Evidence base and strategies for successful smoking cessation

Factors Associated With Tobacco Cessation Advice Recall and Quit Rates in Vascular Surgery Patients. A Single Center Study

OBJECTIVES

Smoking is an important modifiable risk factor in all vascular diseases and verbal advice from providers has been shown to increase rates of tobacco cessation. We sought to identify factors that will improve tobacco cessation and recall of receiving verbal cessation advice in vascular surgery patients at a single institution.

METHODS

The study is a retrospective cohort study. Patients seen in outpatient vascular surgery clinic who triggered a tobacco Best Practice Advisory (BPA) during their office visits over a 10-month period were contacted post-clinic and administered surveys detailing smoking status, cessation advice recall, and validated scales for nicotine dependence and willingness to quit smoking. This BPA is a "hard stop" that requires providers to document actions taken. Charts were reviewed for tobacco cessation documentation. Nine-digit zip-codes identified the area deprivation index, a measure of socioeconomic status. Univariate analysis was used to identify factors associated with cessation and advice recall.

RESULTS

One hundred out of 318 (31.4%) patients responded to the survey. Epic Slicer Dicer found 97 BPA responses. To dismiss the BPA, 89 providers (91.8%) selected "advised tobacco cessation" and "Unable to Advise" otherwise. Of the 318 patients, 115 (36.1%) had cessation intervention documented in their provider notes and 151 (47.5%) received written tobacco cessation advice. Of survey respondents, 70 recalled receiving verbal advice, 27 recalled receiving written advice, 28 reported receiving offers of medication/therapy for cessation. 55 patients reported having tobacco cessation plans, and among those 17 reported having quit tobacco. Recall of receiving written advice (P < .001) and recall of receiving medication/therapy (P = .008) were associated with recall of receiving verbal cessation advice.

CONCLUSIONS

Providing patients with tobacco cessation medication/therapy and written tobacco cessation education during office visits is associated with increased patients' recall of tobacco cessation advice. Vascular surgeons should continue to provide directed tobacco cessation advice.

Perceived usefulness of receiving a potential smoking cessation intervention via mobile phones among smokers in Indonesia

Background: The use of technology to support healthcare in Indonesia holds new promise in light of decreasing costs of owning mobile devices and ease of access to internet. However, it is necessary to assess end-user perceptions regarding mobile health interventions prior to its implementation. This would throw light on the acceptability of mobile phone communication in bringing about behavioral changes among the target Indonesian population. The aim of this study was to explore the perceived usefulness of receiving a potential smoking cessation intervention via mobile phones. Methods: This is an exploratory cross-sectional study involving current and former adult tobacco smokers residing in Indonesia. Online advertisement and snowballing were used to recruit respondents. Data was collected using a web-based survey over a period of 4 weeks. Those willing to participate signed an online consent and were subsequently directed to the online questionnaire that obtained demographics, tobacco usage patterns, perceived usefulness of a mobile phone smoking cessation application and its design. Results: A total of 161 people who smoked tobacco responded to the online survey. The mean age of the participants was 29.4. Of the 123 respondents, 102 were men. Prior experience with using a mobile phone for health communication (OR 3.6, P=0.014) and those willing to quit smoking (OR 5.1, P=0.043) were likely to perceive a mobile phone smoking cessation intervention as useful. A smartphone application was preferred over text messages, media messages or interactive voice response technology. Content consisting of motivational messages highlighting the methods and benefits of quitting smoking were requested. Conclusion: People who smoke in Indonesia perceived receiving a potential smoking cessation intervention via mobile phones as useful. A multi-component, personalized smartphone application was the desired intervention technique. Such an intervention developed and implemented within a public health program could help address the tobacco epidemic in Indonesia.

Perceived usefulness of receiving a potential smoking cessation intervention via mobile phones among smokers in Indonesia

Background: The use of technology to support healthcare in Indonesia holds new promise in light of decreasing costs of owning mobile devices and ease of access to internet. However, it is necessary to assess end-user perceptions regarding mobile health interventions prior to its implementation. This would throw light on the acceptability of mobile phone communication in bringing about behavioural changes among the target Indonesian population. The aim of this study was to explore the perceived usefulness of receiving a potential smoking cessation intervention via mobile phones. Methods: This is an exploratory cross-sectional study involving current and former adult tobacco smokers residing in Indonesia. Online advertisement and snowballing were used to recruit respondents. Data was collected using a web-based survey over a period of 4 weeks. Those willing to participate signed an online consent and were subsequently directed to the online questionnaire that obtained demographics, tobacco usage patterns, perceived usefulness of a mobile phone smoking cessation application and its design. Results: A total of 161 people who smoked tobacco responded to the online survey. The mean age of the participants was 29.4. Of the 123 respondents, 102 were men. Prior experience with using a mobile phone for health communication (OR 3.6, P=0.014) and those willing to quit smoking (OR 5.1, P=0.043) were likely to perceive a mobile phone smoking cessation intervention as useful. A smartphone application was preferred over text messages, media messages or interactive voice response technology. Content comprising of motivational messages highlighting the methods and benefits of quitting smoking were requested. Conclusion: People who smoke in Indonesia perceived receiving a potential smoking cessation intervention via mobile phones as useful. A multi-component, personalized smartphone application was the desired intervention technique. Such an intervention developed and implemented within a public health program could help address the tobacco epidemic in Indonesia.

A little rein on addiction

Rewarding and aversive experiences influence emotions, motivate specific behaviors, and modify future action in animals. Multiple conserved vertebrate neural circuits have been discovered that act in a species-specific manner to reinforce behaviors that are rewarding, while attenuating those with an adverse outcome. A growing body of research now suggests that malfunction of the same circuits is an underlying cause for many human disorders and mental ailments. The habenula (Latin for "little rein") complex, an epithalamic structure that regulates midbrain monoaminergic activity has emerged in recent years as one such region in the vertebrate brain that modulates behavior. Its dysfunction, on the other hand, is implicated in a spectrum of psychiatric disorders in humans such as schizophrenia, depression and addiction. Here, I review the progress in identification of potential mechanisms involving the habenula in addiction.

Smoking and olfactory dysfunction: A systematic literature review and meta-analysis

OBJECTIVES/HYPOTHESIS

A systematic review and meta-analysis of the literature was undertaken, examining the association between tobacco smoking and olfactory function in humans, utilizing PubMed and Web of Science (1970-2015) as data sources.

STUDY DESIGN

Systematic literature review and meta-analysis.

METHODS

This database review of studies of smoking and olfaction, with a focus on identifying high-quality studies (based on modified versions of the Newcastle-Ottawa Scale), used validated olfactory tests among the generally healthy population.

RESULTS

We identified 11 studies meeting inclusion criteria. Of 10 cross-sectional studies, two were excluded from meta-analysis because the cohorts they studied were included in another article in the review. In meta-analysis, current smokers had substantially higher odds of olfactory dysfunction compared to never smokers (odds ratio [OR] = 1.59, 95% confidence interval [CI] = 1.37-1.85). In contrast, former smokers were found to have no difference in risk of impaired olfaction compared to never smokers (OR = 1.05, 95% CI = 0.91-1.21). The single longitudinal study reviewed found a trend toward increased risk of olfactory decline over time in ever smokers; this trend was stronger in current as compared to former smokers.

CONCLUSIONS

Current smoking, but not former smoking, is associated with significantly increased risk of olfactory dysfunction, suggesting that the effects of smoking on olfaction may be reversible. Future studies that prospectively evaluate the impact of smoking cessation on improvement in olfactory function are warranted.

LEVEL OF EVIDENCE

N/A. Laryngoscope, 127:1753-1761, 2017.

Nicotine Dependence and Willingness to Quit Smoking in Vascular Surgery Patients

BACKGROUND

Smoking rates have declined; however, it remains the primary modifiable risk factor for vascular disease. While vascular surgeons often advise patients to quit, few provide assistance. We sought to understand patients' interest in quitting and determine factors that influence this willingness to quit.

METHODS

Anonymous surveys were given to vascular surgery clinic patients in a single institution over a 5-month period. Demographic information, smoking status, cessation attempts, and barriers to quitting were obtained. Nicotine dependence was determined using the Fagerstrom Test, and willingness to quit was assessed using a contemplation ladder. Patient's willingness to quit was evaluated in relation to symptomatic status, previous/planned operation, and nicotine dependence levels.

RESULTS

A total of 490 patients (92%) completed the survey with 109 (22%) current smokers, 195 (40%) former smokers, and 186 (38%) never smokers. Never smokers were more likely to be female and employed while smokers were more likely to be disabled. Although 51% of smokers displayed moderate/high nicotine dependence, 54% demonstrated willingness to consider quitting within 6 months. The primary barrier to cessation identified was previous failed attempt(s) to quit in 44%. Most (90%) had previously attempted quitting, 63% attempted 3 or more times, and the most common technique used was "quitting cold turkey". Fifty-nine percent of patients reported physicians' had offered assistance in cessation, but only 2% had been in a cessation program. There was no correlation between willingness to consider quitting and symptomatic status, previous/planned operation, or nicotine dependence. Smokers of less than 10 cigarettes/day had a lower nicotine dependence level (P = 0.0001) and higher willingness to consider quitting (P = 0.0015), as did those who had fewer failed prior attempts to quit and who did not believe it was too late to quit.

CONCLUSIONS

Most of our vascular patients self-report as nonsmokers. Over half of those who smoke demonstrate willingness to consider quitting within 6 months, which is not dependent on nicotine dependence, previous/planned operation, or symptomatic status. Those who smoke less than 10 cigarettes per day, have fewer past failed attempts to quit, and believe that it is not too late to quit are more likely to consider quitting. Vascular surgeons should be more aware of previous quit attempts and patterns of smoking and be proactive in assisting patients in cessation attempts.

Risk Factor Modification Behaviors of Practicing Vascular Surgeons

BACKGROUND

National smoking rates have declined; however, it remains the primary modifiable risk factor for nearly all vascular disease. While vascular surgeons have the availability to treat patients via medical or surgical/endovascular means, involvement in risk factor modification may be lacking. This study seeks to understand vascular surgeons' involvement in tobacco cessation and risk factor modification and to determine if practice variables had any effect on provision of these services to vascular surgery patients.

METHODS

Anonymous electronic surveys examining tobacco cessation and risk factor modification were sent to the Vascular & Endovascular Surgery Society members (n = 633). Influence of time from training, practice type (dichotomized into academic and nonacademic vascular surgeons), hospital size, region, and workload was assessed, and data were analyzed by univariate contingency tables.

RESULTS

A total of 149 (24%) surveys were completed. While the majority of respondents ask patient's smoking status (97%), assess willingness to quit (84%), and advise patients to quit (95%), only 34% prescribe medications to assist in cessation, 7% see patients in tobacco cessation follow-up, and 3% verify cessation with cotinine levels or carbon monoxide monitoring. Surgeons who prescribed medications for cessation are more likely to assess patient's willingness to quit, prescribe/advise nicotine replacement, or prescribe initial statin or other lipid-lowering medications. There was no difference in perceived education received during training in risk factor modification, but only 26% of respondents thought they were well trained. Comparing academic to private practice vascular surgeons, there was no difference in cessation techniques used; however, academic surgeons were less likely to perform endovascular procedures for claudication in patients who continued to smoke (29% vs. 46%, P = 0.03) and more likely to prescribe an initial antihyperlipid medication (65% vs. 39%, P = 0.0018).

CONCLUSIONS

Tobacco dependence remains a critical issue for vascular surgery patients; however, there is wide variation in cessation techniques used. The majority of vascular surgeons are not well versed in cessation techniques and risk factor modification, and thus, efforts should be made to provide this education in vascular surgery training programs.

Feasibility and pilot efficacy of a brief smoking cessation intervention delivered by vascular surgeons in the Vascular Physician Offer and Report (VAPOR) Trial

BACKGROUND

This study determined the feasibility and potential efficacy of an evidence-based standardized smoking cessation intervention delivered by vascular surgeons to smokers with peripheral arterial disease.

METHODS

We performed a cluster-randomized trial of current adult smokers referred to eight vascular surgery practices from September 1, 2014, to July 31, 2015. A three-component smoking cessation intervention (physician advice, nicotine replacement therapy, and telephone-based quitline referral) was compared with usual care. The primary outcome was smoking cessation for 7 days, assessed 3 months after the intervention. Secondary outcomes were patients' nicotine dependence and health expectancies of smoking assessed using Patient Reported Outcomes Measurement Information System (PROMIS; RAND Corporation, Santa Monica, Calif).

RESULTS

We enrolled 156 patients (65 in four intervention practices, 91 in four control practices), and 141 (90.3%) completed follow-up. Patients in the intervention and control practices were similar in age (mean, 61 years), sex (68% male), cigarettes per day (mean, 14), and prior quit attempts (77%). All three components of the intervention were delivered to 75% of patients in intervention practices vs to 7% of patients at control practices (P < .001). At 3 months, 23 of 57 patients (40.3%) in the intervention group quit smoking (23 of 56 patients quit who completed follow-up, plus 1 death included in the analysis in the denominator as a smoker), and 26 of 84 patients (30.9%) In the control group quit smoking (26 patients of 84 who completed follow-up, including 2 deaths included in the denominator as smokers). This difference (40.3% quit rate in intervention, 31% quit rate in control; P = .250) was not statistically significant in crude analyses (P = .250) or analyses adjusted for clustering (P = .470). Multivariable analysis showed factors associated with smoking cessation were receipt of physician advice (odds ratio for cessation, 1.96; 95% confidence interval, 1.28-3.02; P < .002) and nicotine replacement therapy (odds ratio, 1.92; 95% confidence interval, 1.43-2.56; P < .001).

CONCLUSIONS

Implementation of a brief, surgeon-delivered smoking cessation intervention is feasible for patients with peripheral arterial disease. A larger trial will be necessary to determine whether this is effective for smoking cessation.

Design and initial enrollment in the Vascular Physicians Offer and Report (VAPOR) trial

Although patient smoking cessation is a key priority for vascular surgeons, significant variation exists in the manner in which vascular surgeons address this key process of care. We describe a multicenter, cluster-randomized trial that compares a standardized, brief smoking cessation intervention to usual care for patients facing vascular surgery or endovascular interventions. Eight centers were randomized to provide usual care for smoking cessation or a standardized protocol consisting of (1) physician "very brief advice" to stop smoking, (2) offering nicotine replacement therapy, and (3) referral to a phone-based counseling service. Trial enrollment began on September 1, 2014. At present, 142 patients had been enrolled in the trial across eight sites. Compared with patients in the usual care arm, patients enrolled in the smoking cessation intervention arm were more likely to receive physician advice (98% vs 77%), a prescription for nicotine replacement therapy (77% vs 13%), and quitline referral (93% vs 33%; all P < .001). Although final results of the intervention on smoking cessation rates are still forthcoming, surgeon delivery of a brief, evidence-based smoking cessation intervention appears feasible for patients facing invasive vascular care.

Factors associated with smoking cessation

OBJECTIVE To analyze the prevalence and factors associated with smoking abstinence among patients who were treated in a reference unit for smoking cessation. METHODS This cross-sectional study examined the medical records of 532 patients treated in a reference unit for smoking cessation in Belém, PA, Northern Brazil, between January 2010 and June 2012. Sociodemographic variables and those related to smoking history and treatment were analyzed. Statistical significance was set at p < 0.05. RESULTS The mean age of the participants was 50 years; 57.0% of the patients were women. The mean tobacco load was 30 packs/year, and the mean smoking duration was approximately 32 years. Most patients remained in treatment for four months. The rate of smoking abstinence was 75.0%. Regression analysis indicated that maintenance therapy, absence of relapse triggers, and lower chemical dependence were significantly associated with smoking cessation. CONCLUSIONS The smoking abstinence rate observed was 75.0%. The cessation process was associated with several aspects, including the degree of chemical dependence, symptoms of withdrawal, and period of patient follow-up in a multidisciplinary treatment program. Studies of this nature contribute to the collection of consistent epidemiological data and are essential for the implementation of effective smoking prevention and cessation strategies.

Tobacco and the escalating global cancer burden

The global burden of cancer is escalating as a result of dramatic increases in the use of tobacco in the developing world. The use of tobacco is linked to the development of a broad variety of cancers, mainly lung cancer, the single most common cancer in the world. Tobacco smoking-attributable deaths extends beyond cancer and include stroke, heart attack and COPD. Widening disparities in cancer-related mortality have shifted towards a more dramatic burden in the developing world. Appropriate interventions must be implemented to reduce tobacco use and prevent global mortality that has escalated to epidemic levels. Tobacco control policies, including public health advertisement campaigns, warning labels, adoption of smoke-free laws, comprehensive bans and tax policies are highly effective measures to control tobacco use. Clinicians and academic institutions have to be actively committed to support tobacco control initiatives. The reduction in cancer related morbidity and mortality should be viewed as a global crisis and definitive results will depend on a multilevel effort to effectively reduce the burden of cancer, particularly in underprivileged regions of the world.

Cessação de tabagismo em pacientes de um hospital universitário em Curitiba

OBJETIVO: Determinar a prevalência de tabagismo e do aconselhamento para a cessação do tabagismo em um grupo de pacientes de um hospital universitário, assim como comparar a carga tabágica entre fumantes e ex-fumantes. MÉTODOS: Estudo transversal com 629 pacientes do Hospital de Clínicas da Universidade Federal do Paraná, localizado em Curitiba. RESULTADOS: Dos 629 pacientes, 206 (32,7%) eram do sexo masculino, 76 (12,1%) eram fumantes, 179 (28,5%) eram ex-fumantes, e 374 (59,5%) eram não fumantes. A média de idade dos pacientes foi de 49,9 ± 15,0 anos (variação: 18-84 anos). Dos 76 fumantes e 179 ex-fumantes, 72 (94,7%) e 166 (92,7%), respectivamente, foram indagados sobre o hábito de fumar. A carga tabágica e o grau de dependência de nicotina foram maiores entre os ex-fumantes (p = 0,0292 e p = 0,0125, respectivamente). Gênero, idade ao início do tabagismo, questionamento médico sobre hábito de fumar e orientação para cessação do fumo foram semelhantes entre os dois grupos. O índice de cessação de tabagismo foi de 0,70. A prevalência de fumo pesado variou entre os gêneros e as faixas etárias - maior entre os homens e na faixa etária de 41-70 anos. CONCLUSÕES: A prevalência de tabagismo neste grupo de pacientes foi menor do que a observada em pacientes de outro hospital universitário e na população adulta de Curitiba e do Brasil. O índice de cessação do tabagismo foi maior do que o da população de Curitiba. Fumantes e ex-fumantes diferiram em relação à idade, à carga tabágica e ao grau de dependência. Fumo pesado e dependência média ou elevada não impediram cessação do tabagismo.

Assessment of smoking behaviour in the dental setting. A study comparing self-reported questionnaire data and exhaled carbon monoxide levels

The present study validated the accuracy of data from a self-reported questionnaire on smoking behaviour with the use of exhaled carbon monoxide (CO) level measurements in two groups of patients. Group 1 included patients referred to an oral medicine unit, whereas group 2 was recruited from the daily outpatient service. All patients filled in a standardized questionnaire regarding their current and former smoking habits. Additionally, exhaled CO levels were measured using a monitor. A total of 121 patients were included in group 1, and 116 patients were included in group 2. The mean value of exhaled CO was 7.6 ppm in the first group and 9.2 ppm in the second group. The mean CO values did not statistically significantly differ between the two groups. The two exhaled CO level measurements taken for each patient exhibited very good correlation (Spearman's coefficient of 0.9857). Smokers had a mean difference of exhaled CO values of 13.95 ppm (p < 0.001) compared to non-smokers adjusted for the first or second group. The consumption of one additional pack year resulted in an increase in CO values of 0.16 ppm (p = 0.003). The consumption of one additional cigarette per day elevated the CO measurements by 0.88 ppm (p < 0.001). Based on these results, the correlations between the self-reported smoking habits and exhaled CO values are robust and highly reproducible. CO monitors may offer a non-invasive method to objectively assess current smoking behaviour and to monitor tobacco use cessation attempts in the dental setting.

Cost-effectiveness of intensive smoking cessation therapy among patients with small abdominal aortic aneurysms

INTRODUCTION

Smoking cessation is one of the few available strategies to decrease the risk for expansion and rupture of small abdominal aortic aneurysms (AAAs). The cost-effectiveness of an intensive smoking cessation therapy in patients with small AAAs identified at screening was evaluated.

METHODS

A Markov cohort simulation model was used to compare an 8-week smoking cessation intervention with adjuvant pharmacotherapy and annual revisits vs nonintervention among 65-year-old male smokers with a small AAA identified at screening. The smoking cessation rate was tested in one-way sensitivity analyses in the intervention group (range, 22%-57%) and in the nonintervention group (range, 3%-30%). Literature data on the effect of smoking on AAA expansion and rupture was factored into the model.

RESULTS

The intervention was cost-effective in all tested scenarios and sensitivity analyses. The smoking cessation intervention was cost-effective due to a decreased need for AAA repair and decreased rupture rate even when disregarding the positive effects of smoking cessation on long-term survival. The incremental cost/effectiveness ratio reached the willingness-to-pay threshold value of €25,000 per life-year gained when assuming an intervention cost of > €3250 or an effect of ≤ 1% difference in long-term smoking cessation between the intervention and nonintervention groups. Smoking cessation resulted in a relative risk reduction for elective AAA repair by 9% and for rupture by 38% over 10 years of follow-up.

CONCLUSIONS

An adequate smoking cessation intervention in patients with small AAAs identified at screening can cost-effectively increase long-term survival and decrease the need for AAA repair.

Some Aspects of Preventing Coronary Heart Disease

Coronary heart disease (CHD) is the leading cause of mortality in the industrialized world and that might also soon be the case in other parts of the world. There are several easily measured and potentially modifiable risk factors that account for a substantial proportion of the risk of CHD. The effect of risk factors interventions appears to be consistent in both genders, across different geographic regions, and by all ethnic groups, suggesting that approaches to prevention can be based on similar principles worldwide. Optimal target levels for serum cholesterol and blood pressure are not yet clear. Future risk CHD reduction will mainly be achieved by improved primary prevention.

Current status of medical management for abdominal aortic aneurysm

Previous trials indicate that surgical management of small abdominal aortic aneurysms (AAA) does not reduce mortality. The medical management of AAA, however, has to a large degree been ignored until recently. Medical management is not only needed to limit the expansion of small AAAs but also to reduce the high incidence of other cardiovascular events in these patients. In this review current evidence regarding medical therapy for patients with small AAAs is discussed. Four current randomised controlled trials are examining the efficacy of exercise, doxycycline and angiotensin converting enzyme inhibition in limiting AAA progression. A further trial using a mast cell stabilisation agent is expected to start soon. It is anticipated that a range of novel therapies for small AAAs will be identified within the next decade.