Boosting population quits through evidence-based cessation treatment and policy

Examining the Association between Abstinence from Smoking and Healthcare Costs among Patients with Cancer

Continuous tobacco use in patients with cancer is linked to substantial healthcare costs due to increased risks and complications, whereas quitting smoking leads to improved treatment outcomes and cost reductions. Addressing the need for empirical evidence on the economic impact of smoking cessation, this study examined the association between smoking cessation and healthcare cost utilization among a sample of 930 patients with cancer treated at The University of Texas MD Anderson Cancer Center's Tobacco Research and Treatment Program (TRTP). Applying conditional quantile regression and propensity scores to address confounding, our findings revealed that abstinence achieved through the TRTP significantly reduced the median cost during a 3-month period post-quitting by $1,095 [β = -$1,095, P = 0.007, 95% confidence interval (CI), = (-$1,886 to -$304)]. Sensitivity analysis corroborated these conclusions, showing a pronounced cost reduction when outlier data were excluded. The long-term accrued cost savings from smoking cessation could potentially offset the cost of participation in the TRTP program, underscoring its cost effectiveness. An important implication of this study is that by reducing smoking rates, healthcare systems can more efficiently allocate resources, enhance patient health outcomes, and lessen the overall cancer burden.

PREVENTION RELEVANCE

This study emphasizes the dual impact of smoking cessation programs in patients with cancer: quitting smoking and reducing healthcare costs. It highlights the importance of integrating cessation programs into cancer prevention strategies, ensuring both individual health benefits and broader, system-wide economic efficiencies. See related Spotlight, p. 197.

Short-term effectiveness of the national German quitline for smoking cessation: results of a randomized controlled trial

BACKGROUND

The objective of the present study was to examine the short-term effectiveness of the national German quitline for smoking cessation.

METHODS

A parallel-group, two-arm, superiority, randomized controlled trial with data collection at baseline and post-intervention (three months from baseline) was conducted. Individuals were randomized to either the intervention group, receiving up to six telephone counselling calls, or the control group, receiving an active control intervention (self-help brochure). The primary outcome was the seven-day point prevalence abstinence at post-assessment. Secondary outcomes included changes in smoking-related cognitions and coping strategies from pre- to post-assessment, the perceived effectiveness of intervention components, and the satisfaction with the intervention.

RESULTS

A total of n = 905 adult daily smokers were assigned to either the intervention group (n = 477) or the control group (n = 428). Intention-to-treat analyses demonstrated that individuals allocated to the telephone counselling condition were more likely to achieve seven-day point prevalence abstinence at post-assessment compared to those allocated to the self-help brochure condition (41.1% vs. 23.1%; OR = 2.3, 95% CI [1.7, 3.1]). Participants who received the allocated intervention in both study groups displayed significant improvements in smoking-related cognitions and coping strategies with the intervention group showing greater enhancements than the control group. This pattern was also found regarding the perceived effectiveness of intervention components and the satisfaction with the intervention.

CONCLUSION

The present study provides first empirical evidence on the short-term effectiveness of the national German quitline for smoking cessation, highlighting its potential as an effective public health intervention to reduce the burden of disease associated with smoking.

TRIAL REGISTRATION

This study is registered in the German Clinical Trials Register (DRKS00025343). Date of registration: 2021/06/07.

Tailored text message and web intervention for smoking cessation in U.S. socioeconomically-disadvantaged young adults: A randomized controlled trial

The prevalence of cigarette smoking in young adults is higher among those with socioeconomic disadvantage than those without. Low treatment-seeking among young adult smokers is compounded by few efficacious smoking cessation interventions for this group, particularly socioeconomically-disadvantaged young adults (SDYA) who smoke cigarettes. The goal of this study was to test a tailored smoking-cessation intervention for SDYA. 343 SDYA aged 18-30 living in the U.S. (85% female) who smoke cigarettes with access to a smartphone and interest in quitting smoking in the next six months were recruited online in Spring 2020 and randomized to referral to online quit resources (usual care control; n = 171) or a 12-week tailored text message smoking-cessation program with a companion web-based intervention (n = 172). Intent to treat analyses examined associations between study condition, self-reported 30-day point prevalence abstinence (PPA), and confidence to quit smoking at 12 weeks, controlling for potential confounders. Intervention group participants had greater self-reported 30-day PPA at 12-weeks than controls (adjusted relative risk 3.93, 95% CI 2.14-7.24). Among those who continued smoking, the intervention increased confidence to quit (0.81 points, 95% confidence interval 0.08-1.53). Weekly engagement in the intervention predicted greater cessation. A tailored text message intervention for SDYA increased smoking abstinence and confidence to quit at the end-of-treatment. Findings may have been influenced by recruitment at the start of the COVID pandemic but suggest that text messaging is an acceptable and efficacious cessation strategy for SDYA smokers. Future studies should examine the impact on longer-term smoking-cessation and importance of intervention tailoring for SDYA.

Novel Implementation Strategy to Electronically Screen and Signpost Patients to Health Behavior Apps: Mixed Methods Implementation Study (OptiMine Study)

BACKGROUND

Behavior change apps have the potential to provide individual support on a population scale at low cost, but they face numerous barriers to implementation. Electronic health records (EHRs) in acute care hospitals provide a valuable resource for identifying patients at risk, who may benefit from behavior change apps. A novel, emerging implementation strategy is to use digital technologies not only for providing support to help-seeking individuals but also for signposting patients at risk to support services (also called proactive referral in the United States).

OBJECTIVE

The OptiMine study aimed to increase the reach of behavior change apps by implementing electronic signposting for smoking cessation and alcohol reduction in a large, at-risk population that was identified through an acute care hospital EHR.

METHODS

This 3-phase, mixed methods implementation study assessed the acceptability, feasibility, and reach of electronic signposting to behavior change apps by using a hospital's EHR system to identify patients who are at risk. Phase 1 explored the acceptability of the implementation strategy among the patients and staff through focus groups. Phase 2 investigated the feasibility of using the hospital EHR to identify patients with target risk behaviors and contact them via SMS text message, email, or patient portal. Phase 3 assessed the impact of SMS text messages sent to patients who were identified as smokers or risky drinkers, which signposted them to behavior change apps. The primary outcome was the proportion of participants who clicked on the embedded link in the SMS text message to access information about the apps. The acceptability of the SMS text messages among the patients who had received them was also explored in a web-based survey.

RESULTS

Our electronic signposting strategy-using SMS text messages to promote health behavior change apps to patients at risk-was found to be acceptable and feasible and had good reach. The hospital sent 1526 SMS text messages, signposting patients to either the National Health Service Smokefree or Drink Free Days apps. A total of 13.56% (207/1526) of the patients clicked on the embedded link to the apps, which exceeded our 5% a priori success criterion. Patients and staff contributed to the SMS text message content and delivery approach, which were perceived as acceptable before and after the delivery of the SMS text messages. The feasibility of the SMS text message format was determined and the target population was identified by mining the EHR.

CONCLUSIONS

The OptiMine study demonstrated the proof of concept for this novel implementation strategy, which used SMS text messages to signpost at-risk individuals to behavior change apps at scale. The level of reach exceeded our a priori success criterion in a non-help-seeking population of patients receiving unsolicited SMS text messages, disconnected from hospital visits.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/23669.

Guest Support for Outdoor Smoke-Free Policies within a Homeless Shelter

Roughly 70-80% of adults experiencing homelessness smoke cigarettes. Smoke-free living/workplace policies are an empirically-supported tobacco control intervention. However, homeless shelters may be reluctant to implement smoke-free policies due to fears of it discouraging current/potential shelter guests from taking refuge there. The current study was meant to characterize guest support for on-property smoke-free policies within a homeless shelter with an extant indoor tobacco use ban amongst never smokers, former smokers, and current smokers to provide data on this point. Participants comprised a convenience sample of adult guests of a homeless shelter in Texas (N = 394, 28.2% women; 10.2% former; and 75.9% current smokers). Participant sociodemographics, smoking status, behavioral health diagnoses, and support for two versions of an on-property outdoor courtyard smoke-free policy (one partial, one complete) were assessed. Data were collected in two waves in a repeated cross-sectional design. Overall, 64.0% of participants supported a partial, and 32.0% a full smoking ban. Logistic regressions, controlling for wave of data collection, age, sex, and any additional significant predictors from a semi-adjusted model, examined associations between participant characteristics and policy support. Older participants (OR = 1.024, CI_0.95 = 1.005-1.044), non-veterans (OR = 2.523, CI_0.95 = 1.156-5.506), former smokers (OR = 2.730, CI_0.95 = 1.191-6.258), and those without severe mental illness (OR = 1.731, CI_0.95 = 1.061-2.824) had significantly greater odds of supporting a partial smoking ban. Relative to current smokers, never smokers (OR = 3.902, CI_0.95 = 2.133-7.137) and former smokers (OR = 8.257, CI_0.95 = 3.951-17.258) had significantly greater odds of supporting a complete smoking ban. The implementation of smoke-free living/workplace policies in homeless shelters may enjoy more support from guests-specifically, non-smokers-than anticipated by shelter administrators. Aside from reducing ambient smoke exposure for never and former smokers, these policies can help to reduce ubiquitous smoking cues for those who may want to quit, are undergoing a quit attempt, or are trying to maintain abstinence. Interventionists might partner with shelter guests, particularly smokers, to inform the roll-out of such policies for maximal acceptance and adoption.

Subtypes of smokers in a randomized controlled trial of a web-based smoking cessation program and their role in predicting intervention non-usage attrition: Implications for the development of tailored interventions

INTRODUCTION

Web-based smoking interventions hold potential for smoking cessation; however, many of them report low intervention usage (i.e., high levels of non-usage attrition). One strategy to counter this issue is to tailor such interventions to user subtypes if these can be identified and related to non-usage attrition outcomes. The aim of this study was two-fold: (1) to identify and describe a smoker typology in participants of a web-based smoking cessation program and (2) to explore subtypes of smokers who are at a higher risk for non-usage attrition (i.e., early dropout times).

METHODS

We conducted secondary analyses of data from a large randomized controlled trial (RCT) that investigated effects of a web-based Cognitive Bias Modification intervention in adult smokers. First, we conducted a two-step cluster analysis to identify subtypes of smokers based on participants' baseline characteristics (including demographics, psychological and smoking-related variables, N = 749). Next, we conducted a discrete-time survival analysis to investigate the predictive value of the subtypes on time until dropout.

RESULTS

We found three distinct clusters of smokers: Cluster 1 (25.2%, n = 189) was characterized by participants being relatively young, highly educated, unmarried, light-to-moderate smokers, poly-substance users, and relatively high scores on sensation seeking and impulsivity; Cluster 2 (41.0%, n = 307) was characterized by participants being older, with a relatively high socio-economic status (SES), moderate-to-heavy smokers and regular drinkers; Cluster 3 (33.8%, n = 253) contained mostly females of older age, and participants were further characterized by a relatively low SES, heavy smoking, and relatively high scores on hopelessness, anxiety sensitivity, impulsivity, depression, and alcohol use. Additionally, Cluster 1 was more likely to drop out at the early stage of the intervention compared to Cluster 2 (adjusted Hazard Ratio (HR _adjusted) = 1.51, 95% CI = [1.25, 1.83]) and Cluster 3 (HR _adjusted = 1.52, 95% CI = [1.25, 1.86]).

CONCLUSIONS

We identified three clusters of smokers that differed on a broad range of characteristics and on intervention non-usage attrition patterns. This highlights the heterogeneity of participants in a web-based smoking cessation program. Also, it supports the idea that such interventions could be tailored to these subtypes to prevent non-usage attrition. The subtypes of smokers identified in this study need to be replicated in the field of e-health outside the context of RCT; based on the smoker subtypes identified in this study, we provided suggestions for developing tailored web-based smoking cessation intervention programs in future research.

NoFumo+: A Clinical Trial of an mHealth for Smoking Cessation with Hospitalized Patients

Smartphone applications (apps) improve accessibility to smoking cessation treatments. The NoFumo+ app administers a cognitive behavioral therapy program for smoking cessation. This study evaluates the efficacy of NoFumo+ for quitting smoking or reducing cigarette consumption versus the usual information-based treatment. A clinical trial was conducted with 99 hospitalized smokers, 54 pseudo-randomly assigned to the app treatment and 45 to the usual treatment. The two groups had homogeneous baseline characteristics to ensure comparability. Abstinence was evaluated at post-treatment (two months) and at a six-month follow-up. The results obtained indicate that participants who receive the usual treatment are 5.40 times more likely to continue smoking than those who undergo the app treatment (95% CI = [1.35; 20.15]). Participants who do not succeed in quitting smoking with the app manage to decrease their habitual consumption. Users who successfully complete treatment with NoFumo+ access all its contents and use the chat, but without requesting professional support. There is not enough empirical evidence to attribute this success to any specific element of the app. NoFumo+ achieves better abstinence rates than the usual information-based treatments, and the goal of generalizing its use to the non-hospitalized smoking population may be achievable in the future.

Increasing treatment enrollment among smokers who are not motivated to quit: a randomized clinical trial

There is a significant research-to-practice gap with respect to reaching underserved populations with evidence-based tobacco cessation treatments. Increasing enrollment in evidence-based treatments is necessary to reduce tobacco use and tobacco-related health inequities. The purpose of the current study was to evaluate whether Motivation And Problem Solving (MAPS), a flexible, holistic counseling/navigation approach delivered via phone, and proactive provision of Nicotine Replacement Therapy (NRT) would improve Quitline enrollment among a sample of low SES smokers who were not motivated to quit. In a 3×2 factorial design, cigarette smokers (N = 603) were randomized to one of six treatment conditions (Standard Treatment, MAPS-6, or MAPS-12 by NRT or no NRT). Results indicated that both MAPS-6 and MAPS-12 increased Quitline enrollment compared to Standard Treatment (ps < .03). There were no differences between MAPS conditions. NRT did not increase Quitline enrollment. MAPS is an effective intervention with the potential to be disseminated and implemented in healthcare and community settings to increase the reach of evidence-based interventions for tobacco cessation.

Workflow analysis for design of an electronic health record-based tobacco cessation intervention in community health centers

OBJECTIVE

Tobacco use is the leading cause of preventable morbidity and mortality in the United States. Quitlines are effective telephone-based tobacco cessation services but are underutilized. The goal of this project was to describe current clinical workflows for Quitline referral and design an optimal electronic health record (EHR)-based workflow for Ask-Advice-Connect (AAC), an evidence-based intervention to increase Quitline referrals.

MATERIALS AND METHODS

Ten Community Health Center systems (CHC), which use three different EHRs, participated in this study. Methods included: 9 group discussions with CHC leaders; 33 observations/interviews of clinical teams' workflow; surveys with 57 clinical staff; and assessment of the EHR ecosystem in each CHC. Data across these methods were integrated and coded according to the Fit between Individual, Task, Technology and Environment (FITTE) framework. The current and optimal workflow were notated using Business Process Modelling Notation. We compared the requirements of the optimal workflow with EHR capabilities.

RESULTS

Current workflows are inefficient in data collection, variable in who, how, and when tobacco cessation advice and referral are enacted, and lack communication between referring clinics and the Quitline. In the optimal workflow, medical assistants deliver a standardized AAC intervention during the visit intake. Referrals are submitted electronically, and there is bidirectional communication between the clinic and Quitline. We implemented AAC within all three EHRs; however, deviations from the optimal workflow were necessary.

CONCLUSION

Current workflows for Quitline referral are inefficient and ineffective. We propose an optimal workflow and discuss improvements in EHR capabilities that would improve the implementation of AAC.

Systems thinking in health technology assessment: a scoping review

OBJECTIVE

Our objective was to assess how, and to what extent, a systems-level perspective is considered in decision-making processes for health interventions by illustrating how studies define the boundaries of the system in their analyses and by defining the decision-making context in which a systems-level perspective is undertaken.

METHOD

We conducted a scoping review following the Joanna Briggs Institute methodology. MEDLINE, EMBASE, Cochrane Library, and EconLit were searched and key search concepts included decision making, system, and integration. Studies were classified according to an interpretation of the "system" of analysis used in each study based on a four-level model of the health system (patient, care team, organization, and/or policy environment) and using categories (based on intervention type and system impacts considered) to describe the decision-making context.

RESULTS

A total of 2,664 articles were identified and 29 were included for analysis. Most studies (16/29; 55%) considered multiple levels of the health system (i.e., patient, care team, organization, environment) in their analysis and assessed multiple classes of interventions versus a single class of intervention (e.g., pharmaceuticals, screening programs). Approximately half (15/29; 52%) of the studies assessed the influence of policy options on the system as a whole, and the other half assessed the impact of interventions on other phases of the disease pathway or life trajectory (14/29; 48%).

CONCLUSIONS

We found that systems thinking is not common in areas where health technology assessments (HTAs) are typically conducted. Against this background, our study demonstrates the need for future conceptualizations and interpretations of systems thinking in HTA.

A Telephone-Based Tobacco Cessation Program in the State of Qatar: Protocol of a Feasibility Study

In Qatar, tobacco is the leading preventable cause of death and disease. Telephone-based interventions for smoking are cost-effective and scalable interventions that are effective in promoting smoking behavior change. While many countries have implemented these services within their tobacco control programs, there is a distinct dearth of a telephone-based smoking cessation intervention that is adapted and tailored to meet the needs of people who smoke in Qatar. This study presents the protocol of a primary health care center integrated smoking quitline program in Qatar. Participants will be recruited from seven smoking clinics (recruitment sites). Trained clinic staff will provide brief advice on quitting followed by a referral to the quitline. Eligible participants (male smokers over 18 years of age) will complete baseline questionnaires and receive five weekly proactive counseling calls, an end-of-treatment assessment (approx. 1 week after Session 5), and 1- and 3-month follow-up assessments. The main aim of this study is to assess the feasibility and acceptability, which include the recruitment and retention rate, compliance to pharmacotherapy, and participant satisfaction. This is the first study to integrate an evidence-based smoking cessation intervention delivered via telephone within the healthcare system in Qatar. If effective, results can inform the development of a large-scale telephone-based program that widely reaches users of tobacco in Qatar as well as in the Middle East.

A Model for Advancing Scale-Up of Complex Interventions for Vulnerable Populations: the ALACRITY Center for Health and Longevity in Mental Illness

Many of the most pressing health issues in the USA and worldwide require complex, multi-faceted solutions. Delivery of such solutions is often complicated by the need to reach and engage vulnerable populations facing multiple barriers to care. While the fields of quality improvement and implementation science have made valuable gains in the development and spread of individual strategies to improve evidence-based practice delivery, models for coordinated deployment of numerous strategies to simultaneously implement multiple evidence-based interventions in vulnerable populations are lacking. In this Perspective, we describe a model for this type of comprehensive research-practice translation effort: the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness, which is focused on reducing premature mortality in the population with serious mental illness. We describe the Center's conceptual framework, which is built upon an integrated set of quality improvement and implementation science frameworks, provide an overview of the Center's organizational structure and core research-practice translation activities, and discuss our vision for how the Center may evolve over time. Lessons learned from this Center's efforts could inform models to address other critical health issues in vulnerable populations that require multi-component solutions at the policy, system, provider, and patient levels.

Mining Electronic Health Records to Promote the Reach of Digital Interventions for Cancer Prevention Through Proactive Electronic Outreach: Protocol for the Mixed Methods OptiMine Study

BACKGROUND

Digital behavior change interventions have demonstrated effectiveness for smoking cessation and reducing alcohol intake, which ultimately reduce cancer risk. Leveraging electronic health records (EHR) to identify at-risk patients and increasing the reach of digital interventions through proactive electronic outreach provide a novel approach that may increase the number of individuals who engage with evidence-based treatment.

OBJECTIVE

This study aims to increase the reach of digital behavior change interventions by implementing a proactive electronic message system for smoking cessation and alcohol reduction among a large, at-risk population identified through an acute hospital EHR.

METHODS

This protocol describes a 3-phase, mixed-methods implementation study to assess the acceptability, feasibility, and reach of a proactive electronic message system to digital interventions using a hospital's EHR system to identify eligible patients. In Phase 1, we will conduct focus group discussions with patients and hospital staff to assess the overall acceptability of the electronic message system. In Phase 2, we will conduct a descriptive analysis of the patient population in the hospital EHR regarding target risk behaviors and other person-level characteristics to determine the project's feasibility and potential reach. In Phase 3, we will send proactive messages to patients identified as smokers or risky drinkers. Messages will encourage and provide access to behavior change mobile apps via an embedded link; the primary outcome will be the proportion of participants who click on the link to access information about the apps.

RESULTS

At the time of initial protocol submission, data collection was complete, but analysis had not begun. This study was funded by Cancer Research UK from April 2019 to March 2020. Health Research Authority approval was granted in June 2019.

CONCLUSIONS

Increasing the reach of digital behavior change interventions can improve population health by reducing the burden of preventable death and disease.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/23669.

The Stop-Tabac smartphone application for smoking cessation: study protocol for a randomized controlled trial in the general population

Background

Smartphone-based support can reach thousands of smokers and help those who would otherwise try to quit smoking by themselves with little chance of success. Nicotine medications double the chances of quitting smoking, but few smokers use them, and they often use them for too short a time and at an insufficient dose. It is therefore important to increase access to support for smoking cessation and compliance with nicotine therapy. The objectives of this study are to assess whether the Stop-Tabac application (app) is effective for smoking cessation and to examine whether the outcome is influenced by the personal characteristics of participants.

Methods

Trial design: this is a two-arm, parallel-group, superiority, individually randomized, “placebo” controlled trial in 5200 smokers, with follow up after 1 week, 1 month and 6 months. The participants are adult daily smokers (N = 5200) enrolled on the Internet, living in France or Switzerland. The intervention is the Stop-tabac fully-automated app for smartphones, which was launched in 2012 and continuously improved thereafter. It includes fact sheets; calculators of cigarettes not smoked, money saved, and years of life gained; an interactive “coach” that provides automated, individually tailored counseling messages based on the user’s personal profile, sent regularly for 6 months; immediate feedback during episodes of craving and tobacco withdrawal symptoms; a discussion forum (“The Tribe”) where participants provide and receive social support; a quiz that informs users in a playful way; and a module on nicotine therapy that includes personalized feedback and follow up. The outcome is self-reported smoking cessation after 6 months (no puff of tobacco in the past 4 weeks), and after 1 week and 1 month (no puff in the past 7 days). Participants will be randomized automatically based on a list of random numbers. Participants, assistants in charge of collecting follow-up data and data analysts will be blinded to allocation. Funding is provided by the Swiss National Science Foundation, CHF 194,942 (EUR 182,200, USD 200,700), grant 32003_179369. JFE’s salary is paid by the University of Geneva, YK’s salary is paid by the Lausanne University Hospitals.

Discussion

There is little evidence from randomized trials of the impact of health apps in general and of smoking cessation apps in particular. This study will fill this gap.

Trial registration

ISRCTN Registry: ISRCTN11318024. Registered on 17 May 2018.

Commentary on Beard et al. (2019): A systematic approach sharpens insights on e-cigarettes and smoking cessation

Examining use of e-cigarettes during quit attempts as a key exposure variable and then controlling for the potential impact of other population-level cessation efforts provides important insights into the UK smoking cessation experience. This can inform analyses of tobacco control policy and other public health interventions in the UK and abroad.

Reduction in Cigarettes per Day Prospectively Predicts Making a Quit Attempt: A Fine-Grained Secondary Analysis of a Natural History Study

INTRODUCTION

Reducing cigarettes per day (CPD) aided by medication increases quit attempts (QA) among smokers not trying to quit. If this is due to reducing CPD per se, then a greater reduction should predict making a QA.

AIMS AND METHODS

In this secondary analysis, 132 smokers completed nightly calls to report CPD, intention to quit tomorrow, and QAs over 12 weeks. We provided no treatment. We identified episodes of reduction and tested whether (1) percent reduction in CPD, (2) absolute reduction in CPD, (3) duration of reduction, or (4) CPD on the final day predicted a QA immediately after a reduction episode. We tested this separately among reduction episodes that began with and without an intention to quit.

RESULTS

Among the 1179 episodes that began without intention to quit, all four measures of reduction predicted making a QA. Greater percent reduction, longer duration, and fewer CPD on the final day were retained in a multivariate model (all p < .05). Among the 85 episodes that began with intention to quit, greater percent reduction and greater absolute reduction predicted making a QA. Only mean percent reduction was retained in a multivariate model (p < .001).

CONCLUSIONS

Our results replicate and extend earlier studies by using fine-grained analyses and examining immediately proximal QAs in a sample of self-quitters. Findings suggest that reducing CPD per se increases the probability of a QA among smokers without intention to quit in a dose-related manner. Whether this is the case among smokers who intend to quit remains unclear.

IMPLICATIONS

Reducing CPD appears to be an effective strategy to increase the probability of making a QA for the majority of smokers who do not intend to quit in the near future. However, our findings are mixed regarding the effectiveness of reducing among smokers who intend to quit. Clinical interventions and policies that promote reducing CPD are likely to be an effective way to increase QAs. Reduction may be especially helpful for smokers who have not responded to traditional advice to stop abruptly.

Introduction to the Theme Issue on Dynamics of Health Behavior: Revisiting Systems Science for Population Health

Systems science can help public health professionals to better understand the complex dynamics between factors affecting health behaviors and outcomes and to identify intervention opportunities. Despite their demonstrated utility in addressing health topics such influenza, tobacco control, and obesity, the associated methods continue to be underutilized by researchers and practitioners addressing health behaviors. This article discusses the growth of systems science methods (e.g., system dynamics, social network analysis, and agent-based modeling) in health research, provides a frame for the articles included in this themed issue, and closes with recommendations for enhancing the future of systems science and health behavior research. We argue that integrating systems sciences methods into health behavior research and practice is essential for improved population health and look forward to supporting the evolution of the field.

QuitSMART Utah: an implementation study protocol for a cluster-randomized, multi-level Sequential Multiple Assignment Randomized Trial to increase Reach and Impact of tobacco cessation treatment in Community Health Centers

BACKGROUND

Tobacco use remains the leading cause of death and disability in the USA and is disproportionately concentrated among low socioeconomic status (SES) populations. Community Health Centers (CHCs) are a key venue for reaching low SES populations with evidence-based tobacco cessation treatment such as Quitlines. Electronic health record (EHR)-based interventions at the point-of-care, text messaging (TM), and phone counseling have the potential to increase Quitline reach and are feasible to implement within CHCs. However, there is a lack of data to inform how, when, and in what combination these strategies should be implemented. The aims of this cluster-randomized trial are to evaluate multi-level implementation strategies to increase the Reach (i.e., proportion of tobacco-using patients who enroll in the Quitline) and Impact (i.e., Reach × Efficacy [efficacy is defined as the proportion of tobacco-using patients who enroll in Quitline treatment that successfully quit]) and to evaluate characteristics of healthcare system, providers, and patients that may influence tobacco-use outcomes.

METHODS

This study is a multilevel, three-phase, Sequential Multiple Assignment Randomized Trial (SMART), conducted in CHCs (N = 33 clinics; N = 6000 patients). In the first phase, clinics will be randomized to two different EHR conditions. The second and third phases are patient-level randomizations based on prior treatment response. Patients who enroll in the Quitline receive no further interventions. In phase two, patients who are non-responders (i.e., patients who do not enroll in Quitline) will be randomized to receive either TM or continued-EHR. In phase three, patients in the TM condition who are non-responders will be randomized to receive either continued-TM or TM + phone coaching.

DISCUSSION

This project will evaluate scalable, multi-level interventions to directly address strategic national priorities for reducing tobacco use and related disparities by increasing the Reach and Impact of evidence-based tobacco cessation interventions in low SES populations.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov (NCT03900767) on April 4th, 2019.

The Impact of Implementing Tobacco Control Policies: The 2017 Tobacco Control Policy Scorecard

The Tobacco Control Scorecard, published in 2004, presented estimates of the effectiveness of different policies on smoking rates. Since its publication, new evidence has emerged. We update the Scorecard to include recent studies of demand-reducing tobacco policies for high-income countries. We include cigarette taxes, smoke-free air laws, media campaigns, comprehensive tobacco control programs, marketing bans, health warnings, and cessation treatment policies. To update the 2004 Scorecard, a narrative review was conducted on reviews and studies published after 2000, with additional focus on 3 policies in which previous evidence was limited: tobacco control programs, graphic health warnings, and marketing bans. We consider evaluation studies that measured the effects of policies on smoking behaviors. Based on these findings, we derive estimates of short-term and long-term policy effect sizes. Cigarette taxes, smoke-free air laws, marketing restrictions, and comprehensive tobacco control programs are each found to play important roles in reducing smoking prevalence. Cessation treatment policies and graphic health warnings also reduce smoking and, when combined with policies that increase quit attempts, can improve quit success. The effect sizes are broadly consistent with those previously reported for the 2004 Scorecard but now reflect the larger evidence base evaluating the impact of health warnings and advertising restrictions.

Smoking prevalence and attributable deaths in Thailand: predicting outcomes of different tobacco control interventions

Background

Despite substantial positive impacts of Thailand’s tobacco control policies on reducing the prevalence of smoking, current trends suggest that further reductions are needed to ensure that WHO’s 2025 voluntary global target of a 30% relative reduction in tobacco use is met. In order to confirm this hypothesis, we aim to estimate the effect of tobacco control policies in Thailand on the prevalence of smoking and attributed deaths and assess the possibilities of achieving WHO’s 2025 global target. This paper addresses this knowledge gap which will contribute to policy control measures on tobacco control. Results of this study can help guide policy makers in implementing further interventions to reduce the prevalence of smoking in Thailand.

Method

A Markov chain model was developed to examine the effect of tobacco control policies, such as accessibility restrictions for youths, increased tobacco taxes and promotion of smoking cessation programs, from 2015 to 2025. Outcomes included smoking prevalence and the number of smoking-attributable deaths. Due to the very low prevalence of female smokers in 2014, this study applied the model to estimate the smoking prevalence and attributable mortality among males only.

Results

Given that the baseline prevalence of smoking in 2010 was 41.7% in males, the target of a 30% relative reduction requires that the prevalence be reduced to 29.2% by 2025. Under a baseline scenario where smoking initiation and cessation rates among males are attained by 2015, smoking prevalence rates will reduce to 37.8% in 2025. The combined tobacco control policies would further reduce the prevalence to 33.7% in 2025 and 89,600 deaths would be averted.

Conclusion

Current tobacco control policies will substantially reduce the smoking prevalence and smoking-attributable deaths. The combined interventions can reduce the smoking prevalence by 19% relative to the 2010 level. These projected reductions are insufficient to achieve the committed target of a 30% relative reduction in smoking by 2025. Increased efforts to control tobacco use will be essential for reducing the burden of non-communicable diseases in Thailand.

Tobacco treatment implementation within 28 commission on cancer accredited programs in the Northeast region of the USA: A pilot study

Cancer survivors are a rapidly growing population and an important target for tobacco treatment interventions. Continued smoking after the diagnosis of cancer is associated with a higher risk of cancer recurrence and mortality. Systematic tobacco cessation programs are effective. This study surveyed American College of Surgeons Commission on Cancer (CoC) programs in the Northeast region of the USA regarding their tobacco control programs. Seventy percent of cancer survivors are treated within CoC programs. The purpose of this study was to describe the extent of implementation of tobacco treatment and determine the organizational delivery of tobacco treatment as measured by the presence of goals to address smoking, leadership support, and integration of tobacco treatment guidelines into care delivery. Data were collected by a survey. The Assessment of Chronic Illness Care questionnaire was used to collect data on implementation of tobacco treatment services. Descriptive statistics were used to analyze the data. Most programs (78.6%) had an electronic health record and of these 68% captured smoking status. Implementation of tobacco treatment was not optimal for identifying smokers, providing patients with community linkages or self-care cessation support. Implementation of decision aides for pharmacotherapy and reassessment of smoking status were the least developed areas. Moreover, the organizational delivery for tobacco treatment was less than optimal. Many cancer programs have not implemented systems to deliver optimal tobacco treatment. Efforts should be made to help cancer programs develop sustainable system-wide programs that address the urgent need to deliver tobacco treatment to all cancer survivors.

Smoking cessation in the context of recovery from drug and alcohol problems: Prevalence, predictors, and cohort effects in a national U.S. sample

BACKGROUND

Tobacco and alcohol and other drug (AOD) use remain prominent risk factors for morbidity, mortality, and health care utilization. Moreover, these often cluster together within persons, exponentiating health risks. Little is known regarding if and when people resolving AOD problems stop smoking, who stops, and whether recent general population trends toward smoking cessation are evident also among persons more recently entering recovery.

DESIGN AND PARTICIPANTS

National cross-sectional sample resolving AOD problems (final sample n = 2002).

ANALYSES

Weighted smoking/cessation prevalence; logistic regressions; Hazard-models estimated time to smoking cessation overall, and for different cohorts entering recovery during one of three decades: a) 2006-2015; b) 1996-2005; c) 1986-1995.

RESULTS

Approximately 30% of U.S. adults in AOD recovery with a smoking history stopped smoking before entering recovery, 7% quit smoking and AOD use concurrently, 26% stopped after entering recovery; 37% still smoked. Among those quitting after entering recovery, the prevalence of smoking cessation 5- and 10-years later was 27.2% and 55.1% respectively for the 2006-2015 cohort and 14.9% and 34.5% in the 1986-1995 cohort; time to smoking cessation also was 60% shorter (5yrs vs. 8yrs). Time to smoking cessation was associated with education and income, but not 12-step participation or AOD treatment.

CONCLUSIONS

Smoking rates among those in AOD recovery are more than double that of the general population but those entering recovery in recent years are stopping and stopping sooner. It is plausible that public health-oriented tobacco policy measures and easier access to smoking cessation aids may be contributing to this salutary trend.

Inferring Smoking Status from User Generated Content in an Online Cessation Community

Introduction

User generated content (UGC) is a valuable but underutilized source of information about individuals who participate in online cessation interventions. This study represents a first effort to passively detect smoking status among members of an online cessation program using UGC.

Methods

Secondary data analysis was performed on data from 826 participants in a web-based smoking cessation randomized trial that included an online community. Domain experts from the online community reviewed each post and comment written by participants and attempted to infer the author's smoking status at the time it was written. Inferences from UGC were validated by comparison with self-reported 30-day point prevalence abstinence (PPA). Following validation, the impact of this method was evaluated across all individuals and time points in the study period.

Results

Of the 826 participants in the analytic sample, 719 had written at least one post from which content inference was possible. Among participants for whom unambiguous smoking status was inferred during the 30 days preceding their 3-month follow-up survey, concordance with self-report was almost perfect (kappa = 0.94). Posts indicating abstinence tended to be written shortly after enrollment (median = 14 days).

Conclusions

Passive inference of smoking status from UGC in online cessation communities is possible and highly reliable for smokers who actively produce content. These results lay the groundwork for further development of observational research tools and intervention innovations.

Implications

A proof-of-concept methodology for inferring smoking status from user generated content in online cessation communities is presented and validated. Content inference of smoking status makes a key cessation variable available for use in observational designs. This method provides a powerful tool for researchers interested in online cessation interventions and establishes a foundation for larger scale application via machine learning.

State Tobacco Policies as Predictors of Evidence-Based Cessation Method Usage: Results From a Large, Nationally Representative Dataset

Introduction

Evidence-based cessation methods including nicotine replacement therapy (NRT), non-NRT medications, quitlines, and behavioral treatments are underutilized by smokers attempting to quit. Although a number of studies have demonstrated a relationship between state-level tobacco policies (eg, taxation, appropriations) and cessation, whether such state-level factors influence likelihood of using an evidence-based treatment is unclear. Accordingly, the aims of the present study were: (1) to describe evidence-based cessation method utilization by state and (2) to examine the effect of state-level factors on cessation method utilization above and beyond individual-level predictors.

Methods

Data were utilized from the 2010-2011 Tobacco Use Supplement to the Current Population Survey (TUS-CPS). Participants included 9232 smokers who reported a past-year quit attempt. Data on 11 state-level predictors were collated from national datasets. Analyses were based on: (1) descriptive characterization of quit method usage, (2) logistic regression models to determine state-level factors as predictors of quit method utilization, controlling for individual-level predictors, (3) cluster analyses grouping states with similar state-level factors, and (4) examination of cluster as a predictor of cessation method.

Results

Tobacco control appropriations significantly predicted NRT, quitline, and behavioral treatment utilization. Additional state-level factors that demonstrated significant relationships included Medicaid coverage of non-NRT medications and behavioral treatment, tobacco tax rate, smoking prevalence, and percentage of population uninsured. State clustering significantly predicted quit method across all four methods.

Conclusions

State-level factors influence the likelihood of residents utilizing evidence-based quit methods. Results are discussed in terms of implications for tobacco policy at the state level.

Implications

Results from the present study highlight state tobacco control appropriations as a robust predictor of evidence-based cessation method utilization. Other significant state-level predictors of evidence-based cessation method utilization included Medicaid coverage of non-NRT medications and behavioral treatment, tobacco tax rate, smoking prevalence, and percentage of population uninsured. Moreover, state-level predictors clustered together to significantly predict evidence-based cessation method utilization. Thus, increasing tobacco control appropriations, extending health insurance coverage, maximizing revenue from tobacco taxation and tobacco settlements, and ultimately decreasing smoking prevalence are important targets for individual states to promote utilization of evidence-based cessation methods.

A Randomized Controlled Trial of an Optimized Smoking Treatment Delivered in Primary Care

Background

The effectiveness of smoking cessation treatment is limited in real-world use, perhaps because we have not selected the components of such treatments optimally nor have treatments typically been developed for and evaluated in real-world clinical settings.

Purpose

To validate an optimized smoking cessation treatment package that comprises intervention components identified as effective in factorial screening experiments conducted as per the Multiphase Optimization Strategy (MOST).

Methods

Adult smokers motivated to quit were recruited from primary care clinics (N = 623). Participants were randomized to receive either recommended usual care (R-UC; 10 min of in-person counseling, 8 weeks of nicotine patch, and referral to quitline services) or abstinence-optimized treatment (A-OT; 3 weeks of prequit mini-lozenges, 26 weeks of nicotine patch + mini-lozenges, three in-person and eight phone counseling sessions, and 7-11 automated calls to prompt medication use). The key outcomes were self-reported and biochemically confirmed (carbon monoxide, CO <6 ppm) 7-day point-prevalence abstinence.

Results

A-OT participants had significantly higher self-reported abstinence rates than R-UC participants at 4, 8, 16, and 26 weeks (ORs: 1.91-3.05; p <. 001). The biochemically confirmed 26-week abstinence rates were lower than the self-reported 26-week rates, but revealed a similar treatment effect size (OR = 2.94, p < .001). There was no moderation of treatment effects on 26-week abstinence by demographic, psychiatric, or nicotine dependence variables. A-OT had an incremental cost-effectiveness ratio for 26-week CO-confirmed abstinence of $7,800.

Conclusions

A smoking cessation treatment that is optimized via MOST development meaningfully enhances cessation rates beyond R-UC smoking treatment in smokers seen in primary care.

Clinical Trial Registration

NCT02301403.

Perceived barriers and facilitators of initiation of behavioral weight loss interventions among adults with obesity: a qualitative study

Background

Evidence-based behavioral weight loss interventions are under-utilized. To inform efforts to increase uptake of these interventions, it is important to understand the perspectives of adults with obesity regarding barriers and facilitators of weight loss intervention initiation.

Methods

We conducted a qualitative study in adults with obesity who had recently attempted weight loss either with assistance from an evidence-based behavioral intervention (intervention initiators) or without use of a formal intervention (intervention non-initiators). We recruited primary care patients, members of a commercial weight loss program, and members of a Veterans Affairs weight loss program. Intervention initiators and non-initiators were interviewed separately using a semi-structured interview guide that asked participants about barriers and facilitators of weight loss intervention initiation. Conversations were audio-recorded and transcribed. Data were analyzed with qualitative content analysis. Two researchers used open coding to generate the code book on a subset of transcripts and a single researcher coded remaining transcripts. Codes were combined into subthemes, which were combined in to higher order themes. Intervention initiators and non-initiators were compared.

Results

We conducted three focus groups with participants who had initiated interventions (n = 26) and three focus groups (n = 24) and 8 individual interviews with participants who had not initiated interventions. Intervention initiators and non-initiators were, respectively, 65% and 37.5% white, 62% and 63% female, mean age of 55 and 54 years old, and mean BMI of 34 kg/m². Three themes were identified. One theme was practical factors, with subthemes of reasonable cost and scheduling compatibility. A second theme was anticipated effectiveness of intervention, with subthemes of intervention content addressing individual needs; social aspects influencing effectiveness; and evaluating evidence of effectiveness. A third theme was anticipated pleasantness of intervention, with subthemes of social aspects influencing enjoyment; anticipated dietary and tracking prescriptions; and identity and self-reliance factors. Different perspectives were identified from intervention initiators and non-initiators.

Conclusions

Strategies to engage individuals in evidence-based weight loss interventions can be developed using these results. Strategies could target individuals’ perceived barriers and benefits to initiating interventions, or could focus on refining interventions to appeal to more individuals.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5795-9) contains supplementary material, which is available to authorized users.

Predicting Engagement in Smoking Cessation Treatment Following a Brief Telephone Evaluation and Referral Session

Introduction: Smoking cessation treatment combining medication and counselling yields the best outcomes; however, few smokers employ both modalities.

Aims: The purpose of this study was to examine variables predicting treatment attendance.

Methods: This was a chart review of US military Veterans (N = 340; 89% male, 59% non-Hispanic white) referred for smoking cessation, who completed a telephone call to encourage treatment utilization. Treatment engagement was defined as attending a smoking cessation session within 30 days following telephone contact. A logistic regression analysis examined predictors (demographics, smoking variables, and psychiatric diagnoses) of treatment engagement.

Results/Findings: Greater age (Odds Ratio [OR] = 1.04, 95% confidence interval [CI] 1.01–1.06), more cigarettes (OR = 1.03, 95% CI 1.00–1.06), and higher perceived importance of quitting (OR = 1.11, 95% CI 1.00–1.23) predicted engaging in treatment within 30 days (all p values < 0.05).

Conclusion: Veterans who attended treatment were older, smoked more cigarettes, and perceived quitting as more important than those who did not attend. These findings are consistent with prior studies examining factors associated with treatment utilization. Results highlight the need to identify strategies for engaging into treatment smokers who are younger, smoke fewer cigarettes, and view quitting as less important.

Quit attempts and smoking cessation in Italian adults (25-64 years): factors associated with attempts and successes

Background

Over the past 50 years there was a substantial decrease in the prevalence of smoking in Italy. The objective of this work is to describe attempts to quit and cessation success in Italian smokers.

Methods

A surveillance on health-related behaviors (PASSI) was conducted in 2007-13 on a sample of 203 610 Italian adults 25-64 years of age. An analysis of smokers' characteristics and behaviors was performed, focusing on attempts to quit and quit success. Data from national surveys (ISTAT) from 1983 to 2013 (Italian adults, 25-64 years of age, 1983: 46 634; 1987: 40 915; 1990: 36 622; 2000: 77 531; 2005: 71 032; 2013: 64 205) were used to explore if a cessation trend in Italy exists.

Results

Smokers who quit in the previous year and were still abstinent when interviewed increased from 1990 to 2013. In the years 2011-13, 38% of people who had smoked in the last 12 months reported at least a quit attempt during the same period and 7% were still abstinent when interviewed. An association of successful recent quit attempts with higher educational level, absence of economic difficulties and younger age was found. In the years 2007-13, the great majority tried to stop unaided. Having received assistance from a cessation program did not increase the probability of enduring abstinence.

Conclusions

In Italy interventions to drive more smokers to quit should be focused in particular on disadvantaged groups. Initiatives have to be studied not only to incentive more smokers to try to quit, but also to maintain abstinence over time.

Long-Term Outcomes From Repeated Smoking Cessation Assistance in Routine Primary Care

PURPOSE

To test the association between repeated clinical smoking cessation support and long-term cessation.

DESIGN

Retrospective, observational cohort study using structured and free-text data from electronic health records.

SETTING

Six diverse health systems in the United States.

PARTICIPANTS

Patients aged ≥18 years who were smokers in 2007 and had ≥1 primary care visit in each of the following 4 years (N = 33 691).

MEASURES

Primary exposure was a composite categorical variable (comprised of documentation of smoking cessation medication, counseling, or referral) classifying the proportions of visits for which patients received any cessation assistance (<25% (reference), 25%-49%, 50%-74%, and ≥75% of visits). The dependent variable was long-term quit (LTQ; yes/no), defined as no indication of being a current smoker for ≥365 days following a visit where nonsmoker or former smoker was indicated.

ANALYSIS

Mixed effects logistic regression analysis adjusted for age, sex, race, and comorbidities, with robust standard error estimation to account for within site correlation.

RESULTS

Overall, 20% of the cohort achieved LTQ status. Patients with ≥75% of visits with any assistance had almost 3 times the odds of achieving LTQ status compared to those with <25% visits with assistance (odds ratio = 2.84; 95% confidence interval: 1.50-5.37). Results were similar for specific assistance types.

CONCLUSIONS

These findings provide support for the importance of repeated assistance at primary care visits to increase long-term smoking cessation.

The Effect of Tobacco Control Policies on US Smokeless Tobacco Use: A Structured Review

INTRODUCTION

Tobacco use has shifted increasingly from cigarettes to other products. While the focus has been mostly on cigarette-oriented policies, it is important to gauge the effects of policies targeting other products. We review and critique the literature on how policies affect smokeless tobacco (ST).

METHODS

We conducted a search of the literature on tobacco control policies as they relate to ST use, focusing on tobacco taxes, smoke-free air laws, media campaigns, advertising restrictions, health warnings, cessation treatment policies, and youth access policies. Findings from 78 total studies are summarized.

RESULTS

ST taxes, media campaigns, health warnings, and cessation treatment policies were found to be effective tools in reducing ST use. Evidence on the effects of current youth access policies is less strong. Studies have not yet been conducted on marketing or product content restrictions, but the literature indicates that product marketing, through advertising, packaging, flavorings, and extension of cigarette brands, plays an important role in ST use.

CONCLUSIONS

Although the evidence base is less established for ST policies than for cigarette policies, the existing literature indicates ST use responds to tobacco control policies. Policies should be structured in a way that aims to reduce all tobacco use while at the same time increasing the likelihood that continuing tobacco users use the least risky products.

IMPLICATIONS

Studies find that policies targeting smoking and policies targeting smokeless products affect smokeless use, but studies are needed to examine the effect of policies on the transitions between cigarette and smokeless use.

Public health benefits from pictorial health warnings on US cigarette packs: a SimSmoke simulation

INTRODUCTION

While many countries have adopted prominent pictorial warning labels (PWLs) for cigarette packs, the USA still requires only small, text-only labels located on one side of the cigarette pack that have little effect on smoking-related outcomes. Tobacco industry litigation blocked implementation of a 2011 Food and Drug Administration's (FDA) rule requiring large PWLs. To inform FDA action on PWLs, this study provides research-based estimates of their public health impacts.

METHODS

Literature was reviewed to identify the impact of cigarette PWLs on smoking prevalence, cessation and initiation. Based on this analysis, the SimSmoke model was used to estimate the effect of requiring PWLs in the USA on smoking prevalence and, using standard attribution methods, on smoking-attributable deaths (SADs) and key maternal and child health outcomes.

RESULTS

Available research consistently shows a direct association between PWLs and increased cessation and reduced smoking initiation and prevalence. The SimSmoke model projects that PWLs would reduce smoking prevalence by 5% (2.5%-9%) relative to the status quo over the short term and by 10% (4%-19%) over the long term. Over the next 50 years, PWLs are projected to avert 652 800 (327 000-1 190 500) SADs, 46 600 (17 500-92 300) low-birth-weight cases, 73 600 (27 800-145 100) preterm births and 1000 (400-2000) cases of sudden infant death syndrome.

CONCLUSIONS

Requiring PWLs on all US cigarette packs would be appropriate for the protection of the public health, because it would substantially reduce smoking prevalence and thereby reduce SADs and the morbidity and medical costs associated with adverse smoking-attributable birth outcomes.

Smoking-Cessation Assistance: Before and After Stage 1 Meaningful Use Implementation

INTRODUCTION

Brief smoking-cessation interventions in primary care settings are effective, but delivery of these services remains low. The Centers for Medicare and Medicaid Services' Meaningful Use (MU) of Electronic Health Record (EHR) Incentive Program could increase rates of smoking assessment and cessation assistance among vulnerable populations. This study examined whether smoking status assessment, cessation assistance, and odds of being a current smoker changed after Stage 1 MU implementation.

METHODS

EHR data were extracted from 26 community health centers with an EHR in place by June 15, 2009. AORs were computed for each binary outcome (smoking status assessment, counseling given, smoking-cessation medications ordered/discussed, current smoking status), comparing 2010 (pre-MU), 2012 (MU preparation), and 2014 (MU fully implemented) for pregnant and non-pregnant patients.

RESULTS

Non-pregnant patients had decreased odds of current smoking over time; odds for all other outcomes increased except for medication orders from 2010 to 2012. Among pregnant patients, odds of assessment and counseling increased across all years. Odds of discussing or ordering of cessation medications increased from 2010 compared with the other 2 study years; however, medication orders alone did not change over time, and current smoking only decreased from 2010 to 2012. Compared with non-pregnant patients, a lower percentage of pregnant patients were provided counseling.

CONCLUSIONS

Findings suggest that incentives for MU of EHRs increase the odds of smoking assessment and cessation assistance, which could lead to decreased smoking rates among vulnerable populations. Continued efforts for provision of cessation assistance among pregnant patients is warranted.

Trends in serious quit attempts in the United States, 2009-14

BACKGROUND AND AIMS

Quitting smoking is the most potent way to reduce the health risks associated with smoking cigarettes, and public health objectives in the United States include dramatic increases in the proportion of smokers making a serious quit attempt each year. The US Centers for Disease Control and Prevention (CDC) has, since 2000, set as its Healthy People 2020 objective to encourage 80% of smokers to make a serious quit attempt per year. This study assessed the trend in quit attempts from 2009 to 2014.

DESIGN

We examined the percentage of US smokers making a serious quit attempt each year from 2009 to 2014 from the repeating cross-sectional National Health Interview Survey (NHIS).

SETTING

United States.

PARTICIPANTS

The number of qualifying respondents per year ranged from 5748 in 2010 to 7219 in 2012, with a total of 40 362 respondents included in the analysis.

MEASUREMENTS

Respondents were deemed to have made a serious quit attempt if they were either current smokers who reported that they stopped smoking for more than 1 day in the past 12 months because they were trying to quit smoking, or reported being former smokers (smoked 100+ cigarettes life-time, but now not smoking) who quit in the past year.

FINDINGS

Analyses of trends from 2009 to 2014 showed an overall linear increase in quit attempts [odds ratio (OR) = 1.02, 95% confidence interval (CI) = 1.01-1.04, P = 0.0075], but also a quadratic trend (OR = 1.01, 95% CI = 1.00-1.02, P = 0.0189).

CONCLUSIONS

The proportion of US smokers making a serious quit attempt has increased since 2009, due to an upward trend since 2011. The 2014 serious quit attempt rate was 55.0%. These rates are still below the Healthy People 2020 objective of 80% of smokers making a serious quit attempt per year.

The Influence of Engagement and Satisfaction on Smoking Cessation Interventions: A Qualitative Study

BACKGROUND

Tobacco use remains the leading cause of preventable disease and death. Most smokers are not motivated to quit; however, most smoking cessation interventions are designed for smokers who are ready to take action.

OBJECTIVES

The aim of the present study was to describe participant engagement and satisfaction with telephonic smoking cessation coaching with a population of smokers at different stages of readiness to quit.

METHODS

Qualitative description was used to capture the experiences of 62 individuals who participated in telephonic smoking cessation coaching using semistructured interviews.

RESULTS

Results indicate that person-centered communication facilitated engagement and was valued equally or more than perceived coach smoking cessation knowledge. Engagement with the intervention was associated with increased satisfaction, smoking cessation/reduction and perceived convenience of intervention. Conclusions/Importance: Findings indicate that unmotivated smokers can be proactively recruited and engaged in telephonic smoking cessation treatment and that person-centered communication and convenience are important variables that should be considered when implementing health interventions. Telephonic coaching has the potential to reach a large segment of the population with access barriers and could lead to important health behavior change. Intensive provider training that includes person-centered communication strategies is strongly recommended. Specific suggestions for successful implementation and dissemination are provided.

Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders

BACKGROUND

Smoking rates in people with alcohol and other drug dependencies are two to four times those of the general population. Concurrent treatment of tobacco dependence has been limited due to concern that these interventions are not successful in this population or that recovery from other addictions could be compromised if tobacco cessation was combined with other drug dependency treatment.

OBJECTIVES

To evaluate whether interventions for tobacco cessation are associated with tobacco abstinence for people in concurrent treatment for or in recovery from alcohol and other drug dependence.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and clinicaltrials.gov databases, with the most recent search completed in August 2016. A grey literature search of conference abstracts from the Society on Nicotine Research and Treatment and the ProQuest database of digital dissertations yielded one additional study, which was excluded.

SELECTION CRITERIA

We included randomised controlled trials assessing tobacco cessation interventions among people in concurrent treatment for alcohol or other drug dependence or in outpatient recovery programmes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study risk of bias and extracted data. We resolved disagreements by consensus. The primary outcome was abstinence from tobacco use at the longest period of follow-up, and the secondary outcome was abstinence from alcohol or other drugs, or both. We reported the strictest definition of abstinence. We summarised effects as risk ratios and 95% confidence intervals (CI). Two clustered studies did not provide intraclass correlation coefficients, and were excluded from the sensitivity analysis. We used the I² statistic to assess heterogeneity.

MAIN RESULTS

Thirty-five randomised controlled trials, one ongoing, involving 5796 participants met the criteria for inclusion in this review. Included studies assessed the efficacy of tobacco cessation interventions, including counselling, and pharmacotherapy consisting of nicotine replacement therapy (NRT) or non-NRT, or the two combined, in both inpatient and outpatient settings for participants in treatment and in recovery. Most studies did not report information to assess the risk of allocation, selection, and attrition bias, and were classified as unclear.Analyses considered the nature of the intervention, whether participants were in treatment or recovery and the type of dependency. Of the 34 studies included in the meta-analysis, 11 assessed counselling, 11 assessed pharmacotherapy, and 12 assessed counselling in combination with pharmacotherapy, compared to usual care or no intervention. Tobacco cessation interventions were significantly associated with tobacco abstinence for two types of interventions. Pharmacotherapy appeared to increase tobacco abstinence (RR 1.60, 95% CI 1.22 to 2.12, 11 studies, 1808 participants, low quality evidence), as did combined counselling and pharmacotherapy (RR 1.74, 95% CI 1.39 to 2.18, 12 studies, 2229 participants, low quality evidence) at the period of longest follow-up, which ranged from six weeks to 18 months. There was moderate evidence of heterogeneity (I² = 56% with pharmacotherapy and 43% with counselling plus pharmacotherapy). Counselling interventions did not significantly increase tobacco abstinence (RR 1.33, 95% CI 0.90 to 1.95).Interventions were significantly associated with tobacco abstinence for both people in treatment (RR 1.99, 95% CI 1.59 to 2.50) and people in recovery (RR 1.33, 95% CI 1.06 to 1.67), and for people with alcohol dependence (RR 1.47, 95% CI 1.20 to 1.81) and people with other drug dependencies (RR 1.85, 95% CI 1.43 to 2.40).Offering tobacco cessation therapy to people in treatment or recovery for other drug dependence was not associated with a difference in abstinence rates from alcohol and other drugs (RR 0.97, 95% CI 0.91 to 1.03, 11 studies, 2231 participants, moderate evidence of heterogeneity (I² = 66%)).Data on adverse effect of the interventions were limited.

AUTHORS' CONCLUSIONS

The studies included in this review suggest that providing tobacco cessation interventions targeted to smokers in treatment and recovery for alcohol and other drug dependencies increases tobacco abstinence. There was no evidence that providing interventions for tobacco cessation affected abstinence from alcohol and other drugs. The association between tobacco cessation interventions and tobacco abstinence was consistent for both pharmacotherapy and combined counselling and pharmacotherapy, for participants both in treatment and in recovery, and for people with alcohol dependency or other drug dependency. The evidence for the interventions was low quality due primarily to incomplete reporting of the risks of bias and clinical heterogeneity in the nature of treatment. Certain results were sensitive to the length of follow-up or the type of pharmacotherapy, suggesting that further research is warranted regarding whether tobacco cessation interventions are associated with tobacco abstinence for people in recovery, and the outcomes associated with NRT versus non-NRT or combined pharmacotherapy. Overall, the results suggest that tobacco cessation interventions incorporating pharmacotherapy should be incorporated into clinical practice to reduce tobacco addiction among people in treatment for or recovery from alcohol and other drug dependence.

Development and initial testing of a tailored telephone intervention delivered by peers to prevent recurring opioid-overdoses (TTIP-PRO)

Individuals with opioid use disorder experiencing a non-fatal opioid-overdose (OOD) are at heightened risk for future OODs; there are no interventions to facilitate treatment enrollment for these patients. Our goal was to develop and initially test the 'tailored telephone intervention delivered by peers to prevent recurring opioid-overdoses' (TTIP-PRO), a computer-facilitated, peer-delivered, individually tailored secondary prevention intervention designed to: (i) encourage patients to initiate medication-assisted treatment (MAT) and (ii) increase OOD knowledge. A pre-post-study assessed TTIP-PRO-content acceptability and software performance. Two Peer Interventionists, who were abstinent from illicit opioids, enrolled in MAT and had experience with OOD, were recruited from a MAT clinic. Recruitment letters were sent to patients treated for OOD in a hospital emergency department within the prior 8 months. Eight patients received TTIP-PRO and completed pre-/post-assessment. Peer Interventionists completed training within 4 h and reported high satisfaction with TTIP-PRO. There were no performance issues with the software. All participants rated TTIP-PRO as 'very helpful'. Participants' OOD knowledge increased significantly, with 69.9% correct responses pre-TTIP-PRO and 93.6% post-TTIP-PRO. Interest in receiving MAT, measured on a 10-point scale, increased from 8.1 to 9.5, but this change was not statistically significant. Further development and testing of TTIP-PRO appears warranted.

Evaluating the impacts of screening and smoking cessation programmes on lung cancer in a high-burden region of the USA: a simulation modelling study

OBJECTIVE

While the US Preventive Services Task Force has issued recommendations for lung cancer screening, its effectiveness at reducing lung cancer burden may vary at local levels due to regional variations in smoking behaviour. Our objective was to use an existing model to determine the impacts of lung cancer screening alone or in addition to increased smoking cessation in a US region with a relatively high smoking prevalence and lung cancer incidence.

SETTING

Computer-based simulation model.

PARTICIPANTS

Simulated population of individuals 55 and older based on smoking prevalence and census data from Northeast Pennsylvania.

INTERVENTIONS

Hypothetical lung cancer control from 2014 to 2050 through (1) screening with CT, (2) intensified smoking cessation or (3) a combination strategy.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were lung cancer mortality rates. Secondary outcomes included number of people eligible for screening and number of radiation-induced lung cancers.

RESULTS

Combining lung cancer screening with increased smoking cessation would yield an estimated 8.1% reduction in cumulative lung cancer mortality by 2050. Our model estimated that the number of screening-eligible individuals would progressively decrease over time, indicating declining benefit of a screening-only programme. Lung cancer screening achieved a greater mortality reduction in earlier years, but was later surpassed by smoking cessation.

CONCLUSIONS

Combining smoking cessation programmes with lung cancer screening would provide the most benefit to a population, especially considering the growing proportion of patients ineligible for screening based on current recommendations.

Meeting the Tobacco Cessation Coverage Requirement of the Patient Protection and Affordable Care Act: State Smoking Cessation Quitlines and Cost Sharing

OBJECTIVES

We explored whether various key stakeholders considered cost sharing with state telephone-based tobacco cessation quitlines, because including tobacco cessation services as part of the required essential health benefits is a new requirement of the Patient Protection and Affordable Care Act (ACA).

METHODS

We analyzed qualitative data collected from interviews conducted in April and May of 2014 with representatives of state health departments, quitline service providers, health plans, and insurance brokers in 4 US states.

RESULTS

State health departments varied in the strategies they considered the role their state quitline would play in meeting the ACA requirements. Health plans and insurance brokers referred to state quitlines because they were perceived as effective and free, but in 3 of the 4 states, the private stakeholder groups did not consider cost sharing.

CONCLUSIONS

If state health departments are going to initiate cost-sharing agreements with private insurance providers, then they will need to engage a broad array of stakeholders and will need to overcome the perception that state quitline services are free.

Predicting use of assistance when quitting: a longitudinal study of the role of quitting beliefs

BACKGROUND

A growing literature addresses the need to reduce cigarette smoking prevalence by increasing the use of assistance when quitting. A key focus is to identify strategies for enhancing adoption of effective interventions in order to increase utilization of evidence-based treatments.

PURPOSE

To examine the effect of beliefs regarding ability to quit on utilization of assistance for smoking cessation. A mediation model was hypothesized whereby the relationship between smoking and use of assistance is influenced by beliefs in ability to quit.

METHODS

The present study includes 474 of 1000 respondents to baseline and follow-up California Smokers Cohort surveys conducted from 2011 to 2013. Included were baseline smokers who reported a 24-h quit attempt at follow-up. Baseline variables were used to predict use of assistance when quitting.

RESULTS

The hypothesized model was tested using a product of coefficients method, controlling for demographics. Greater heaviness of smoking and lower belief in ability to quit were significantly related to use of assistance. Quitting beliefs significantly mediated the relationship between nicotine dependence and use of assistance.

CONCLUSIONS

The present data support a mechanism whereby the effect of smoking rate on treatment utilization is mediated by beliefs in ability to quit. Greater belief in one's ability to quit may represent an obstacle to treatment utilization by reducing the likelihood of successful cessation. The present findings suggest the value of targeted messages from health care providers that normalize the need for assistance when attempting to change an addictive behavior and emphasize the difficulty of quitting without assistance.

A pre-post pilot study of a brief, web-based intervention to engage disadvantaged smokers into cessation treatment

BACKGROUND

People with low education and/or income are more likely to smoke, less likely to quit, and experience disparately poor health outcomes compared to those with education and income advantage. Cost-effective strategies are needed to inform and engage this group into effective cessation treatments. We developed a novel, web-based, motivational, decision-support system that was designed to engage disadvantaged smokers into tobacco cessation treatment. We piloted the system among smokers in a primary care safety net clinic.

METHODS

Thirty-nine eligible subjects were assessed at baseline and used the decision-support system; 38 were assessed 2 months later. Chi-square or Fisher's exact tests were used to assess whether participants who used the program were more likely to use cessation treatment than a randomly selected group of 60 clinic patients.

RESULTS

Thirty-nine percent of smokers initiated cessation treatment after using the decision-support system, compared to 3 percent of the comparison group (Fisher's exact = 21.2; p = 0.000). Over 10 percent achieved continuous abstinence over the 2-month follow-up. Users were satisfied with the program - 100 percent stated they would recommend it to a friend.

CONCLUSIONS

Our data indicate that this web-based, motivational, decision-support system is feasible, satisfactory, and promising in its ability to engage smokers into cessation treatment in a primary care safety net clinic. Further evaluation research is warranted.

A preliminary randomized controlled trial of a behavioral exercise intervention for smoking cessation

INTRODUCTION

Previous exercise intervention studies for smoking cessation have been challenged by a number of methodological limitations that confound the potential efficacy of aerobic exercise for smoking cessation.

METHODS

The preliminary efficacy of a behavioral exercise intervention that incorporated features designed to address prior limitations was tested in a randomized controlled trial (RCT). Sixty-one smokers (65.6% female, mean age = 47.3 years, smoked a mean of 19.7 cigarettes/day) were randomized to receive either a 12-week exercise intervention or a 12-week health education contact control. Participants in both conditions received an 8-week telephone-delivered, standard smoking cessation protocol (with the transdermal nicotine patch). Follow-ups were conducted at the end of treatment (EOT), 6- and 12-month timepoints.

RESULTS

There were no differences between conditions with respect to the number of weekly exercise or health education sessions attended (9.3±2.8 vs. 9.3±3.0, respectively). While not statistically significant, participants in the exercise condition demonstrated higher verified abstinence rates (EOT: 40% vs. 22.6%, odds ratio [OR] = 2.28; 6- and 12-month follow-ups: 26.7% vs. 12.9%, OR = 2.46). Irrespective of treatment condition, higher levels of moderate-to-vigorous exercise were associated with lower levels of depressive symptoms during the intervention.

CONCLUSIONS

The results of this small RCT point toward the benefit of a behavioral exercise intervention designed to address previous methodological limitations for smoking cessation. Given the potential public health impact of the demonstrated efficacy of exercise for smoking cessation, the continued development and optimization of exercise interventions for smokers through larger RCTs merits pursuit.

Systems science: a good investment for the public's health

This supplement of Health Education & Behavior showcases the current state of the field of systems science applications in health promotion and public health. Behind this work lies a steady stream of public dollars at the federal level. This perspective details nearly a decade of investment by the National Institutes of Health's Office of Behavioral and Social Sciences Research. These investments have included funding opportunity announcements, training programs, developing resources for researchers, cross-disciplinary fertilization, and publication. While much progress has been made, continuing investment is needed in the future to ensure the viability and sustainability of this young but increasingly important field.

Emerging drugs for the treatment of tobacco dependence: 2014 update

INTRODUCTION

Tobacco dependence remains a global epidemic and the largest preventable cause of morbidity and mortality around the world. Smoking cessation has benefits at all ages but remains challenging for several reasons, among which are the complexities of nicotine addiction and limitations of available pharmacotherapies.

AREAS COVERED

This review summarizes current and emerging pharmacotherapies for the treatment of tobacco dependence, including first- and second-line recommended agents. Medications with alternative primary indications that have been investigated as potential treatments for tobacco dependence are also discussed. Articles reviewed were obtained through searches of PubMed, Ovid MEDLINE, ClinicalTrials.gov and the Pharmaprojects database.

EXPERT OPINION

Current evidence suggests that the two most effective pharmacotherapies to treat tobacco dependence are varenicline and combination nicotine replacement therapy. Alternative agents investigated demonstrate mixed rates of success in achieving long-term abstinence from smoking. No single pharmacotherapy will serve as a universally successful treatment given the complex underpinnings of tobacco dependence and individuality of smokers. The ultimate goal of tobacco research with respect to pharmacotherapeutic development continues to be providing clinicians with an armamentarium of drugs to choose from allowing for tailoring of treatment for smokers.

Community-level adult daily smoking prevalence moderates the association between adolescents' cigarette smoking and perceived smoking by friends

Few studies have investigated the complex interactions among the individual- and community-level social risk factors that underlie adolescents' smoking behaviors. This study investigated whether community-level adult daily smoking prevalence is associated with adolescents' smoking and whether it moderates the associations between perceived friends' smoking approval and smoking behavior and adolescents' own smoking. Self-reported data from 1,190 youths (50.3% female; 13-18 years old) in 50 midsized Californian cities were obtained through telephone interviews. Community characteristics were obtained from 2010 GeoLytics data. Community adult daily smoking prevalence was ascertained from telephone interviews with 8,918 adults conducted in the same 50 cities. Multilevel analyses, controlling for individual and city characteristics, were used to predict adolescents' past 12-month smoking from perceived friends' smoking approval and smoking behavior and from community adult daily smoking prevalence. Results showed that perceived friends' smoking approval and behavior were associated positively with adolescents' smoking, as was the community-level prevalence of adult daily smoking. Furthermore, the association between perceived friends' smoking behavior and adolescents' own smoking was moderated by the prevalence of adult daily smokers in the community. Specifically, the association was stronger in cities with higher prevalence of adult smokers. These results suggest that adult community norms that are more supportive of smoking may enhance the influence of friends' smoking behavior. Therefore, interventions designed to prevent or reduce youths' smoking should also focus on reducing smoking by adults.

What do we know about unassisted smoking cessation in Australia? A systematic review, 2005-2012

CONTEXT

A significant proportion of smokers who quit do so on their own without formal help (ie, without professionally or pharmacologically mediated assistance), yet research into how smokers quit focuses primarily on assisted methods of cessation.

OBJECTIVE

The aim of the present work was to systematically review recent smoking cessation research in Australia, a nation advanced in tobacco control, to determine what is known about smokers who quit unassisted in order to (1) inform a research agenda to develop greater understanding of the many smokers who quit unassisted and (2) elucidate possible lessons for policy and mass communication about cessation.

METHODS

In January 2013, four e-databases and the grey literature were searched for articles published between 2005 and 2012 on smoking cessation in Australia. Articles focusing solely on interventions designed to stimulate cessation were excluded, as were articles focusing solely on assisted cessation, leaving articles reporting on smokers who quit unassisted. Data from articles reporting on unassisted cessation were extracted and grouped into related categories.

RESULTS

A total of 248 articles reported on smoking cessation, of which 63 focused solely on interventions designed to stimulate cessation, leaving 185 reporting on the method of cessation ('how' a smoker quits). Of these, 166 focused solely on assisted cessation, leaving 19 reporting, either directly or indirectly, on smokers who quit unassisted. Data from these studies indicated 54% to 69% of ex-smokers quit unassisted and 41% to 58% of current smokers had attempted to quit unassisted.

CONCLUSIONS

The majority of Australian smokers quit or attempt to quit unassisted, yet little research has been dedicated to understanding this process. Almost all research that reported unassisted cessation referenced it as a comparator to the focal point of assisted cessation. Public health may benefit from insights gained from greater research into the cessation method used by most smokers. Suggestions and a rationale for such research are provided.

A cost-utility analysis of lung cancer screening and the additional benefits of incorporating smoking cessation interventions

BACKGROUND

A 2011 report from the National Lung Screening Trial indicates that three annual low-dose computed tomography (LDCT) screenings for lung cancer reduced lung cancer mortality by 20% compared to chest X-ray among older individuals at high risk for lung cancer. Discussion has shifted from clinical proof to financial feasibility. The goal of this study was to determine whether LDCT screening for lung cancer in a commercially-insured population (aged 50-64) at high risk for lung cancer is cost-effective and to quantify the additional benefits of incorporating smoking cessation interventions in a lung cancer screening program.

METHODS AND FINDINGS

The current study builds upon a previous simulation model to estimate the cost-utility of annual, repeated LDCT screenings over 15 years in a high risk hypothetical cohort of 18 million adults between age 50 and 64 with 30+ pack-years of smoking history. In the base case, the lung cancer screening intervention cost $27.8 billion over 15 years and yielded 985,284 quality-adjusted life years (QALYs) gained for a cost-utility ratio of $28,240 per QALY gained. Adding smoking cessation to these annual screenings resulted in increases in both the costs and QALYs saved, reflected in cost-utility ratios ranging from $16,198 per QALY gained to $23,185 per QALY gained. Annual LDCT lung cancer screening in this high risk population remained cost-effective across all sensitivity analyses.

CONCLUSIONS

The findings of this study indicate that repeat annual lung cancer screening in a high risk cohort of adults aged 50-64 is highly cost-effective. Offering smoking cessation interventions with the annual screening program improved the cost-effectiveness of lung cancer screening between 20% and 45%. The cost-utility ratios estimated in this study were in line with other accepted cancer screening interventions and support inclusion of annual LDCT screening for lung cancer in a high risk population in clinical recommendations.

Smoking-related deaths averted due to three years of policy progress

OBJECTIVE

To evaluate the global impact of adopting highest-level MPOWER tobacco control policies in different countries and territories from 2007 to 2010.

METHODS

Policy effect sizes based on previously-validated SimSmoke models were applied to determine the reduction in the number of smokers as a result of policy adoption during this period. Based on previous research suggesting that half of all smokers die from smoking, we also derived the estimated smoking-attributable deaths (SADs) averted due to MPOWER policy implementation. The results from use of this simple yet powerful method are consistent with those predicted by using previously validated SimSmoke models.

FINDINGS

In total, 41 countries adopted at least one highest-level MPOWER policy between 2007 and 2010. As a result of all policies adopted during this period, the number of smokers is estimated to have dropped by 14.8 million, with a total of 7.4 million SADs averted. The largest number of SADs was averted as a result of increased cigarette taxes (3.5 million), smoke-free air laws (2.5 million), health warnings (700,000), cessation treatments (380,000), and bans on tobacco marketing (306,000).

CONCLUSION

From 2007 to 2010, 41 countries and territories took action that will collectively prevent nearly 7.5 million smoking-related deaths globally. These findings demonstrate the magnitude of the actions already taken by countries and underscore the potential for millions of additional lives to be saved with continued adoption of MPOWER policies.

Nurse practitioners, wake up and smell the smoke

PURPOSE

With the focus of modern health care on preventive care, and the well-known benefits of smoking cessation on improving health and reducing healthcare costs, smoking cessation is a key focus of healthcare reform. To change the smoking habits of the U.S. population, two strategies are of particular importance to healthcare professionals: promoting tobacco-free environments in healthcare systems and expanding affordable and effective treatments.

DATA SOURCES

Recent policy literature.

CONCLUSIONS

Barriers to providing smoking cessation counseling most frequently cited by healthcare professionals are lack of training and poor reimbursement; however, recent legislation, for example, the Patient Protection and Affordable Care Act (PPACA), should make preventive services more available and affordable. Nurse practitioners (NPs) have vast experience in addressing health promotion and disease prevention, and are therefore well placed to lead this reform. However, despite consistently higher referrals of tobacco-dependent patients for smoking cessation interventions than any other group of healthcare provider, evidence suggests that NPs are not adequately trained to treat this addiction.

IMPLICATIONS FOR PRACTICE

This article is a call to action for NPs to become familiar with the tobacco cessation policy changes affecting clinical practice, to become experts in tobacco treatment, and to take the lead in this healthcare reform initiative.