Smoking Cessation for Smokers Not Ready to Quit: Meta-analysis and Cost-effectiveness Analysis

A Novel mHealth App for Smokers Living With HIV Who Are Ambivalent About Quitting Smoking: Formative Research and Randomized Feasibility Study

BACKGROUND

More people who smoke and are living with HIV now die from tobacco-related diseases than HIV itself. Most people are ambivalent about quitting smoking and want to quit someday but not yet. Scalable, effective interventions are needed to motivate and support smoking cessation among people ambivalent about quitting smoking (PAQS) who are living with HIV.

OBJECTIVE

This study aims to develop an app-based intervention for PAQS who are living with HIV and assess its feasibility, acceptability, and potential impact. Results of this study will inform plans for future research and development.

METHODS

In phase 1, PAQS living with HIV (n=8) participated in user-centered design interviews to inform the final intervention app design and recruitment plan for a subsequent randomized pilot study. In phase 2, PAQS living with HIV were randomized to either a standard care control app or a similar experimental app with additional content tailored for PAQS and those with HIV. Participants were followed for 3 months. Feasibility focused on recruitment, retention, and participants' willingness to install the app. The study was not powered for statistical significance. Indices of acceptability (satisfaction and use) and impact (smoking behavior change and treatment uptake) were assessed via automated data and self-report among those who installed and used the app (n=19).

RESULTS

Recruitment for both study phases was a challenge, particularly via web-based and social media platforms. Enrollment success was greater among people living with HIV recruited from a health care provider and research registry. Once enrolled, retention for the phase 2 randomized study was good; 74% (14/19) of the participants completed the 3-month follow-up. Phase 1 findings suggested that PAQS living with HIV were receptive to using an app-based intervention to help them decide whether, when, and how to stop smoking, despite not being ready to quit smoking. Phase 2 findings further supported this conclusion based on feedback from people who agreed to use an app, but group differences were observed. Indices of acceptability favored the experimental arm, including a descriptively higher mean number of sessions and utilization badges. Similarly, indices of potential impact were descriptively higher in the experimental arm (proportion reducing smoking, making a quit attempt, or calling free tobacco quitline). No participants in either arm quit smoking at the 3-month follow-up.

CONCLUSIONS

On the basis of this formative work, PAQS living with HIV may be receptive to using a mobile health-based app intervention to help them decide whether, when, or how to stop using tobacco. Indices of acceptability and impact indicate that additional research and development are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05339659; https://clinicaltrials.gov/study/NCT05339659.

Project phoenix: Pilot randomized controlled trial of a smartphone-delivered intervention for people who are not ready to quit smoking

BACKGROUND

Most people who smoke cigarettes report they want to quit in the future, but only 20 % are ready to quit within the next 30 days. This 3-arm pilot randomized controlled trial examined the feasibility and initial efficacy of a novel smartphone-based intervention that aimed to induce smoking cessation attempts among adults not initially ready to quit.

METHODS

Participants randomized into the two intervention groups (Group 1: Phoenix App Only; Group 2: Phoenix App + Nicotine Replacement Therapy) received daily smoking cessation messages via smartphone application that were tailored to their current readiness to quit, while the attention control group (i.e., Factoid) received messages not related to smoking cessation. All participants completed a weekly survey for 26 weeks and used the app to set quit dates when/if desired.

RESULTS

Participants (N=152) were female (67.8 %), White (75.7 %), 50.0 years old (SD=12.5), and smoked 20.4 cigarettes per day (SD=10.5). Results indicated that the Phoenix interventions were feasible (e.g., participants viewed ~185 messages over 26 weeks; 74.8 % of weekly surveys were completed; 85.5 % completed the 26-week follow-up assessment). Phoenix participants set more quit dates, set quit dates sooner, were abstinent for more days, and used smoking cessation medications on more days than those assigned to the Factoid group.

CONCLUSIONS

This low-burden, smartphone-based smoking cessation induction intervention may increase smoking cessation attempts, and may reduce barriers that are encountered with traditional in-person or call-based interventions.

TRIAL REGISTRATION

Clinicaltrials.gov number: NCT03405129; https://clinicaltrials.gov/ct2/show/NCT03405129.

Adolescent Tobacco/Nicotine Use and the Potential Role of Contingency Management-based Interventions

ABSTRACT

The high prevalence of tobacco/nicotine use among youth, including e-cigarettes, is a public health problem in the United States. Early exposure leads to an increased risk of dependence and health consequences in adulthood. We reviewed the literature on current treatment approaches for nicotine/tobacco use in adolescents/young adults and highlighted underexplored areas of treatment research. There are no current Food and Drug Administration-approved medications for treatment of nicotine/tobacco use disorders in adolescents. However, in research settings and on a case-to-case basis, clinical practice medications (including nicotine replacement therapy, bupropion, and varenicline) have been prescribed to this population with consideration of risk-benefit analysis when behavioral treatments are not sufficient to address dependence. Among the nonpharmacological interventions, there is evidence to support the potential for expanded use of contingency management in youth. Neural differences predisposing adolescents to substance use, along with higher attentiveness to value of options in decision making (flexible reward system) may enhance the effectiveness of reward-based approaches for treatment of substance use disorders in this population. The overall high rates of nonresponders across psychosocial and pharmacological treatments highlight the importance of considering novel strategies to improve existing interventions. We suggest that future research be done that considers unique characteristics of today's adolescents, such as high social activism and engagement with digital rewards to tailor contingency management for this age group and assess its effectiveness. Adolescents could potentially benefit from rewards administered through digital media (eg, video games, computer-based apps, and social media influencers).

Tobacco-Free Nicotine Pouches and Their Potential Contribution to Tobacco Harm Reduction: A Scoping Review

Tobacco harm reduction (THR) refers to strategies designed to reduce the health risks associated with tobacco smoking but may involve continued use of nicotine and/or tobacco. Next-generation products (NGPs) are a THR alternative as they do not burn tobacco or produce smoke and deliver nicotine and have fewer and substantially lower levels of harmful chemicals compared to cigarettes. Tobacco‑free nicotine pouches (TFNPs) are an emerging category of nicotine‑containing oral products that do not combust or contain tobacco leaf. Similar to Swedish snus, TFNPs are placed between a user's lip and gum, and nicotine is absorbed through the oral mucosa rather than being inhaled. The aim of this scoping review was to systematically collate and evaluate published scientific evidence (cut‑off of 31 May 2023) identified from bibliometric databases investigating the potential of TFNPs to contribute to THR. Overall, studies examining chemical constituents indicated that the use of TFNPs may result in lower exposure to toxicants than other tobacco or nicotine-containing products, both combustible and non‑combustible. This reduction in toxicant exposure has been demonstrated by multiple human biomarker studies and in vitro toxicological assessments to translate to harm reduction potential in smokers switching to TFNPs. However, further study is warranted. At present, there is some evidence from human behavioral research that TFNPs can support either transitioning away from smoking or reducing cigarette consumption. Furthermore, TFNP use appears very much limited to current users of traditional tobacco products, and youth uptake has been limited. In conclusion, the findings of this review indicate that TFNPs have the potential to support THR efforts and may help inform evidence‑based regulation.

DNA methylation status of SHATI/NAT8L promoter in the blood of cigarette smokers

AIMS

Cigarette smoking is a preventable risk factor for various diseases such as cancer, ischemic stroke, cardiac stroke, and chronic obstructive pulmonary disease. Smoking cessation is of great importance not only for individual smokers but also for social health. Regarding current cessation therapies, the effectiveness of nicotine replacement is limited, and the cost of varenicline medication is considerable. Thus, a method for screening smokers who are responsive to cessation therapy based on the therapeutic effectiveness is required. Peripheral biomarkers reflecting smoking dependence status are necessary to establish a method for achieving effective cessation therapy.

METHODS

Methylation status of smokers' blood DNA was evaluated focusing on SHATI/NAT8L, an addiction-related gene. Eight CpG sites in SHATI/NAT8L were quantified by pyrosequencing.

RESULTS

There was no difference in the methylation status of this gene between smokers (n = 129) and non-smokers (n = 129) at all CpG sites. No correlations between the methylation status of SHATI/NAT8L and indicators of smoking dependence were found.

CONCLUSIONS

Although the present study found no significance in the DNA methylation of SHATI/NAT8L among smokers, the exploration of predictable peripheral biomarkers for the effectiveness of smoking cessation therapy is required.

Clinical Practice Guideline of Spanish Society of Pneumology and Thoracic Surgery (SEPAR) on Pharmacological Treatment of Tobacco Dependence 2023

INTRODUCTION

There are multiple systematic reviews and meta-analyses on the efficacy and safety of pharmacological treatments against nicotine dependence. However, there are few guidelines to answer frequent questions asked by a clinician treating a smoker. Therefore, the aim of this paper is to facilitate the treatment of tobacco addiction.

MATERIAL AND METHODS

12 PICO questions are formulated from a GLOBAL PICO question: "Efficacy and safety of pharmacological treatment of tobacco dependence". A systematic review was carried out to answer each of the questions and recommendations were made. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system was used to grade the certainty of the estimated effects and the strength of the recommendations.

RESULTS

Varenicline, nicotine replacement therapy (NRT), bupropion and cytisine are more effective than placebo. Varenicline and combined nicotine therapy are superior to the other therapies. In smokers with high dependence, a combination of drugs is recommended, being more effective those associations containing varenicline. Other optimization strategies with lower efficacy consist of increasing the doses, the duration, or retreat with varenicline. In specific populations varenicline or NRT is recommended. In hospitalized, the treatment of choice is NRT. In pregnancy it is indicated to prioritize behavioral treatment. The financing of smoking cessation treatments increases the number of smokers who quit smoking. There is no scientific evidence of the efficacy of pharmacological treatment of smoking cessation in adolescents.

CONCLUSIONS

The answers to the 12 questions allow us to extract recommendations and algorithms for the pharmacological treatment of tobacco dependence.

Reengagement for Long-Term Smoking-Cessation In Military Personnel, Retirees, Family Members (TRICARE): A Randomized Trial

INTRODUCTION

We sought to determine what type of treatment reengagement after smoking relapse would increase long-term cessation.

AIMS AND METHODS

Participants were military personnel, retirees, and family members (TRICARE beneficiaries) recruited across the United States from August 2015 through June 2020. At baseline, consented participants (n = 614) received a validated, four-session, telephonic tobacco-cessation intervention with free nicotine replacement therapy. At the 3-month follow-up, 264 participants who failed to quit or relapsed were offered the opportunity to reengage in cessation. Of these, 134 were randomized into three reengagement conditions: (1) repeat initial intervention ("recycle"), (2) Smoking reduction with eventual cessation goal ("rate reduction"), or (3) Choose #1 or #2 ("choice"). Prolonged abstinence and 7-day point prevalence abstinence were measured at 12 months.

RESULTS

Despite being in a clinical trial advertised as having the opportunity for reengagement, only 51% (134 of the 264) of participants who still smoked at 3-month follow-up were willing to reengage. Overall, participants randomized to recycle had higher prolonged cessation rates at 12 months than rate reduction conditions (OR = 16.43, 95% CI: 2.52 to 107.09, Bonferroni adjusted p = .011). When participants who randomly received recycle or rate reduction were pooled, respectively, with participants who chose recycle or rate reduction in the Choice group, recycle had higher prolonged cessation rates at 12 months than rate reduction (OR = 6.50, 95% CI: 1.49 to 28.42, p = .013).

CONCLUSIONS

Our findings suggest service members and their family members who fail to quit smoking but are willing to reengage in a cessation program are more likely to benefit from repeating the same treatment.

IMPLICATIONS

Finding methods that are both successful and acceptable to reengage people who smoke who want to quit can have a significant impact on improving the health of the public by reducing the portion of the population who smoke. This study suggests that repeating established cessation programs will result in more people ready to quit successfully achieving their goal.

Feasibility, Acceptability, and Potential Impact of a Novel mHealth App for Smokers Ambivalent About Quitting: Randomized Pilot Study

BACKGROUND

Most smokers are ambivalent about quitting-they want to quit someday, but not now. Interventions are needed that can engage ambivalent smokers, build their motivation for quitting, and support future quit attempts. Mobile health (mHealth) apps offer a cost-effective platform for such interventions, but research is needed to inform their optimal design and assess their acceptability, feasibility, and potential effectiveness.

OBJECTIVE

This study aims to assess the feasibility, acceptability, and potential impact of a novel mHealth app for smokers who want to quit smoking someday but are ambivalent about quitting in the near term.

METHODS

We enrolled adults across the United States who smoked more than 10 cigarettes a day and were ambivalent about quitting (n=60). Participants were randomly assigned to 1 of 2 versions of the GEMS app: standard care (SC) versus enhanced care (EC). Both had a similar design and identical evidence-based, best-practice smoking cessation advice and resources, including the ability to earn free nicotine patches. EC also included a series of exercises called experiments designed to help ambivalent smokers clarify their goals, strengthen their motivation, and learn important behavioral skills for changing smoking behavior without making a commitment to quit. Outcomes were analyzed using automated app data and self-reported surveys at 1 and 3 months post enrollment.

RESULTS

Participants who installed the app (57/60, 95%) were largely female, White, socioeconomically disadvantaged, and highly nicotine dependent. As expected, key outcomes trended in favor of the EC group. Compared to SC users, EC participants had greater engagement (mean sessions 19.9 for EC vs 7.3 for SC). An intentional quit attempt was reported by 39.3% (11/28) of EC users and 37.9% (11/29) of SC users. Seven-day point prevalence smoking abstinence at the 3-month follow-up was reported by 14.7% (4/28) of EC users and 6.9% (2/29) of SC users. Among participants who earned a free trial of nicotine replacement therapy based on their app usage, 36.4% (8/22) of EC participants and 11.1% (2/18) of SC participants requested the treatment. A total of 17.9% (5/28) of EC and 3.4% (1/29) of SC participants used an in-app feature to access a free tobacco quitline. Other metrics were also promising. EC participants completed an average of 6.9 (SD 3.1) out of 9 experiments. Median helpfulness ratings for completed experiments ranged from 3 to 4 on a 5-point scale. Finally, satisfaction with both app versions was very good (mean 4.1 on a 5-point Likert scale) and 95.3% (41/43) of all respondents would recommend their app version to others.

CONCLUSIONS

Ambivalent smokers were receptive to the app-based intervention, but the EC version, which combined best-practice cessation advice with self-paced, experiential exercises, was associated with greater use and evidence of behavior change. Further development and evaluation of the EC program is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04560868; https://clinicaltrials.gov/ct2/show/NCT04560868.

Cost-effectiveness analysis of the SMART quit clinic program in smokers with cardiovascular disease in Thailand

INTRODUCTION

The SMART Quit Clinic Program (FAHSAI Clinic) has been implemented in Thailand since 2010; however, it remains unclear whether the benefits gained from this program justify its costs. We assessed its cost-effectiveness compared to usual care in a population of Thai smokers with cardiovascular disease (CVD) from a societal perspective.

METHODS

We conducted a cost-utility analysis using a Markov model to simulate lifetime costs and quality-adjusted life years (QALYs) of Thai smokers aged ≥35 years receiving smoking cessation services offered from FAHSAI Clinic or usual care over a horizon of 50 years. The model used a 6-month continuous abstinence rate from a multicenter prospective study of 24 FAHSAI Clinics. A series of sensitivity analyses including probabilistic sensitivity analysis were conducted to assess robustness of study findings. Cost data are presented in US$ for 2020.

RESULTS

The FAHSAI Clinic was dominant as it was less costly ($9537.92 vs $10964.19) and more effective (6.06 vs 5.96 QALYs) compared with usual care over the 50-year time horizon. Changes in risks of stroke and coronary heart disease among males had the largest impact on the cost-effectiveness findings. The probability that FAHSAI Clinic was cost-effective was 99.8% at a willingness-to-pay threshold of $5120.

CONCLUSIONS

The FAHSAI Clinic smoking cessation program was clinically superior and cost-saving compared to usual care for Thai patients with CVD in all scenarios. A budget impact analysis is needed to estimate the financial impact of adopting this program within the Thai healthcare system.

The Cost-Effectiveness of Nicotine Replacement Therapy Sampling in Primary Care: a Markov Cohort Simulation Model

BACKGROUND

Pharmacotherapies remain a central focus of successful tobacco control, but uptake remains very low.

OBJECTIVE

To estimate the cost effectiveness of a primary care nicotine replacement therapy (NRT) sampling intervention.

DESIGN

A Markov cohort simulation model was constructed to conduct cost-effectiveness analyses. Clinical trial results were used to initialize the Markov model. All other model parameters were derived from the literature. The study was conducted over a lifetime horizon, from the payers' budgetary perspective.

PARTICIPANTS

Smokers with a primary care visit.

INTERVENTION

Medication sampling, which provided short, starter packets of NRT (nicotine patch and lozenge) to smokers in the primary care setting.

MAIN MEASURES

Lifetime healthcare expenditures, quality-adjusted life years, and life years.

KEY RESULTS

Medication sampling was the dominant strategy compared to standard care. Our intervention cost $75, yielding a discounted lifetime savings of $1065 in healthcare expenditures, and increased both discounted quality-adjusted life years and discounted life years by 0.01. One-way sensitivity analyses showed that medication sampling remained dominant in plausible ranges except when it failed to increase cessation relative to standard care. Probabilistic sensitivity analyses confirmed that medication sampling was dominant in 94.1% of the simulated cases, with an implementation cost of $74 (95% CI $73-$76) and discounted lifetime savings in health expenditures of $1061 (- $1106 to - $1,017), increasing quality-adjusted life years by 0.008 (0.0085-0.0093) and life years by 0.008 (0.0081-0.0089).

CONCLUSION

Medication sampling, an easily implementable, scalable and low-cost intervention to encourage smoking cessation, is cost saving and improves quality of life.

A Randomized Trial of Telephone-Based Smoking Cessation Treatment in the Lung Cancer Screening Setting

BACKGROUND

Lung cancer mortality is reduced via low-dose CT screening and treatment of early-stage disease. Evidence-based smoking cessation treatment in the lung screening setting can further reduce mortality. We report the results of a cessation trial from the NCI's SCALE collaboration.

METHODS

Eligible patients (N = 818) aged 50-80 were randomized (May 2017-January 2021) to the Intensive vs. Minimal arms (8 vs. 3 phone sessions plus 8 vs. 2 weeks of nicotine patches, respectively). Bio-verified (primary) and self-reported 7-day abstinence rates were assessed 3-, 6-, and 12-months post-randomization. Logistic regression analyses evaluated the effects of study arm. All statistical tests were two-sided.

RESULTS

Participants reported 48.0 (SD = 17.2) pack-years and 51.6% were not ready to quit in < 30 days. Self-reported 3-month quit rates were significantly higher in the Intensive vs. Minimal arm (14.3% vs. 7.9%; OR = 2.00, 95% confidence interval [CI] = 1.26,3.18). Bio-verified abstinence was lower but with similar relative differences between arms (9.1% vs. 3.9%; OR = 2.70, 95% CI = 1.44, 5.08). Compared to the Minimal arm, the Intensive arm was more effective among those with greater nicotine dependence (OR = 3.47, 95% CI = 1.55, 7.76), normal screening results (OR = 2.58, 95% CI = 1.32, 5.03), high engagement in counseling (OR = 3.03, 95% CI = 1.50, 6.14) and patch use (OR = 2.81, 95% CI = 1.39, 5.68). Abstinence rates did not differ significantly between arms at 6-months (OR = 1.2, 95% CI = 0.68, 2.11) or 12-months (OR = 1.4, 95% CI = 0.82, 2.42).

CONCLUSIONS

Delivering intensive telephone counseling and nicotine replacement with lung screening is an effective strategy to increase short-term smoking cessation. Methods to maintain short-term effects are needed. Even with modest quit rates, integrating cessation treatment into lung screening programs may have a large impact on tobacco-related mortality.

Association Between Smoking Cessation Treatment and Healthcare Costs in a Single-Payer Public Healthcare System

INTRODUCTION

There has been little investigation of whether the clinical effectiveness of smoking cessation treatments translates into differences in healthcare costs, using real-world cost data, to determine whether anticipated benefits of smoking cessation treatment are being realized.

AIMS AND METHODS

We sought to determine the association between smoking cessation treatment and healthcare costs using linked administrative healthcare data. In total, 4752 patients who accessed a smoking cessation program in Ontario, Canada between July 2011 and December 2012 (treatment cohort) were each matched to a smoker who did not access these services (control cohort). The primary outcome was total healthcare costs in Canadian dollars, and secondary outcomes were sector-specific costs, from one year prior to the index date until December 31, 2017, or death. Costs were partitioned into four phases: pretreatment, treatment, posttreatment, and end-of-life for those who died.

RESULTS

Among females, total healthcare costs were similar between cohorts in pretreatment and posttreatment phases, but higher for the treatment cohort during the treatment phase ($4,554 vs. $3,237, p < .001). Among males, total healthcare costs were higher in the treatment cohort during pretreatment ($3,911 vs. $2,784, p < .001), treatment ($4,533 vs. $3,105, p < .001) and posttreatment ($5,065 vs. $3,922, p = .001) phases. End-of-life costs did not differ. Healthcare sector-specific costs followed a similar pattern.

CONCLUSIONS

Five-year healthcare costs were similar between females who participated in a treatment program versus those that did not, with a transient increase during the treatment phase only. Among males, treatment was associated with persistently higher healthcare costs. Further study is needed to address the implications with respect to long-term costs.

IMPLICATIONS

The clinical effectiveness of pharmacological and behavioral smoking cessation treatments is well established, but whether such treatments are associated with healthcare costs, using real-world data, has received limited attention. Our findings suggest that the use of a smoking cessation treatment offered by their health system is associated with persistent higher healthcare costs among males but a transient increase among females. Given increasing access to evidence-based smoking cessation treatments is an important component in national tobacco control strategies, these data highlight the need for further exploration of the relations between smoking cessation treatment engagement and healthcare costs.

Cost-Effectiveness of a Telephone-Based Smoking Cessation Randomized Trial in the Lung Cancer Screening Setting

BACKGROUND

There are limited data on the cost-effectiveness of smoking cessation interventions in lung cancer screening settings. We conducted an economic analysis embedded in a national randomized trial of 2 telephone counseling cessation interventions.

METHODS

We used a societal perspective to compare the short-term cost per 6-month bio-verified quit and long-term cost-effectiveness of the interventions. Trial data were used to micro-cost intervention delivery, and the data were extended to a lifetime horizon using an established Cancer Intervention Surveillance and Modeling Network lung cancer model. We modeled the impact of screening accompanied by 8 weeks vs 3 weeks of telephone counseling (plus nicotine replacement) vs screening alone based on 2021 screening eligibility. Lifetime downstream costs (2021 dollars) and effects (life-years gained, quality-adjusted life-years [QALYs]) saved were discounted at 3%. Sensitivity analyses tested the effects of varying quit rates and costs; all analyses assumed nonrelapse after quitting.

RESULTS

The costs for delivery of the 8-week vs 3-week protocol were $380.23 vs $144.93 per person, and quit rates were 7.14% vs 5.96%, respectively. The least costly strategy was a 3-week counseling approach. An 8-week (vs 3-week) counseling approach increased costs but gained QALYs for an incremental cost-effectiveness ratio of $4029 per QALY. Screening alone cost more and saved fewer QALYs than either counseling strategy. Conclusions were robust in sensitivity analyses.

CONCLUSIONS

Telephone-based cessation interventions with nicotine replacement are considered cost-effective in the lung screening setting. Integrating smoking cessation interventions with lung screening programs has the potential to maximize long-term health benefits at reasonable costs.

Planning a Change Easily (PACE) for smokers who are not ready to quit: a telephone-based, randomized controlled trial

AIMS

To compare brief advice (BA), motivational interviewing (MI), rate reduction (RR), and combined MI and RR (MI + RR) to promote smoking cessation in smokers not ready to quit.

DESIGN

Randomized controlled trial with four parallel groups of smoking cessation intervention. Participants were randomly assigned 1:2:2:2 to receive one of the following interventions: BA (n = 128), MI (n = 258), RR (n = 257), and MI + RR (n = 260).

SETTING

The United States. All participant contact occurred over the telephone to be consistent with the typical quit line format.

PARTICIPANTS

A total of 903 adult smokers. Participants had a mean age of 49 (SD = 13.3) years and were 28.9% male and 63.3% Caucasian.

INTERVENTIONS

The BA group received advice similar to typical smoking cessation quit lines. The MI group received advice using basic MI principles to elicit language that indicates behavioral change. The RR group received behavioral skills training and nicotine gum. The MI + RR group combined elements of MI and RR conditions. All interventions were six sessions.

MEASUREMENTS

The primary outcome measure was self-reported point prevalence at 12 months. The secondary outcome was self-reported prolonged abstinence at 12 months.

FINDINGS

Intention to treat (ITT) point prevalence at 12 months indicated that BA (10.9%) had significantly lower point prevalence rates than RR (27.2%, OR = 3.17, 1.69-5.94), and MI + RR (26.9%, OR = 3.16, 1.68-5.93). BA did not have a significantly lower point prevalence rate than MI (15.5%, OR = 1.56, 95% CI = 0.81-3.02).

CONCLUSIONS

This randomized controlled trial provided evidence that rate reduction, which offers structured behavioral skills and nicotine gum, either alone or combined with motivational interviewing, is the most effective form of cessation intervention for smokers not ready to quit.

Optimizing Smoking Cessation Counseling in a University Hospital: Results and Pitfalls

Background

Healthcare professionals (HPs) can play a substantial role in smoking cessation counseling (SCC) but in practice often skip this task due to time constraints. This study evaluates the implementation of the rapid Ask-Advise-Connect (AAC) method in a University hospital setting.

Methods

This mixed methods pre-post interventional study was performed at the Cardiology department of a University hospital and consisted of (1) a quantitative assessment of patient smoking registration and HP connection rates to external SCC from the Electronic Medical Record, (2) semi-structured interviews with 10 HPs to assess their attitudes toward AAC, and (3) a blended intervention aimed to implement AAC. The blended intervention consisted of face-to-face and online AAC psychoeducation for HPs followed-up with motivational messages on their smart pagers over a period of 6 weeks.

Results

In total, 48,321 patient registrations and 67 HPs were included. Before AAC implementation, HPs assessed smoking status in 74.0% of patients and connected 9.3% of identified smokers with SCC. Post intervention, these percentages did not increase (73.2%, p = 0.20; and 10.9%, p = 0.18, respectively). Nonetheless, the vast majority (90%) of HPs feel it is important to discuss patient smoking, and view it as their duty to do so. Main barriers to AAC reported by HPs were forgetfulness and time pressure.

Conclusion

This study shows that this AAC intervention does not increase Asking after smoking status or Connection of patients to SCC in a University Hospital. However, HPs hold positive attitudes toward AAC. A better understanding of the mechanisms required for optimizing HPs practice behavior is needed.

Evaluating four motivation-phase intervention components for use with primary care patients unwilling to quit smoking: a randomized factorial experiment

AIMS

To assess the effectiveness of intervention components designed to increase quit attempts and promote abstinence in patients initially unwilling to quit smoking.

DESIGN

A four-factor, randomized factorial experiment.

SETTING

Sixteen primary care clinics in southern Wisconsin.

PARTICIPANTS

A total of 577 adults who smoke (60% women, 80% White) recruited during primary care visits who were currently willing to reduce their smoking but unwilling to try to quit. Interventions Four factors contrasted intervention components administered over a 1-year period: (i) nicotine mini-lozenge versus none; (ii) reduction counseling versus none; (iii) behavioral activation (BA) counseling versus none; and (iv) motivational 5Rs counseling versus none. Participants could request cessation treatment at any time.

MEASUREMENTS

The primary outcome was 7-day point-prevalence abstinence at 52 weeks post enrollment; secondary outcomes were point-prevalence abstinence at 26 weeks and making a quit attempt by weeks 26 and 52.

FINDINGS

No abstinence main effects were found but a mini-lozenge × reduction counseling × BA interaction was found at 52 weeks; P = 0.03. Unpacking this interaction showed that the mini-lozenge alone produced the highest abstinence rate (16.7%); combining it with reduction counseling produced an especially low abstinence rate (4.1%). Reduction counseling decreased the likelihood of making a quit attempt by 52 weeks relative to no reduction counseling (P = 0.01).

CONCLUSIONS

Nicotine mini-lozenges may increase smoking abstinence in people initially unwilling to quit smoking, but their effectiveness declines when used with smoking reduction counseling or other behavioral interventions. Reduction counseling decreases the likelihood of making a quit attempt in people initially unwilling to quit smoking.

Implementation Intentions to Reduce Smoking: A Systematic Review of the Literature

Implementation intentions are a goal-setting technique in which an individual commits to perform a particular behavior when a specific context arises. Recently, researchers have begun studying how implementation intention (II) interventions can facilitate antismoking efforts. The current systematic review synthesized results of experimental studies that tested the effect of an II intervention on smoking cognitions and behavior. Of 29 reviewed articles, 11 studies met inclusion criteria. Nine studies (81.8%) tested an II intervention as a cessation tool for current smokers, whereas two tested II interventions as a tool to prevent smoking among predominantly nonsmoking adolescents. A majority of the studies (66.7%) testing II interventions as a cessation tool reported a positive effect on cessation at long-term follow-up. Of the two studies testing II interventions as a tool for prevention, one study found a positive effect on long-term follow-up. Methodology varied between the studies, highlighting the discrepancies between what researchers consider "implementation intentions" to be. II interventions are a promising tool for antismoking efforts, but more research is necessary to determine the best methodology and the populations for whom this intervention will be most effective.

IMPLICATIONS

Brief, free, and easily scalable, II interventions to prevent smoking are highly attractive for antismoking efforts. This review outlines the circumstances under which II interventions have demonstrated effectiveness in helping people resist smoking cigarettes. We illuminate gaps in the existing literature, limitations, methodological discrepancies between studies, and areas for future study.

Motivational Interviewing to Encourage Quit Attempts Among Smokers Not Ready to Quit: A Trial-Based Economic Analysis

INTRODUCTION

This study used data from a randomized controlled trial evaluating the efficacy of motivational interviewing (MI) relative to health education (HE) and brief advice (BA) to encourage quit attempts and cessation in order to determine their relative cost-effectiveness.

AIMS AND METHODS

Urban community residents (n = 255) with low desire to quit smoking were randomized to MI, HE, or BA which differed in communication style and/or number of treatment sessions. Incremental cost-effectiveness ratios were used to compare the intensive interventions (MI and HE) to BA for facilitating quit attempts and smoking cessation. Costs were calculated from the perspective of an agency that might engage in program delivery. Sensitivity analysis examined different assumptions for MI training and pharmacotherapy costs.

RESULTS

Total intervention delivery time costs per participant for MI, HE, and BA were $46.63, $42.87, and $2.4, respectively. Cost-effectiveness ratios per quit attempt at 24 weeks were $380 for MI, $272 for HE, and $209 for BA. The cost per additional quit attempt for MI and HE relative to BA was $508 and $301, respectively. The cost per additional quit for MI and HE relative to BA was $2030 and $752, respectively. Four separate sensitivity analyses conducted in our study did not change the conclusion the HE had a lower Incremental Cost-Effectiveness Ratio for both quit attempts and cessation.

CONCLUSIONS

HE was the most cost-effective of the three types of smoking cessation induction therapies and therefore may be preferable for smokers who are less motivated to quit. Providing valuable cost information in choosing different clinical methods for motivating smokers to quit.

IMPLICATIONS

All direct costs and activity-based time costs associated with delivering the intervention were analyzed from the perspective of an agency that may wish to replicate these strategies. A randomized controlled trial evaluating the efficacy of MI relative to HE and BA to encourage quit attempts and cessation determined their relative cost-effectiveness. HE was the most cost-effective of the three types of smoking cessation induction therapies and therefore may be preferable. Despite guideline recommendations, MI may not be the best approach to encourage quit attempts in diverse populations. Rather, a structured, intensive HE intervention might be the most cost-effective alternative.

Nicotine replacement therapy sampling for smoking cessation within primary care: results from a pragmatic cluster randomized clinical trial

BACKGROUND AND AIMS

Within the context of busy clinical settings, health-care providers need practical, evidence-based options to engage smokers in quitting. Sampling of nicotine replacement therapy [i.e. provision of nicotine replacement therapy (NRT starter kits)] is a brief, pragmatic strategy to address this need. We aimed to compare the effects of NRT sampling plus standard care (SC), relative to SC alone, provided by primary care providers during routine clinic visits.

DESIGN

Cluster-randomized clinical trial.

SETTING

Twenty-two primary care clinics in South Carolina, USA.

PARTICIPANTS

Adult smokers [n = 1245; 61% female, mean age = 50.7, standard deviation (SD) = 13.5] both motivated and unmotivated to quit, seen during routine clinical visit. Interventions were provider-delivered SC (n = 652, 12 clinics) cessation advice or SC + a 2-week supply of both nicotine patch and lozenge, with minimal instructions on use (n = 593; 10 clinics).

MEASUREMENTS

The primary outcome was 7-day point prevalence smoking abstinence at 6-month follow-up, using intent-to-treat. Additional outcomes included NRT use and quit attempts, assessed at 1, 3 and 6 months following baseline.

FINDINGS

Seven-day point prevalence abstinence rates were significantly higher in the NRT sampling group throughout follow-up, including at 6 months [12 versus 8%, odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.0-2.4]. NRT sampling increased prevalence of any use of NRT (65 versus 25%, OR = 5.8, 95% CI = 4.3-7.7), with higher prevalence of use at 6 months (25 versus 14%, OR = 2.0, 95% CI = 1.5-2.7). NRT sampling increased the rate of quit attempts in the initial month (24 versus 18%, OR = 1.5, 95% CI = 1.0-2.3) but had no significant effect on overall rate of quit attempts (48 versus 45%, OR = 1.2, 95% CI = 0.8-1.7).

CONCLUSION

Providing smokers with a free 2-week starter kit of nicotine replacement therapy increased quit attempts, use of stop smoking medications and smoking abstinence compared with standard care in a primary care setting.

The impact of cigarette smoking on infarct location and in-hospital outcome following acute ST-elevation myocardial infarction

Introduction: Smoking, which is a major modifiable risk factor for coronary artery diseases, affects cardiovascular system with different mechanisms. We designed this study to investigate the association of smoking with location of ST-segment elevation myocardial infarction (STEMI), and short-term outcomes during hospitalization. Methods: In 1017 consecutive patients with anterior/inferior STEMI, comprehensive demographic, biochemical data, as well as clinical complications and mortality rate, were recorded. Patients were allocated into two groups based on smoking status and compared regarding the location of myocardial infarction, the emergence of clinical complications and in-hospital mortality in univariate and multivariate logistic regression analysis. Results: Among 1017 patients, 300 patients (29.5%) were smoker and 717 patients (70.5 %) were non-smoker. Smokers were significantly younger and had lower prevalence of diabetes, hyperlipidemia and hypertension. Inferior myocardial infarction was considerably more common in smokers than in non-smokers (45.7% vs. 36%, P = 0.001). Heart failure was developed more commonly in non-smokers (33.9% vs. 20%, P = 0.001). In-hospital mortality was significantly lower in smokers (6.7% vs. 17.3%, P = 0.001). After adjustment for confounding variables, smoking was independently associated with inferior myocardial infarction and lower heart failure [odds ratio: 1.44 (1.06-1.96), P = 0.01 and odds ratio: 0.61 (0.40-0.92), P = 0.02, respectively]. However, in-hospital mortality was not associated with smoking after adjustment for other factors [odds ratio: 0.69 (0.36-1.31), P = 0.2]. Conclusion: Smoking is independently associated with inferior myocardial infarction. Although smokers had lower incidence of heart failure, in-hospital mortality was not different after adjustment for other factors.

Effectiveness and cost-effectiveness of incentives as a tool for prevention of non-communicable diseases: A systematic review

The rising epidemic of non-communicable diseases (NCDs) poses substantial health and economic challenges to both individuals and society. Application of incentive-based strategies based on traditional and behavioural economic theory has emerged as a potential strategy to address rising rates of NCDs. Yet, whether or not incentives truly represent a promising strategy for addressing NCDs has not been systematically addressed nor is it clear whether certain behavioural economic strategies outperform others or simply offering a cash-based incentive for meeting a goal. In this systematic review we aim to determine whether there is an evidence base for any of these strategies. Forty-eight published randomized controlled trials (70 contrasts) evaluating the effectiveness of incentive-based strategies for improvements in NCD risk-factors were reviewed. Our primary conclusion is that there is a lack of compelling evidence that incentives of any form represent a compelling NCD reduction strategy. More evidence for long-term effectiveness and cost-effectiveness is needed to justify third party funding of any incentive based strategy.

Effects of motivation phase intervention components on quit attempts in smokers unwilling to quit: A factorial experiment

BACKGROUND

Smoking reduction treatment is a promising approach to increase abstinence amongst smokers initially unwilling to quit. However, little is known about which reduction treatment elements increase quit attempts and the uptake of cessation treatment amongst such smokers.

METHODS

This study is a secondary analysis of a 4-factor randomized factorial experiment conducted amongst primary care patients (N = 517) presenting for regular healthcare visits in Southern Wisconsin who were unwilling to quit smoking but willing to cut down. We evaluated the main and interactive effects of Motivation-phase intervention components on whether participants: 1) made a quit attempt (intentional abstinence ≥24 h) by 6- and 26-weeks post-study enrollment and, 2) used cessation treatment. We also evaluated the relations of quit attempts with abstinence. The four intervention components evaluated were: 1) Nicotine Patch vs. None; 2) Nicotine Gum vs. None; 3) Motivational Interviewing (MI) vs. None; and 4) Behavioral Reduction Counseling (BR) vs. None. Intervention components were administered over 6 weeks, with an option to repeat treatment; participants could request cessation treatment at any point.

RESULTS

Nicotine gum significantly increased the likelihood of making a quit attempt by 6 weeks (23% vs. 15% without gum; p < .05). Conversely, nicotine patch reduced quit attempts when used with BR. Patch also discouraged use of cessation treatment (15.8% vs. 23% without patch; p < .05). Aided vs. unaided quit attempts produced abstinence in 42% vs. 10% of participants, respectively.

CONCLUSION

Nicotine gum is a promising Motivation-phase intervention that may spur quit attempts amongst smokers initially unwilling to quit.

Effectiveness of a Workplace Smoking Cessation Program based on Self-determination Theory Using Individual Counseling and Tailored Text Messaging: A Pilot Study

PURPOSE

Adverse health effects of smoking could be made worse by worker's tobacco use, and combining tobacco use with occupational hazards could enhance the likelihood of occupational disease and injury. This study was aimed to develop a workplace smoking cessation program based on self-determination theory (SDT) and then to examine the effectiveness of the program.

METHODS

A quasi-experimental design with nonequivalent control group pretest-posttest design was used. An intervention group (n = 30) received a smoking cessation program using individual counseling and tailored text messaging based on SDT during 12 weeks. Participants in the control group (n = 30) received a smoking cessation leaflet and telephonic follow-up for 3 times.

RESULTS

At 6 and 12 weeks, there were significant differences between the two groups on autonomous regulation, perceived competence, nicotine dependence, tobacco abstinence rate, and exhaled carbon monoxide concentration. At 12 weeks, the abstinence rate in the intervention group was 96.7%, whereas that in the control group was 12.9%.

CONCLUSION

SDT-based workplace smoking cessation program using individual counseling and tailored text messaging is effective in encouraging autonomous regulation and competence for workers.

Restricting tobacco sales to only pharmacies combined with cessation advice: a modelling study of the future smoking prevalence, health and cost impacts

OBJECTIVE

Restricting tobacco sales to pharmacies only, including the provision of cessation advice, has been suggested as a potential measure to hasten progress towards the tobacco endgame. We aimed to quantify the impacts of this hypothetical intervention package on future smoking prevalence, population health and health system costs for a country with an endgame goal: New Zealand (NZ).

METHODS

We used two peer-reviewed simulation models: 1) a dynamic population forecasting model for smoking prevalence and 2) a closed cohort multi-state life-table model for future health gains and costs by sex, age and ethnicity. Greater costs due to increased travel distances to purchase tobacco were treated as an increase in the price of tobacco. Annual cessation rates were multiplied with the effect size for brief opportunistic cessation advice on sustained smoking abstinence.

RESULTS

The intervention package was associated with a reduction in future smoking prevalence, such that by 2025 prevalence was 17.3%/6.8% for Māori (Indigenous)/non-Māori compared to 20.5%/8.1% projected under no intervention. The measure was furthermore estimated to accrue 41 700 discounted quality-adjusted life-years (QALYs) (95% uncertainty interval (UI): 33 500 to 51 600) over the remainder of the 2011 NZ population's lives. Of these QALYs gained, 74% were due to the provision of cessation advice over and above the limiting of sales to pharmacies.

CONCLUSIONS

This work provides modelling-level evidence that the package of restricting tobacco sales to only pharmacies combined with cessation advice in these settings can accelerate progress towards the tobacco endgame, and achieve large population health benefits and cost-savings. :.