most of these studies used more than one mailing. Pooling studies that compared tailored self-help with no self-help, either on its own or compared with advice, or as an adjunct to advice, showed a benefit of providing tailored self-help interventions (12 studies; n = 19,190; RR 1.34, 95% CI 1.20 to 1.49; I² = 0%) with little evidence of difference between subgroups (10 studies compared tailored with no materials, n = 14,359; RR 1.34, 95% CI 1.19 to 1.51; I² = 0%; two studies compared tailored materials with brief advice, n = 2992; RR 1.13, 95% CI 0.86 to 1.49; I² = 0%; and two studies evaluated tailored materials as an adjunct to brief advice, n = 1839; RR 1.72, 95% CI 1.17 to 2.53; I² = 10%). When studies compared tailored self-help with non-tailored self-help, results favoured tailored interventions when the tailored interventions involved more mailings than the non-tailored interventions (9 studies; n = 14,166; RR 1.42, 95% CI 1.20 to 1.68; I² = 0%), but not when the two conditions were contact-matched (10 studies; n = 11,024; RR 1.07, 95% CI 0.89 to 1.30; I² = 50%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for risk of bias.Five studies evaluated self-help materials as an adjunct to nicotine replacement therapy; pooling three of these provided no evidence of additional benefit (n = 1769; RR 1.05, 95% CI 0.86 to 1.30; I² = 0%). Four studies evaluating additional written materials favoured the intervention, but the lower confidence interval crossed the line of no effect (RR 1.20, 95% CI 0.91 to 1.58; I² = 73%). A small number of other studies did not detect benefit from using targeted materials, or find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that when no other support is available, written self-help materials help more people to stop smoking than no intervention. When people receive advice from a health professional or are using nicotine replacement therapy, there is no evidence that self-help materials add to their effect. However, small benefits cannot be excluded. Moderate-certainty evidence shows that self-help materials that use data from participants to tailor the nature of the advice or support given are more effective than no intervention. However, when tailored self-help materials, which typically involve repeated assessment and mailing, were compared with untailored materials delivered similarly, there was no evidence of benefit.Available evidence tested self-help interventions in high-income countries, where more intensive support is often available. Further research is needed to investigate effects of these interventions in low- and middle-income countries, where more intensive support may not be available.

Which eHealth interventions are most effective for smoking cessation? A systematic review

PURPOSE

To synthesize evidence of the effects and potential effect modifiers of different electronic health (eHealth) interventions to help people quit smoking.

METHODS

Four databases (MEDLINE, PsycINFO, Embase, and The Cochrane Library) were searched in March 2017 using terms that included "smoking cessation", "eHealth/mHealth" and "electronic technology" to find relevant studies. Meta-analysis and meta-regression analyses were performed using Mantel-Haenszel test for fixed-effect risk ratio (RR) and restricted maximum-likelihood technique, respectively. Protocol Registration Number: CRD42017072560.

RESULTS

The review included 108 studies and 110,372 participants. Compared to nonactive control groups (eg, usual care), smoking cessation interventions using web-based and mobile health (mHealth) platform resulted in significantly greater smoking abstinence, RR 2.03 (95% CI 1.7-2.03), and RR 1.71 (95% CI 1.35-2.16), respectively. Similarly, smoking cessation trials using tailored text messages (RR 1.80, 95% CI 1.54-2.10) and web-based information and conjunctive nicotine replacement therapy (RR 1.29, 95% CI 1.17-1.43) may also increase cessation. In contrast, little or no benefit for smoking abstinence was found for computer-assisted interventions (RR 1.31, 95% CI 1.11-1.53). The magnitude of effect sizes from mHealth smoking cessation interventions was likely to be greater if the trial was conducted in the USA or Europe and when the intervention included individually tailored text messages. In contrast, high frequency of texts (daily) was less effective than weekly texts.

CONCLUSIONS

There was consistent evidence that web-based and mHealth smoking cessation interventions may increase abstinence moderately. Methodologic quality of trials and the intervention characteristics (tailored vs untailored) are critical effect modifiers among eHealth smoking cessation interventions, especially for web-based and text messaging trials. Future smoking cessation intervention should take advantages of web-based and mHealth engagement to improve prolonged abstinence.

Lifetime Depression, Other Mental Illness, and Smoking Cessation

Objectives In this study, we attempt to elucidate the relationship between lifetime mental illness (LMI), particularly a depression diagnosis, and smoking cessation. Methods Data were drawn from a previous study and include LMI, demographics, mood, and smoking cessation outcomes. We evaluated the relationship between multiple LMIs and smoking cessation at 7 months post-intervention, and depression in combination with another LMI. Results At 7 months, the adjusted odds of cessation for those with one LMI, including depression, were 0.74 (p = .102), and for those with 2+ LMIs, 0.69 (p = .037), both in comparison with participants who reported no history of LMI. Among those with 2+ LMIs, the adjusted odds of cessation for those with a depression diagnosis were 0.34 (p = .007) compared to those whose multiple LMIs did not include depression. Conclusions Among smokers seeking cessation treatment, those who had 2+ LMIs were at greater risk of relapse, an effect particularly marked in smokers with depression. This study adds to the literature examining the potential impact of LMI on smokers' ability to quit by considering the potential impact of 2+ LMIs and highlights the potential impact of depression as a risk factor for continued smoking.

Nicotine replacement therapy versus control for smoking cessation

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

BACKGROUND AND AIMS

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

DESIGN

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

SETTING

United States.

PARTICIPANTS

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

INTERVENTIONS

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

MEASUREMENTS

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

FINDINGS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Feasibility of biochemical verification in a web-based smoking cessation study

BACKGROUND AND AIMS

Cogent arguments have been made against the need for biochemical verification in population-based studies with low-demand characteristics. Despite this fact, studies involving digital interventions (low-demand) are often required in peer review to report biochemically verified abstinence. To address this discrepancy, we examined the feasibility and costs of biochemical verification in a web-based study conducted with a national sample.

METHODS

Participants were 600U.S. adult current smokers who registered on a web-based smoking cessation program and completed surveys at baseline and 3months. Saliva sampling kits were sent to participants who reported 7-day abstinence at 3months, and analyzed for cotinine.

RESULTS

The response rate at 3-months was 41.2% (n=247): 93 participants reported 7-day abstinence (38%) and were mailed a saliva kit (71% returned). The discordance rate was 36.4%. Participants with discordant responses were more likely to report 3-month use of nicotine replacement therapy or e-cigarettes than those with concordant responses (79.2% vs. 45.2%, p=0.007). The total cost of saliva sampling was $8280 ($125/sample).

CONCLUSIONS

Biochemical verification was both time- and cost-intensive, and yielded a relatively small number of samples due to low response rates and use of other nicotine products during the follow-up period. There was a high rate of discordance of self-reported abstinence and saliva testing. Costs for data collection may be prohibitive for studies with large sample sizes or limited budgets. Our findings echo previous statements that biochemical verification is not necessary in population-based studies, and add evidence specific to technology-based studies.

Internet-based interventions for smoking cessation

BACKGROUND

Tobacco use is estimated to kill 7 million people a year. Nicotine is highly addictive, but surveys indicate that almost 70% of US and UK smokers would like to stop smoking. Although many smokers attempt to give up on their own, advice from a health professional increases the chances of quitting. As of 2016 there were 3.5 billion Internet users worldwide, making the Internet a potential platform to help people quit smoking.

OBJECTIVES

To determine the effectiveness of Internet-based interventions for smoking cessation, whether intervention effectiveness is altered by tailoring or interactive features, and if there is a difference in effectiveness between adolescents, young adults, and adults.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, which included searches of MEDLINE, Embase and PsycINFO (through OVID). There were no restrictions placed on language, publication status or publication date. The most recent search was conducted in August 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). Participants were people who smoked, with no exclusions based on age, gender, ethnicity, language or health status. Any type of Internet intervention was eligible. The comparison condition could be a no-intervention control, a different Internet intervention, or a non-Internet intervention. To be included, studies must have measured smoking cessation at four weeks or longer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and extracted data. We extracted and, where appropriate, pooled smoking cessation outcomes of six-month follow-up or more, reporting short-term outcomes narratively where longer-term outcomes were not available. We reported study effects as a risk ratio (RR) with a 95% confidence interval (CI).We grouped studies according to whether they (1) compared an Internet intervention with a non-active control arm (e.g. printed self-help guides), (2) compared an Internet intervention with an active control arm (e.g. face-to-face counselling), (3) evaluated the addition of behavioural support to an Internet programme, or (4) compared one Internet intervention with another. Where appropriate we grouped studies by age.

MAIN RESULTS

We identified 67 RCTs, including data from over 110,000 participants. We pooled data from 35,969 participants.There were only four RCTs conducted in adolescence or young adults that were eligible for meta-analysis.Results for trials in adults: Eight trials compared a tailored and interactive Internet intervention to a non-active control. Pooled results demonstrated an effect in favour of the intervention (RR 1.15, 95% CI 1.01 to 1.30, n = 6786). However, statistical heterogeneity was high (I2 = 58%) and was unexplained, and the overall quality of evidence was low according to GRADE. Five trials compared an Internet intervention to an active control. The pooled effect estimate favoured the control group, but crossed the null (RR 0.92, 95% CI 0.78 to 1.09, n = 3806, I2 = 0%); GRADE quality rating was moderate. Five studies evaluated an Internet programme plus behavioural support compared to a non-active control (n = 2334). Pooled, these studies indicated a positive effect of the intervention (RR 1.69, 95% CI 1.30 to 2.18). Although statistical heterogeneity was substantial (I2 = 60%) and was unexplained, the GRADE rating was moderate. Four studies evaluated the Internet plus behavioural support compared to active control. None of the studies detected a difference between trial arms (RR 1.00, 95% CI 0.84 to 1.18, n = 2769, I2 = 0%); GRADE rating was moderate. Seven studies compared an interactive or tailored Internet intervention, or both, to an Internet intervention that was not tailored/interactive. Pooled results favoured the interactive or tailored programme, but the estimate crossed the null (RR 1.10, 95% CI 0.99 to 1.22, n = 14,623, I2 = 0%); GRADE rating was moderate. Three studies compared tailored with non-tailored Internet-based messages, compared to non-tailored messages. The tailored messages produced higher cessation rates compared to control, but the estimate was not precise (RR 1.17, 95% CI 0.97 to 1.41, n = 4040), and there was evidence of unexplained substantial statistical heterogeneity (I2 = 57%); GRADE rating was low.Results should be interpreted with caution as we judged some of the included studies to be at high risk of bias.

AUTHORS' CONCLUSIONS

The evidence from trials in adults suggests that interactive and tailored Internet-based interventions with or without additional behavioural support are moderately more effective than non-active controls at six months or longer, but there was no evidence that these interventions were better than other active smoking treatments. However some of the studies were at high risk of bias, and there was evidence of substantial statistical heterogeneity. Treatment effectiveness in younger people is unknown.

The 2016 Ferno Award Address: Three Things

Researchers may optimize smoking treatment by addressing three research topics that have been relatively neglected. First, researchers have neglected to intensively explore how counseling contents affect smoking cessation success. Worldwide, millions of smokers are exposed to different smoking cessation contents and messages, yet existing research evidence does not permit strong inference about the value of particular counseling contents or strategies. Research in this area could enhance smoking outcomes and yield new insights into smoking motivation. Second, researchers have focused great attention on inducing smokers to make quit attempts when they contact healthcare systems; the success of such efforts may have plateaued. Also, the vast majority of quit attempts are self-quit attempts, largely unsuccessful, that occur outside such contacts. Researchers should explore strategies for using healthcare systems as conduits for digital- and other population-based interventions independent of healthcare visits. Such resources should be used to graft timely access to evidence-based intervention onto self-quitting, yielding evidence-based, patient-managed quit attempts. Third, most smoking treatments are assembled via selection of components based on informal synthesis of empirical and impressionistic evidence and are evaluated as a package. However, recent factorial experiments show that components of smoking treatments often interact meaningfully; for example, some components may interfere with the effectiveness of other components. Many extant treatments likely comprise suboptimal sets of components; future treatment development should routinely use factorial experiments to permit the assembly of components that yield additive or synergistic effects.Research in the above three areas should significantly advance our understanding of tobacco use and its treatment.

IMPLICATIONS

A lack of relevant research, and the likely prospect of significant clinical and public health benefit, underscore the importance of performing research on three topics related to smoking intervention: (1) researchers need to identify which contents of smoking counseling are effective; (2) researchers need to devise innovative strategies that use healthcare systems as conduits of smoking treatment delivery outside of clinical contacts; and (3) researchers need to use factorial designs to guide their development of smoking treatments. Research on these topics should yield complementary evidence that guides the development of more effective smoking treatments.

Implementing Clinical Research Using Factorial Designs: A Primer

Factorial experiments have rarely been used in the development or evaluation of clinical interventions. However, factorial designs offer advantages over randomized controlled trial designs, the latter being much more frequently used in such research. Factorial designs are highly efficient (permitting evaluation of multiple intervention components with good statistical power) and present the opportunity to detect interactions amongst intervention components. Such advantages have led methodologists to advocate for the greater use of factorial designs in research on clinical interventions (Collins, Dziak, & Li, 2009). However, researchers considering the use of such designs in clinical research face a series of choices that have consequential implications for the interpretability and value of the experimental results. These choices include: whether to use a factorial design, selection of the number and type of factors to include, how to address the compatibility of the different factors included, whether and how to avoid confounds between the type and number of interventions a participant receives, and how to interpret interactions. The use of factorial designs in clinical intervention research poses choices that differ from those typically considered in randomized clinical trial designs. However, the great information yield of the former encourages clinical researchers' increased and careful execution of such designs.

Internet-Delivered Health Interventions That Work: Systematic Review of Meta-Analyses and Evaluation of Website Availability

BACKGROUND

Due to easy access and low cost, Internet-delivered therapies offer an attractive alternative to improving health. Although numerous websites contain health-related information, finding evidence-based programs (as demonstrated through randomized controlled trials, RCTs) can be challenging. We sought to bridge the divide between the knowledge gained from RCTs and communication of the results by conducting a global systematic review and analyzing the availability of evidence-based Internet health programs.

OBJECTIVES

The study aimed to (1) discover the range of health-related topics that are addressed through Internet-delivered interventions, (2) generate a list of current websites used in the trials which demonstrate a health benefit, and (3) identify gaps in the research that may have hindered dissemination. Our focus was on Internet-delivered self-guided health interventions that did not require real-time clinical support.

METHODS

A systematic review of meta-analyses was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO Registration Number CRD42016041258). MEDLINE via Ovid, PsycINFO, Embase, Cochrane Database of Systematic Reviews, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched. Inclusion criteria included (1) meta-analyses of RCTs, (2) at least one Internet-delivered intervention that measured a health-related outcome, and (3) use of at least one self-guided intervention. We excluded group-based therapies. There were no language restrictions.

RESULTS

Of the 363 records identified through the search, 71 meta-analyses met inclusion criteria. Within the 71 meta-analyses, there were 1733 studies that contained 268 unique RCTs which tested self-help interventions. On review of the 268 studies, 21.3% (57/268) had functional websites. These included evidence-based Web programs on substance abuse (alcohol, tobacco, cannabis), mental health (depression, anxiety, post-traumatic stress disorder [PTSD], phobias, panic disorders, obsessive compulsive disorder [OCD]), and on diet and physical activity. There were also evidence-based programs on insomnia, chronic pain, cardiovascular risk, and childhood health problems. These programs tended to be intensive, requiring weeks to months of engagement by the user, often including interaction, personalized and normative feedback, and self-monitoring. English was the most common language, although some were available in Spanish, French, Portuguese, Dutch, German, Norwegian, Finnish, Swedish, and Mandarin. There were several interventions with numbers needed to treat of <5; these included painACTION, Mental Health Online for panic disorders, Deprexis, Triple P Online (TPOL), and U Can POOP Too. Hyperlinks of the sites have been listed.

CONCLUSIONS

A wide range of evidence-based Internet programs are currently available for health-related behaviors, as well as disease prevention and treatment. However, the majority of Internet-delivered health interventions found to be efficacious in RCTs do not have websites for general use. Increased efforts to provide mechanisms to host "interventions that work" on the Web and to assist the public in locating these sites are necessary.

Extended Self-Help for Smoking Cessation: A Randomized Controlled Trial

INTRODUCTION

Far too few smokers receive recommended interventions at their healthcare visits, highlighting the importance of identifying effective, low-cost smoking interventions that can be readily delivered. Self-help interventions (e.g., written materials) would meet this need, but they have shown low efficacy. The purpose of this RCT was to determine the efficacy of a self-help intervention with increased duration and intensity.

DESIGN

Randomized parallel trial design involving enrollment between April 2010 and August 2011 with follow-up data for 24 months.

SETTING/PARTICIPANTS

U.S. national sample of daily smokers (N=1,874).

INTERVENTION

Participants were randomized to one of three arms of a parallel trial design: Traditional Self-Help (TSH, n=638), Standard Repeated Mailings (SRM, n=614), or Intensive Repeated Mailings (IRM, n=622). TSH received an existing self-help booklet for quitting smoking. SRM received eight different cessation booklets mailed over a 12-month period. IRM received monthly mailings of ten booklets and additional material designed to enhance social support over 18 months.

MAIN OUTCOME MEASURES

The primary outcome was 7-day point-prevalence abstinence collected at 6, 12, 18, and 24 months.

RESULTS

Data were analyzed between 2013 and 2015. A dose-response effect was found across all four follow-up points. For example, by 24 months, IRM produced the highest abstinence rate (30.0%), followed by SRM (24.4%) and TSH (18.9%). The difference in 24-month abstinence rates between IRM and TSH was 11.0% (95% CI=5.7%, 16.3%). Cost analyses indicated that, compared with TSH, the incremental cost per quitter who received SRM and IRM was $560 and $361, respectively.

CONCLUSIONS

Self-help interventions with increased intensity and duration resulted in significantly improved abstinence rates that extended 6 months beyond the end of the intervention. Despite the greater intensity, the interventions were highly cost effective, suggesting that widespread dissemination in healthcare settings could greatly enhance quitting.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01352195.

A Pilot Test of Self-Affirmations to Promote Smoking Cessation in a National Smoking Cessation Text Messaging Program

Background

Although effective smoking cessation treatments, including mHealth interventions, have been empirically validated and are widely available, smoking relapse is likely. Self-affirmation, a process through which individuals focus on their strengths and behaviors, has been shown to reduce negative effects of self-threats and to promote engagement in healthier behavior.

Objective

To assess the feasibility of incorporating self-affirmations into an existing text messaging-based smoking cessation program (Smokefree TXT) and to determine whether self-affirmation led to greater engagement and higher cessation rates than the standard intervention.

Methods

Data were collected from smokers (n=1261) who subscribed to a free smoking cessation program and met eligibility criteria. The intervention lasted 42 days. The original design was a 2 (Baseline affirmation: 5-item questionnaire present vs absent) × 2 (Integrated affirmation: texts present vs absent) factorial design. Only 17 eligible users completed all baseline affirmation questions and these conditions did not influence any outcomes, so we collapsed across baseline affirmation conditions in analysis. In the integrated affirmation conditions, affirmations replaced approximately 20% of texts delivering motivational content.

Results

In all, 687 users remained enrolled throughout the 42-day intervention and 81 reported smoking status at day 42. Among initiators (n=1261), self-affirmation did not significantly improve (1) intervention completion, (2) days enrolled, (3) 1-week smoking status, or (4) 6-week smoking status (all Ps>.10); and among the 687 completers, there were no significant effects of affirmation on cessation (Ps>.25). However, among the 81 responders, those who received affirmations were more likely to report cessation at 6 weeks (97.5%; 39 of 40) than those not given affirmations (78.1%; 32 of 41; χ²(1)=7.08, P=.008).

Conclusion

This proof-of-concept study provides preliminary evidence that self-affirmation can be integrated into existing text-based cessation programs, as the affirmations did not lead to any adverse effects (ie, less engagement or lower rates of cessation). Among those who reported smoking status at the end of the intervention period (6.4% of eligible respondents), affirmations facilitated cessation. This study provides a “proof-of-concept” that brief, low-touch interventions may be integrated into a text messaging program with potential benefits, minimal disruption to the program or users, and little cost. Many questions remain regarding how self-affirmation and similar approaches can promote engagement in population interventions.

Systematic review and meta-analysis of Internet interventions for smoking cessation among adults

BACKGROUND

The aim of this systematic review was to determine the effectiveness of Internet interventions in promoting smoking cessation among adult tobacco users relative to other forms of intervention recommended in treatment guidelines.

METHODS

This review followed Cochrane Collaboration guidelines for systematic reviews. Combinations of "Internet," "web-based," and "smoking cessation intervention" and related keywords were used in both automated and manual searches. We included randomized trials published from January 1990 through to April 2015. A modified version of the Cochrane risk of bias assessment tool was used. We calculated risk ratios (RRs) for each study. Meta-analysis was conducted using random-effects method to pool RRs. Presentation of results follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

Forty randomized trials involving 98,530 participants were included. Most trials had a low risk of bias in most domains. Pooled results comparing Internet interventions to assessment-only/waitlist control were significant (RR 1.60, 95% confidence interval [CI] 1.15-2.21, I (2)=51.7%; four studies). Pooled results of largely static Internet interventions compared to print materials were not significant (RR 0.83, 95% CI 0.63-1.10, I (2)=0%; two studies), whereas comparisons of interactive Internet interventions to print materials were significant (RR 2.10, 95% CI 1.25-3.52, I (2)=41.6%; two studies). No significant effects were observed in pooled results of Internet interventions compared to face-to-face counseling (RR 1.35, 95% CI 0.97-1.87, I (2)=0%; four studies) or to telephone counseling (RR 0.95, 95% CI 0.79-1.13, I (2)=0%; two studies). The majority of trials compared different Internet interventions; pooled results from 15 such trials (24 comparisons) found a significant effect in favor of experimental Internet interventions (RR 1.16, 95% CI 1.03-1.31, I (2)=76.7%).

CONCLUSION

Internet interventions are superior to other broad reach cessation interventions (ie, print materials), equivalent to other currently recommended treatment modes (telephone and in-person counseling), and they have an important role to play in the arsenal of tobacco-dependence treatments.

Mobile phone-based interventions for smoking cessation

BACKGROUND

Access to mobile phones continues to increase exponentially globally, outstripping access to fixed telephone lines, fixed computers and the Internet. Mobile phones are an appropriate and effective option for the delivery of smoking cessation support in some contexts. This review updates the evidence on the effectiveness of mobile phone-based smoking cessation interventions.

OBJECTIVES

To determine whether mobile phone-based smoking cessation interventions increase smoking cessation in people who smoke and want to quit.

SEARCH METHODS

For the most recent update, we searched the Cochrane Tobacco Addiction Group Specialised Register in April 2015. We also searched the UK Clinical Research Network Portfolio for current projects in the UK, and the ClinicalTrials.gov register for ongoing or recently completed studies. We searched through the reference lists of identified studies and attempted to contact the authors of ongoing studies. We applied no restrictions on language or publication date.

SELECTION CRITERIA

We included randomised or quasi-randomised trials. Participants were smokers of any age who wanted to quit. Studies were those examining any type of mobile phone-based intervention for smoking cessation. This included any intervention aimed at mobile phone users, based around delivery via mobile phone, and using any functions or applications that can be used or sent via a mobile phone.

DATA COLLECTION AND ANALYSIS

Review authors extracted information on risk of bias and methodological details using a standardised form. We considered participants who dropped out of the trials or were lost to follow-up to be smoking. We calculated risk ratios (RR) and 95% confidence intervals (CI) for each included study. Meta-analysis of the included studies used the Mantel-Haenszel fixed-effect method. Where meta-analysis was not possible, we presented a narrative summary and descriptive statistics.

MAIN RESULTS

This updated search identified 12 studies with six-month smoking cessation outcomes, including seven studies completed since the previous review. The interventions were predominantly text messaging-based, although several paired text messaging with in-person visits or initial assessments. Two studies gave pre-paid mobile phones to low-income human immunodeficiency virus (HIV)-positive populations - one solely for phone counselling, the other also included text messaging. One study used text messages to link to video messages. Control programmes varied widely. Studies were pooled according to outcomes - some providing measures of continuous abstinence or repeated measures of point prevalence; others only providing 7-day point prevalence abstinence. All 12 studies pooled using their most rigorous 26-week measures of abstinence provided an RR of 1.67 (95% CI 1.46 to 1.90; I(2) = 59%). Six studies verified quitting biochemically at six months (RR 1.83; 95% CI 1.54 to 2.19).

AUTHORS' CONCLUSIONS

The current evidence supports a beneficial impact of mobile phone-based smoking cessation interventions on six-month cessation outcomes. While all studies were good quality, the fact that those studies with biochemical verification of quitting status demonstrated an even higher chance of quitting further supports the positive findings. However, it should be noted that most included studies were of text message interventions in high-income countries with good tobacco control policies. Therefore, caution should be taken in generalising these results outside of this type of intervention and context.

Combined pharmacotherapy and behavioural interventions for smoking cessation

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Comparative effectiveness of motivation phase intervention components for use with smokers unwilling to quit: a factorial screening experiment

AIMS

To screen promising intervention components designed to reduce smoking and promote abstinence in smokers initially unwilling to quit.

DESIGN

A balanced, four-factor, randomized factorial experiment.

SETTING

Eleven primary care clinics in southern Wisconsin, USA.

PARTICIPANTS

A total of 517 adult smokers (63.4% women, 91.1% white) recruited during primary care visits who were willing to reduce their smoking but not quit.

INTERVENTIONS

Four factors contrasted intervention components designed to reduce smoking and promote abstinence: (1) nicotine patch versus none; (2) nicotine gum versus none; (3) motivational interviewing (MI) versus none; and (4) behavioral reduction counseling (BR) versus none. Participants could request cessation treatment at any point during the study.

MEASUREMENTS

The primary outcome was percentage change in cigarettes smoked per day at 26 weeks post-study enrollment; the secondary outcomes were percentage change at 12 weeks and point-prevalence abstinence at 12 and 26 weeks post-study enrollment.

FINDINGS

There were few main effects, but a significant four-way interaction at 26 weeks post-study enrollment (P = 0.01, β = 0.12) revealed relatively large smoking reductions by two component combinations: nicotine gum combined with BR and BR combined with MI. Further, BR improved 12-week abstinence rates (P = 0.04), and nicotine gum, when used without MI, increased 26-week abstinence after a subsequent aided quit attempt (P = 0.01).

CONCLUSIONS

Motivation-phase nicotine gum and behavioral reduction counseling are promising intervention components for smokers who are initially unwilling to quit.

Comparative effectiveness of intervention components for producing long-term abstinence from smoking: a factorial screening experiment

AIMS

To identify promising intervention components that help smokers attain and maintain abstinence during a quit attempt.

DESIGN

A 2 × 2 × 2 × 2 × 2 randomized factorial experiment.

SETTING

Eleven primary care clinics in Wisconsin, USA.

PARTICIPANTS

A total of 544 smokers (59% women, 86% white) recruited during primary care visits and motivated to quit.

INTERVENTIONS

Five intervention components designed to help smokers attain and maintain abstinence: (1) extended medication (26 versus 8 weeks of nicotine patch + nicotine gum); (2) maintenance (phone) counseling versus none; (3) medication adherence counseling versus none; (4) automated (medication) adherence calls versus none; and (5) electronic medication monitoring with feedback and counseling versus electronic medication monitoring alone.

MEASUREMENTS

The primary outcome was 7-day self-reported point-prevalence abstinence 1 year after the target quit day.

FINDINGS

Only extended medication produced a main effect. Twenty-six versus 8 weeks of medication improved point-prevalence abstinence rates (43 versus 34% at 6 months; 34 versus 27% at 1 year; P = 0.01 for both). There were four interaction effects at 1 year, showing that an intervention component's effectiveness depended upon the components with which it was combined.

CONCLUSIONS

Twenty-six weeks of nicotine patch + nicotine gum (versus 8 weeks) and maintenance counseling provided by phone are promising intervention components for the cessation and maintenance phases of smoking treatment.

Enhancing the effectiveness of smoking treatment research: conceptual bases and progress

BACKGROUND AND AIMS

A chronic care strategy could potentially enhance the reach and effectiveness of smoking treatment by providing effective interventions for all smokers, including those who are initially unwilling to quit. This paper describes the conceptual bases of a National Cancer Institute-funded research program designed to develop an optimized, comprehensive, chronic care smoking treatment.

METHODS

This research is grounded in three methodological approaches: (1) the Phase-Based Model, which guides the selection of intervention components to be experimentally evaluated for the different phases of smoking treatment (motivation, preparation, cessation, and maintenance); (2) the Multiphase Optimization Strategy (MOST), which guides the screening of intervention components via efficient experimental designs and, ultimately, the assembly of promising components into an optimized treatment package; and (3) pragmatic research methods, such as electronic health record recruitment, that facilitate the efficient translation of research findings into clinical practice. Using this foundation and working in primary care clinics, we conducted three factorial experiments (reported in three accompanying papers) to screen 15 motivation, preparation, cessation and maintenance phase intervention components for possible inclusion in a chronic care smoking treatment program.

RESULTS

This research identified intervention components with relatively strong evidence of effectiveness at particular phases of smoking treatment and it demonstrated the efficiency of the MOST approach in terms both of the number of intervention components tested and of the richness of the information yielded.

CONCLUSIONS

A new, synthesized research approach efficiently evaluates multiple intervention components to identify promising components for every phase of smoking treatment. Many intervention components interact with one another, supporting the use of factorial experiments in smoking treatment development.

The Past, Present, and Future of Nicotine Addiction Therapy

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