A review of smoking cessation interventions for smokers aged 50 and older

Global burden of cardiovascular disease attributable to smoking, 1990-2019: an analysis of the 2019 Global Burden of Disease Study

AIMS

This study aims to investigate the trends in the global cardiovascular disease (CVD) burden attributable to smoking from 1990 to 2019.

METHODS AND RESULTS

Global Burden of Disease Study 2019 was used to analyse the burden of CVD attributable to smoking (i.e. ischaemic heart disease, peripheral artery disease, stroke, atrial fibrillation and flutter, and aortic aneurysm). Age-standardized mortality rates (ASMRs) per 100 000 and age-standardized disability-adjusted life year rates (ASDRs) per 100 000, as well as an estimated annual percentage change (EAPC) in ASMR and ASDR, were determined by age, sex, year, socio-demographic index (SDI), regions, and countries or territories. The global ASMR of smoking-attributed CVD decreased from 57.16/100 000 [95% uncertainty interval (UI) 54.46-59.97] in 1990 to 33.03/100 000 (95% UI 30.43-35.51) in 2019 [EAPC -0.42 (95% UI -0.47 to -0.38)]. Similarly, the ASDR of smoking-attributed CVD decreased between 1990 and 2019. All CVD subcategories showed a decline in death burden between 1990 and 2019. The burden of smoking-attributed CVD was higher in men than in women. Significant geographic and regional variations existed such that Eastern Europe had the highest ASMR and Andean Latin America had the lowest ASMR in 2019. In 2019, the ASMR of smoking-attributed CVD was lowest in high SDI regions.

CONCLUSION

Smoking-attributed CVD morbidity and mortality are declining globally, but significant variation persists, indicating a need for targeted interventions to reduce smoking-related CVD burden.

Patients' perception of lifestyle advice as a mechanism between health shocks and health behaviours: Evidence from a longitudinal study in China

Background

The heavy burden of non-communicable chronic diseases (NCDs) and the deficiency of health behaviours (HB) are threatening the middle- and older-aged population in China. However, little is known about the relational mechanism between health shocks (HS) and HBs, while the importance of patients' perception of lifestyle advice (PPLA) to initiate HB is insufficiently emphasised. In this study, we aimed to examine this perception as a mediator between HS and HB and the variety of mediation effects caused by the different contents of lifestyle advice.

Methods

We retrieved panel data from the two latest waves of a nationally representative cohort, the China Health and Retirement Longitudinal Study (CHARLS). After constructing well-balanced groups through propensity score matching, we conducted descriptive and multilevel logistic regression analyses to analyse the state of and factors influencing PPLA. We employed the Preacher's Sobel test with 1000 replications bootstrap to examine the mediating effect of PPLA.

Results

On a sample of 7922 respondents (post-propensity score matching), we found that HSs had a positive direct effect on HB, with observed decreases in smoking and drinking and increases in exercise. A limited and selected perception of lifestyle advice showed a gap between the advice given by providers and perceived by patients, with gender, education level, social support inside the family, self-reported health, comorbidity, treatment regimens, and utilisation of family doctors being significant influencing factors. Nevertheless, any content of lifestyle advice partially mediated the relationship in which HS increases non-addictive HB (exercise), while only the targeted and detailed content of lifestyle advice about corresponding behaviours partially mediated the effect between HS and addictive HB (smoking and drinking).

Conclusions

This study provides the first evidence that PPLA partially mediates the positive effect of HS on HB. Personalised chronic disease management; targeted advice and interventions; and multiple social resources COULD BE beneficial for patients with HS to initiate HB.

Knowledge, attitudes and practices of primary healthcare professionals regarding smoking and smoking cessation among the elderly in France

INTRODUCTION

Smoking remains a leading cause of preventable death in France, even among the elderly. Although smoking prevalence has decreased overall, it still affects a significant portion of older adults. This study investigates the knowledge, attitudes, and practices of primary healthcare professionals regarding smoking and smoking cessation among the elderly in France.

METHODS

A cross-sectional study involved 300 primary care professionals (general practitioners, pharmacists, nurses) in the Ile-de-France region. Data collection occurred via telephone interviews in September and October 2019. The study employed a questionnaire focusing on knowledge (10 questions), attitudes (12 statements), and clinical practices (7 questions) related to tobacco dependence in older adults. Responses were scored based on correctness for knowledge and appropriateness for attitudes and practices.

RESULTS

The surveyed professionals were predominantly female (57.7%), with a mean age of 53.0 years, and most were non-smokers or former smokers (85.3%). While 66.7% believed older smokers had lower cessation rates, only 64.3% knew it was safe to prescribe nicotine replacement therapy for the elderly. Attitude scores averaged 8.8/12, with pharmacists scoring highest (9.9) and nurses lowest (8.2). Practices scores averaged 2.8/7, with physicians scoring highest (3.8) and pharmacists lowest (1.9).

CONCLUSIONS

Primary healthcare professionals have a relatively good knowledge of the management of tobacco dependence in the elderly and consider it to be part of their mission. However, their confidence in their abilities needs to be strengthened, and many opportunities to counsel and assist this population to quit smoking are still being missed. Preventive approaches to older smokers are essential, in keeping with the concept that 'every contact with the healthcare system counts'. Improving practice will require education and training that will not only build knowledge but also change perceptions, leading to better attitudes and practices in the management of smoking cessation among older adults.

Effectiveness of non-pharmacological community-based nursing interventions for smoking cessation in adults: A systematic review

OBJECTIVE

The purpose of this systematic review was to determine the effectiveness of non-pharmacological community-based nursing interventions for smoking cessation in adults.

METHOD

Studies published between January 1, 2008 and December 31, 2017 were comprehensively searched to 14 databases. Quality Assessment Tool for Quantitative Studies was used to examine the methodological quality of the included studies. The obtained studies were listed on a code table by title, summary, and author/s' name. A narrative synthesis was used interpreting the data. This study was registered to PROSPERO (ID: CRD42018088007).

RESULTS

Strong-quality rated three randomized controlled studies were included. Nurses were found to perform intensive behavioral support, brief-advice and mTobacco cessation interventions. These were effective on changing knowledge, belief and attitudes. No sufficient evidence on the cessation rate and the non-relapse rate was found.

DISCUSSION

This review puts forward that non-pharmacological community-based smoking cessation interventions by nurses has an impact on changing knowledge, belief and attitudes in adult smokers. Findings can encourage public health nurses to use their counsellor role more actively. Improving the health literacy of the adult smokers via these findings can facilitate their intention to behavior change. Findings can be a useful resource for policy makers and governments in controlling the smoking epidemic.

Predictors of Cessation Outcomes Among Older Adult Smokers Enrolled in a Proactive Tobacco Quitline Intervention

OBJECTIVES

To identify predictors of older adults' likelihood of quitting following engagement in a proactive tobacco quit line.

METHODS

Older (>60 years) participants (N = 186) enrolled in a four-session quit line with 8-weeks of nicotine replacement therapy reported demographics, beliefs, and information about tobacco use. Point prevalence abstinence was reported at 3 and 12-months.

RESULTS

In final models, endorsement of quitting to take control of one's life and confidence in quitting were positively associated with 3-month cessation (OR = 1.74, 95% CI = 1.16, 2.62; OR = 1.75, 95% CI = 1.21, 2.52, respectively). At 12 months, stronger endorsement of quitting to take control of one's life and decreased nicotine dependence were associated with higher cessation (OR = 1.51, 95% CI = 1.05, 2.17; OR = 0.84, 95% CI = 0.71,0.99, respectively).

DISCUSSION

For tobacco cessation among older adults, programs should provide additional support to those with higher nicotine dependence, promote quitting self-efficacy, and encourage quitting as means to gain control of life and health.

Older adults who smoke: Do they engage with and benefit from web-based smoking cessation interventions?

Quitting smoking at any age increases life expectancy, but older adults face barriers to receiving cessation services. Despite the promise of web-based smoking cessation interventions to help address access barriers, whether older adults who participate in smoking cessation programs engage with and benefit from these tools at the same rate as younger adults remains unknown. In this secondary analysis, we compared engagement and satisfaction with two web-based smoking cessation interventions and quit rates between older, middle-aged, and young adults in the United States enrolled in the WebQuit trial between March 2014 and August 2015. Participants were divided into age groups: older (60 years and older, n = 439/2637), middle-aged (40-59 years, n = 1308/2637), and young adults (18-39 years, n = 890/2637). Treatment engagement and satisfaction, and 12-month quit rates (self-reported complete-case 30-day PPA and missing-as-smoking) were compared between groups. Older adults engaged more with the websites than young adults through multiple indicators of intervention engagement (i.e., number of sessions, unique days of use, and time spent on the site), and older adults spent more time on the site per session than their counterparts. Satisfaction with websites was high (81%) and non-differential between groups. Older and middle-aged adults quit smoking at a similar rate as younger adults (24%, 24%, 27%, respectively, p = 0.905). Older and middle-aged adults who participated in a web-delivered smoking cessation intervention engaged more with the intervention than their younger counterparts and they quit smoking at a similar rate, thereby demonstrating high acceptability and potential of digital interventions to help older adults quit smoking. Trial registration:ClinicalTrials.gov Identifier: NCT1166334.

Impact of Depression and Nicotine Dependence on Executive Functioning in Rural Older Adult Smokers: A Brief Report (NCT02510716)

INTRODUCTION

Rural older adults are an underserved population with high rates of smoking and related morbidity and mortality. Age-related executive function deficits are common in older smokers; however, the association of depression and nicotine dependence on executive function has not been explored. This study addressed whether depression and nicotine dependence are related to executive dysfunction in rural older adult smokers.

METHODS

The sample included 40 rural older adults recruited from two primary care clinics in North Carolina. Executive function was evaluated with the Behavioral Regulation Index (BRI), Metacognition Index, and Global Executive Composite (GEC) T scores from the Behavior Rating Inventory of Executive Function-Adult. Nicotine dependence and depression symptoms were assessed using the Fagerstrom Test and Center for Epidemiologic Depression Scale-10, respectively. Analysis of variance was used to explore whether depression and/or nicotine dependence influences executive function. Nondirectional tests were performed with significance set at .10.

RESULTS

Smokers who screened positive for depression had significantly greater executive dysfunction than those who did not (BRI: p = .0003, Metacognition Index: p < .0001, GEC: p < .0001), and moderate/high dependence was associated with greater executive function deficits compared with those with mild dependence (BRI: p = .0942). Together, depression and nicotine dependence explained 50% of the variability of the GEC overall scores.

CONCLUSIONS

Executive dysfunction is common in rural older adult smokers and associated with depression and nicotine dependence severity. Futures studies should test the relationship of executive function and smoking cessation in the older adult population as it may have implications for cessation in this population.

Smoking-Cessation Interventions After Lung Cancer Screening Guideline Change

INTRODUCTION

Recent guideline changes for lung cancer screening with low-dose computed tomography recommend smoking-cessation interventions be done in parallel with screening. The purpose of this study is to determine the post-guideline rates of smoking-cessation interventions among patients eligible and ineligible for lung cancer screening.

METHODS

Using electronic health records collected from a large ambulatory care system in northern California between 2010 and 2017, authors identified new patients who were current smokers aged 55-80 years visiting a primary care provider, and grouped patients into lung cancer screening-eligible heavy smokers, screening-ineligible moderate smokers, and screening-ineligible light smokers. Screening-eligible smokers versus screening-ineligible smokers were compared in receipt of smoking-cessation interventions before (2010-2013) and after (2014-2017) the guideline change, overall and by intervention type (formal counseling, informal counseling, pharmacotherapy) using hierarchical generalized linear models. Analyses were conducted in 2018-2019.

RESULTS

After the guideline change, the likelihood of receiving any smoking-cessation intervention (OR=1.44, 95% CI=1.28, 1.61, p<0.05), informal counseling (OR=1.29, 95% CI=1.15, 1.46, p<0.05), and pharmacotherapy (OR=1.24, 95% CI=1.02, 1.50, p<0.05) during a new patient visit significantly increased, with the increase not varying by level of smoking. For formal counseling, the post-guideline increase was greater for screening-eligible heavy smokers (OR=3.15, 95% CI=1.18, 8.36, p<0.05) and moderate smokers (OR=3.58, 95% CI=1.29, 9.95, p<0.05) relative to light smokers.

CONCLUSIONS

Smoking-cessation interventions increased after new lung cancer screening guidelines. Given the sizable adverse impacts of smoking on morbidity and mortality, small increases in the implementation of smoking-cessation interventions could have substantial public health benefits.

Smoking cessation interventions for potential use in the lung cancer screening setting: A systematic review and meta-analysis

OBJECTIVES

Current guidelines recommend delivery of smoking cessation interventions with lung cancer screening (LCS). Unfortunately, there are limited data to guide clinicians and policy-makers in choosing cessation interventions in this setting. Several trials are underway to fill this evidence gap, but results are not expected for several years.

METHODS AND MATERIALS

We conducted a systematic review and meta-analysis of current literature on the efficacy of smoking cessation interventions among populations eligible for LCS. We searched PubMed, Medline, and PsycINFO for randomized controlled trials of smoking cessation interventions published from 2010-2017. Trials were eligible for inclusion if they sampled individuals likely to be eligible for LCS based on age and smoking history, had sample sizes >100, follow-up of 6- or 12-months, and were based in North America, Western Europe, Australia, or New Zealand.

RESULTS

Three investigators independently screened 3,813 abstracts and identified 332 for full-text review. Of these, 85 trials were included and grouped into categories based on the primary intervention: electronic/web-based, in-person counseling, pharmacotherapy, and telephone counseling. At 6-month follow-up, electronic/web-based (odds ratio [OR] 1.14, 95% CI 1.03-1.25), in-person counseling (OR 1.46, 95% CI 1.25-1.70), and pharmacotherapy (OR 1.53, 95% CI 1.33-1.77) interventions significantly increased the odds of abstinence. Telephone counseling increased the odds but did not reach statistical significance (OR 1.21, 95% CI 0.98-1.50). At 12-months, in-person counseling (OR 1.28 95% CI 1.10-1.50) and pharmacotherapy (OR 1.46, 95% CI 1.17-1.84) remained efficacious, although the decrement in efficacy was of similar magnitude across all intervention categories.

CONCLUSIONS

Several categories of cessation interventions are promising for implementation in the LCS setting.

Double Whammy for Older Smokers: Marginalized by Tobacco Control and Valued by the Tobacco Industry

In the last 20 years, the United States has made stunning progress reducing the rate of adult smoking. However, the smallest reduction is among older adults. Compared to younger smokers, older smokers are more likely to be lower socioeconomic status (SES), have several tobacco related comorbidities, and are less likely to be treated for tobacco addiction yet, in tobacco policy, they are not considered a marginalized group. The tobacco industry's interest in older smokers contrasts with the lack of interest shown by tobacco control. A double whammy is a set of two bad events or situations that have an effect at the same time. The purposes of this article are to use the health disparity paradigm to (a) discuss the "double whammy" of marginalization by tobacco control and valuation by the tobacco industry on the health of older smokers and (b) provide strategies to promote health equity for older smokers.

Lung Cancer Screening and Smoking Cessation Clinical Trials. SCALE (Smoking Cessation within the Context of Lung Cancer Screening) Collaboration

National recommendations for lung cancer screening for former and current smokers aged 55-80 years with a 30-pack-year smoking history create demand to implement efficient and effective systems to offer smoking cessation on a large scale. These older, high-risk smokers differ from participants in past clinical trials of behavioral and pharmacologic interventions for tobacco dependence. There is a gap in knowledge about how best to design systems to extend reach and treatments to maximize smoking cessation in the context of lung cancer screening. Eight clinical trials, seven funded by the National Cancer Institute and one by the Veterans Health Administration, address this gap and form the SCALE (Smoking Cessation within the Context of Lung Cancer Screening) collaboration. This paper describes methodological issues related to the design of these clinical trials: clinical workflow, participant eligibility criteria, screening indication (baseline or annual repeat screen), assessment content, interest in stopping smoking, and treatment delivery method and dose, all of which will affect tobacco treatment outcomes. Tobacco interventions consider the "teachable moment" offered by lung cancer screening, how to incorporate positive and negative screening results, and coordination of smoking cessation treatment with clinical events associated with lung cancer screening. Unique data elements, such as perceived risk of lung cancer and costs of tobacco treatment, are of interest. Lung cancer screening presents a new and promising opportunity to reduce morbidity and mortality resulting from lung cancer that can be amplified by effective smoking cessation treatment. SCALE teamwork and collaboration promise to maximize knowledge gained from the clinical trials.

Cigarette use and smoking beliefs among older Americans: findings from a nationally representative survey

Background: Between 2005 and 2015, the prevalence of smoking among US adults has decreased for all age subgroups, except those aged 65 and older. Aim: In order to identify potential correlates of smoking behaviors in older adults, this research examined associations between age, smoking beliefs, and quitline utilization. Methods: Self-reported, nationally representative data from the Health Information National Trends Survey 2015 cycle (HINTS-FDA) were used (n = 3738). Multivariable logistic regression analyses examined associations between sociodemographic characteristics and beliefs about smoking behaviors. All analyses were conducted with jackknife estimation using sampling weights. Results: Among all survey respondents, 10.5% of those aged 65+ were current smokers (smoked 100 lifetime cigarettes and currently smoked every day or some days). These older adults, compared to those aged 18-29 years, had significantly higher odds of agreeing that smoking behavior is something one can do little to change (AOR = 1.89, 95% CI =1.08, 3.28) and agreeing that nicotine is the substance that causes cancer (AOR = 3.93, 95% CI = 2.17, 7.12). Post hoc analyses compared midlife adults (ages 50-64) with older adults (ages 65+), and indicated older adults had lower odds of having used a quitline/smoking cessation website (AOR = 0.36, 95% CI = 0.14, 0.94, p = 0.04) compared to their midlife peers. Discussion: US adults aged 65 and older hold erroneous beliefs about cigarette smoking behaviors and are less likely to utilize quitline supports. This may be contributing to the stagnant smoking rates among older adults. Smoking cessation efforts targeting older adult Americans are critical in order to stem tobacco use among all Americans.

Exploring Factors Associated With Physical Activity in Older Adults: An Ecological Approach

According to ecological models of behavior, the physical environment can influence physical activity engagement by a series of mediating and moderating processes. This study tested such a model to identify factors relevant to older adults' engagement in moderate-vigorous physical activity. Sociodemographic, psychological, physical, and environmental factors were assessed in 432 Western Australians aged 60 and older. Moderate-vigorous physical activity was measured objectively using accelerometers. No environmental variables were related to engagement in moderate-vigorous physical activity either directly or indirectly. However, various individual-level factors were significant, indicating that these may be more important than environmental factors in locations such as Australia that have generally conducive environments and ambient conditions.

Predictors of Continued Smoking and Interest in Cessation Among Older Female Smokers

OBJECTIVES

Older female smokers are highly vulnerable, yet little is known about their attitudes, beliefs, and behaviors regarding smoking cessation.

METHODS

Southeast region Women's Health Initiative participants identified as smokers on at least one prior assessment were surveyed in 2012 regarding current tobacco use.

RESULTS

Most of these current and former smokers ( N = 409, 63% response) were non-Hispanic White (81.7%) and had some college (80%), with mean age of 75.1 years. Current smoking was confirmed by 56%, and while 61% of these reported a past-year quit attempt, less than half used quit aids. Of current smokers, 57.5% intended to quit within 6 months (26.6% within 30 days), and 68% were interested in joining a cessation study.

CONCLUSIONS

Older female smokers were highly motivated to quit, yet profoundly underutilized proven quit aids. Results support high acceptability of cessation interventions for this undertreated population.

Project reach: Piloting a risk-tailored smoking cessation intervention for lung screening

The purpose of this study was to explore the feasibility, acceptability, and efficacy of a telephone-based smoking cessation intervention for lung screening patients. Participants (N = 39) were enrolled in a single-arm pilot study of a four-session telephone-based intervention. Self-report measures were completed at baseline, post-intervention, and 3-month follow-up. Participants were long-term smokers; 62 percent were not motivated to quit. Twenty-three percent attempted quitting, 29 percent decreased their smoking, and 11 percent reported abstinence. Confidence increased (p < .001) and there were trends toward increased importance (p = .09) and comparative disease risk (p = .02). This intervention was acceptable and associated with improvements in smoking-related beliefs and behaviors.

Technology-Based Interventions for Substance Use and Comorbid Disorders: An Examination of the Emerging Literature

Among individuals with substance use disorders (SUDs), comorbidity with other psychiatric disorders is common and often noted as the rule rather than the exception. Standard care that provides integrated treatment for comorbid diagnoses simultaneously has been shown to be effective. Technology-based interventions (TBIs) have the potential to provide a cost-effective platform for, and greater accessibility to, integrated treatments. For the purposes of this review, we defined TBIs as interventions in which the primary targeted aim was delivered by automated computer, Internet, or mobile system with minimal to no live therapist involvement. A search of the literature identified nine distinct TBIs for SUDs and comorbid disorders. An examination of this limited research showed promise, particularly for TBIs that address problematic alcohol use, depression, or anxiety. Additional randomized, controlled trials of TBIs for comorbid SUDs and for anxiety and depression are needed, as is future research developing TBIs that address SUDs and comorbid eating disorders and psychotic disorders. Ways of leveraging the full capabilities of what technology can offer should also be further explored.

Feasibility of a text-based smoking cessation intervention in rural older adults

Text-based interventions are effective for smoking cessation, but have not been tested in rural older adults. The purpose of this study was to compare the feasibility, acceptability and preliminary efficacy of a text-based Scheduled Gradual Reduction (SGR) program to a non-SGR text messaging support condition among rural older adults. Adults over 60 years were randomized to either: (i) the SGR program (n = 20), a text-based program to reduce smoking over 4-weeks plus text-based support messages; or (ii) control (n = 20), receipt of text-based support messages only. Participants completed surveys at baseline and end of program to assess feasibility and acceptability of the intervention, and biochemically validated 7-day point prevalence cessation was assessed at end of treatment. Most participants (81%) reported reading all the messages they received. Participants found both interventions useful in quitting smoking (SGR = 57%, Control = 63%) and would recommend it to a friend (SGR = 72%, Control = 79%). Although not statically significant, the SGR group had a higher rate of biochemically validated cessation (SGR = 15%, Control = 5%, Cohen d = 0.67). Among those still smoking, the median percent reduction in cigarettes was 33.3% for both groups. Text-based cessation interventions are feasible, acceptable and can be easily disseminated to rural older adult tobacco users.

An integrated digital/clinical approach to smoking cessation in lung cancer screening: study protocol for a randomized controlled trial

Background

Delivering effective tobacco dependence treatment that is feasible within lung cancer screening (LCS) programs is crucial for realizing the health benefits and cost savings of screening. Large-scale trials and systematic reviews have demonstrated that digital cessation interventions (i.e. web-based and text message) are effective, sustainable over the long-term, scalable, and cost-efficient. Use of digital technologies is commonplace among older adults, making this a feasible approach within LCS programs. Use of cessation treatment has been improved with models that proactively connect smokers to treatment rather than passive referrals. Proactive referral to cessation treatment has been advanced through healthcare systems changes such as modifying the electronic health record to automatically link smokers to treatment.

Methods

This study evaluates the impact of a proactive enrollment strategy that links LCS-eligible smokers with an evidence-based intervention comprised of a web-based (WEB) program and integrated text messaging (TXT) in a three-arm randomized trial with repeated measures at one, three, six, and 12 months post randomization. The primary outcome is biochemically confirmed abstinence at 12 months post randomization. We will randomize 1650 smokers who present for a clinical LCS to: (1) a usual care control condition (UC) which consists of Ask–Advise–Refer; (2) a digital (WEB + TXT) cessation intervention; or (3) a digital cessation intervention combined with tobacco treatment specialist (TTS) counseling (WEB + TXT + TTS).

Discussion

The scalability and sustainability of a digital intervention may represent the most cost-effective and feasible approach for LCS programs to proactively engage large numbers of smokers in effective cessation treatment. We will also evaluate the impact and cost-effectiveness of adding proven clinical intervention provided by a TTS. We expect that a combined digital/clinical intervention will yield higher quit rates than digital alone, but that it may not be as cost-effective or feasible for LCS programs to implement. This study is innovative in its use of interoperable, digital technologies to deliver a sustainable, scalable, high-impact cessation intervention and to facilitate its integration within clinical practice. It will add to the growing knowledge base about the overall effectiveness of digital interventions and their role in the healthcare delivery system.

Trial registration

ClinicalTrials.gov, NCT03084835. Registered on 9 March 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2312-x) contains supplementary material, which is available to authorized users.

What are older smokers' attitudes to quitting and how are they managed in primary care? An analysis of the cross-sectional English Smoking Toolkit Study

OBJECTIVES

To investigate whether age is associated with access to smoking cessation services.

DESIGN

Data from the Smoking Toolkit Study 2006-2015, a repeated multiwave cross-sectional household survey (n=181 157).

SETTING

England.

PARTICIPANTS

Past-year smokers who participated in any of the 102 waves stratified into age groups.

OUTCOME MEASURES

Amount smoked and nicotine dependency, self-reported quit attempts and use of smoking cessation interventions. Self-report of whether the general practitioner (GP) raised the topic of smoking and made referrals for pharmacological support (prescription of nicotine replacement therapies (NRTs)) or other support (counselling or support groups).

RESULTS

Older smokers (75+ years) were less likely to report that they were attempting to quit smoking or seek help from a GP, despite being less nicotine-dependent. GPs raised smoking as a topic equally across all age groups, but smokers aged 70+ were more likely not to be referred for NRT or other support (ORs relative to 16-54 years; 70-74 years 1.27, 95% CI 1.03 to 1.55; 75-79 years 1.87, 95% CI 1.43 to 2.44; 80+ years 3.16, 95% CI 2.20 to 4.55; p value for trend <0.001).

CONCLUSIONS

Our findings suggest that there are potential missed opportunities in facilitating smoking cessation in older smokers. In this large population-based study, older smokers appeared less interested in quitting and were less likely to be offered support, despite being less addicted to nicotine than younger smokers. It is unclear whether this constitutes inequitable access to services or reflects informed choices by older smokers and their GPs. Future research is needed to understand why older smokers and GPs do not pursue smoking cessation. Service provision should consider how best to reduce these variations, and a stronger effectiveness evidence base is required to support commissioning for this older population so that, where appropriate, older smokers are not missing out on smoking cessation therapies and the health benefits of cessation at older ages.

Treatment barriers among younger and older socioeconomically disadvantaged smokers

OBJECTIVES

Underutilization of smoking cessation treatments contributes to high rates of smoking in socioeconomically disadvantaged populations. Guided by a conceptual framework, the present study explored how healthcare provider factors, social environment characteristics, and cessation beliefs influence treatment utilization among low-income smokers and whether these associations vary by age.

STUDY DESIGN

Analyses were conducted on baseline data from 2406 participants enrolled in a randomized controlled trial that evaluated the effectiveness of a proactive outreach cessation intervention among a sample of younger (18-34 years) and older (35-64 years) smokers enrolled in public healthcare assistance programs.

METHODS

Multivariable logistic regression models predicted past year cessation treatment utilization (CTU) among younger and older smokers. Independent variables included measures of healthcare provider barriers, social environment characteristics, and cessation beliefs.

RESULTS

Younger smokers were less likely to have CTU than older smokers (27.2% vs 36.2%; P <.001). In both groups, number of cigarettes per day, more problems accessing healthcare, receiving medication-related cessation advice, and readiness to quit were positively associated with CTU (P <.05). Among younger smokers, living with another smoker was associated with lower odds of CTU while receipt of cessation advice was associated (P = .033) with higher odds of CTU.

CONCLUSIONS

In this sample of low-income smokers, interest in quitting was high but treatment utilization was low. Increasing utilization of cessation treatments via interventions that target issues specific to low-income smokers, including healthcare provider access and advice, the home environment, and motivation to quit, is an important step toward reducing smoking rates in this population.

Population Health Management for Older Adults: Review of Interventions for Promoting Successful Aging Across the Health Continuum

Background: The older adult population is expanding, living longer, with multiple chronic conditions. Understanding and managing their needs over time is an integral part of defining successful aging. Population health is used to describe the measurement and health outcomes of a population. Objectives: To define population health as applied to older adults, summarize lessons learned from current research, and identify potential interventions designed to promote successful aging and improved health for this population. Method: Online search engines were utilized to identify research on population health and health interventions for older adults. Results: Population health management (PHM) is one strategy to promote the health and well-being of target populations. Interventions promoting health across a continuum tend to be disease, risk, or health behavior specific rather than encompassing a global concept of health. Conclusion: Many existing interventions for older adults are simply research based with limited generalizability; as such, further work in this area is warranted.

Pairing smoking-cessation services with lung cancer screening: A clinical guideline from the Association for the Treatment of Tobacco Use and Dependence and the Society for Research on Nicotine and Tobacco

Smoking cessation is crucial for reducing cancer risk and premature mortality. The US Preventive Services Task Force (USPSTF) has recommended annual lung cancer screening with low-dose computed tomography (LDCT), and the Center for Medicare and Medicaid Services recently approved lung screening as a benefit for patients ages 55 to 77 years who have a 30 pack-year history. The Society for Research on Nicotine and Tobacco (SRNT) and the Association for the Treatment of Tobacco Use and Dependence (ATTUD) developed the guideline described in this commentary based on an illustrative literature review to present the evidence for smoking-cessation health benefits in this high-risk group and to provide clinical recommendations for integrating evidence-based smoking-cessation treatment with lung cancer screening. Unfortunately, extant data on lung cancer screening participants were scarce at the time this guideline was written. However, in this review, the authors summarize the sufficient evidence on the benefits of smoking cessation and the efficacy of smoking-cessation interventions for smokers ages 55 to 77 years to provide smoking-cessation interventions for smokers who seek lung cancer screening. It is concluded that smokers who present for lung cancer screening should be encouraged to quit smoking at each visit. Access to evidence-based smoking-cessation interventions should be provided to all smokers regardless of scan results, and motivation to quit should not be a necessary precondition for treatment. Follow-up contacts to support smoking-cessation efforts should be arranged for smokers. Evidence-based behavioral strategies should be used at each visit to motivate smokers who are unwilling to try quitting/reducing smoking or to try evidence-based treatments that may lead to eventual cessation.

Pharmacological Smoking Cessation Therapies in Older Adults: A Review of the Evidence

Nearly 12% of adults 65 years and over in Europe and 9% in the USA are current cigarette smokers. Numerous studies have demonstrated tangible benefits of smoking cessation, regardless of advanced age. However, it is unclear which pharmacotherapy strategies are most effective in the elderly population. To that end, the literature on smoking cessation in older adults was reviewed with the aim of identifying the safest and most effective cessation pharmacotherapies. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for all articles pertaining to elderly smoking cessation strategies. Randomized controlled trials and cohort studies were included. Studies were included without regard to population or intervention, as long as results were analyzed with a group of smokers aged 60 years and above and at least one arm of the study involved a pharmacotherapy. Only 12 studies were identified that met our inclusion criteria. The limited existing literature does not allow for a definitive answer to the most effective pharmacotherapy for smoking cessation in older adult smokers. Nicotine replacement therapy (NRT) is the pharmacotherapy most studied in older adults, and the limited evidence that exists suggests that NRT is effective for smoking cessation among this population. Higher-quality studies that directly compare cessation strategies, including bupropion and varenicline, are needed in the older population in order to guide treatment decision making.

Behavioral Counseling and Pharmacotherapy Interventions for Tobacco Cessation in Adults, Including Pregnant Women: A Review of Reviews for the U.S. Preventive Services Task Force

BACKGROUND

Tobacco use is the leading cause of preventable death in the United States.

PURPOSE

To review the effectiveness and safety of pharmacotherapy and behavioral interventions for tobacco cessation.

DATA SOURCES

5 databases and 8 organizational Web sites were searched through 1 August 2014 for systematic reviews, and PubMed was searched through 1 March 2015 for trials on electronic nicotine delivery systems.

STUDY SELECTION

Two reviewers examined 114 articles to identify English-language reviews that reported health, cessation, or adverse outcomes.

DATA EXTRACTION

One reviewer abstracted data from good- and fair-quality reviews, and a second checked for accuracy.

DATA SYNTHESIS

54 reviews were included. Behavioral interventions increased smoking cessation at 6 months or more (physician advice had a pooled risk ratio [RR] of 1.76 [95% CI, 1.58 to 1.96]). Nicotine replacement therapy (RR, 1.60 [CI, 1.53 to 1.68]), bupropion (RR, 1.62 [CI, 1.49 to 1.76]), and varenicline (RR, 2.27 [CI, 2.02 to 2.55]) were also effective for smoking cessation. Combined behavioral and pharmacotherapy interventions increased cessation by 82% compared with minimal intervention or usual care (RR, 1.82 [CI, 1.66 to 2.00]). None of the drugs were associated with major cardiovascular adverse events. Only 2 trials addressed efficacy of electronic cigarettes for smoking cessation and found no benefit. Among pregnant women, behavioral interventions benefited cessation and perinatal health; effects of nicotine replacement therapy were not significant.

LIMITATION

Evidence published after each review's last search date was not included.

CONCLUSION

Behavioral and pharmacotherapy interventions improve rates of smoking cessation among the general adult population, alone or in combination. Data on the effectiveness and safety of electronic nicotine delivery systems are limited.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Readiness of Lung Cancer Screening Sites to Deliver Smoking Cessation Treatment: Current Practices, Organizational Priority, and Perceived Barriers

INTRODUCTION

Lung cancer screening represents an opportunity to deliver smoking cessation advice and assistance to current smokers. However, the current tobacco treatment practices of lung cancer screening sites are unknown. The purpose of this study was to describe organizational priority, current practice patterns, and barriers for delivery of evidence-based tobacco use treatment across lung cancer screening sites within the United States.

METHODS

Guided by prior work examining readiness of health care providers to deliver tobacco use treatment, we administered a brief online survey to a purposive national sample of site coordinators from 93 lung cancer screening sites.

RESULTS

Organizational priority for promoting smoking cessation among lung cancer screening enrollees was high. Most sites reported that, at the initial visit, patients are routinely asked about their current smoking status (98.9%) and current smokers are advised to quit (91.4%). Fewer (57%) sites provide cessation counseling or refer smokers to a quitline (60.2%) and even fewer (36.6%) routinely recommend cessation medications. During follow-up screening visits, respondents reported less attention to smoking cessation advice and treatment. Lack of patient motivation and resistance to cessation advice and treatment, lack of staff training, and lack of reimbursement were the most frequently cited barriers for delivering smoking cessation treatment.

CONCLUSIONS

Although encouraging that lung cancer screening sites endorsed the importance of smoking cessation interventions, greater attention to identifying and addressing barriers for tobacco treatment delivery is needed in order to maximize the potential benefit of integrating smoking cessation into lung cancer screening protocols.

IMPLICATIONS

This study is the first to describe practice patterns, organizational priority, and barriers for delivery of smoking cessation treatment in a national sample of lung cancer screening sites.

Reciprocal associations between smoking cessation and depression in older smokers: findings from the English Longitudinal Study of Ageing

BACKGROUND

Depression is a particular problem in older people and it is important to know how it affects and is affected by smoking cessation.

AIMS

To identify reciprocal, longitudinal relationships between smoking cessation and depression among older smokers.

METHOD

Across four waves, covering six years (2002-2008), changes in smoking status and depression, measured using the 8-item Centre for Epidemiologic Studies Depression Scale, were assessed among recent ex-smokers and smokers (n = 2375) in the English Longitudinal Study of Ageing.

RESULTS

In latent growth curve analysis, smoking at baseline predicted depression caseness longitudinally and vice versa. When both processes were modelled concurrently, depression predicted continued smoking longitudinally (B(β) = 0.21 (0.27); 95% CI = 0.08-0.35) but not the other way round. This was the case irrespective of mental health history and adjusting for a range of covariates.

CONCLUSIONS

In older smokers, depression appears to act as an important barrier to quitting, although quitting has no long-term impact on depression.

Smoking cessation interventions for adults aged 50 or older: A systematic review and meta-analysis

BACKGROUND

The older population size has increased substantially, and a considerable proportion of older adults are cigarette smokers. Quitting smoking is associated with reduced health risk. This review is among the first to quantitatively assess the relative efficacy of types of cessation interventions for smokers aged ≥50 years.

METHODS

We conducted searches of the Cochrane Library, Embase, MEDLINE, and PsycINFO to identify smoking cessation studies on adults aged ≥50 years. Twenty-nine randomized clinical trials met the inclusion criteria. Three main types of interventions were identified. We analyzed relative cessation rates or Risk Ratios (RRs) between the type of intervention groups and the control group by fixed- and random-effects meta-analyses at the study level. We conducted a weighted least squares meta-regression of cessation rates on trial and sample characteristics to determine sources of outcome heterogeneity.

RESULTS

Fixed-effects analysis showed significant treatment effects for pharmacological (RR=3.18, 95% CI: 1.89-5.36), non-pharmacological (RR=1.80, 95% CI: 1.67-1.94), and multimodal interventions (RR=1.61, 95% CI: 1.41-1.84) compared with control group. Estimations based on meta-regression suggested that pharmacological intervention (mean point prevalence abstinence rate (PPA)=26.10%, CI: 15.20-37.00) resembled non-pharmacological (27.97%, CI: 24.00-31.94), and multimodal interventions (36.64%, CI: 31.66-41.62); and non-pharmacological and multimodal interventions had higher PPAs than the control group (18.80%, CI: 14.48-23.12), after adjusting for a number of trial and sample characteristics.

CONCLUSIONS

A small number of smoking cessation studies examined smokers aged ≥50 years. Additional research is recommended to determine smoking cessation efficacy for diverse older population groups (e.g., ethnic minorities).

Constructing and pre-testing an instrument to assess smoking cessation services within the Brazilian public health system

RATIONALE, AIMS AND OBJECTIVES

Assessing public health interventions is crucial for the development of public policies. Currently, there is no instrument to assess the inputs, activities and short-term outcomes of the smoking cessation programme in the Brazilian public health system. This study reports the development of a questionnaire for that purpose and assesses its suitability.

METHODS

A multidimensional self-administered questionnaire was constructed. Questions were compiled from three Brazilian governmental acts that define the standards and requirements for smoking cessation services. A panel of experts familiar with tobacco control programmes reviewed the instrument. A pre-test was conducted to assess its suitability, with 18 health professionals working in eight different multidisciplinary teams, which treat smokers in two different Brazilian cities. Descriptive statistics were computed. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS 21; IBM, São Paulo, Brazil). This study was approved by the Committee on Ethics and Research of the Brazilian National Cancer Institute.

RESULTS

A self-administered multidimensional questionnaire comprising 30 questions was developed in Portuguese. The instrument had a high level of acceptance, and was considered clear and covering all parameters necessary to assess the treatment for smoking cessation by 100% of the pre-test participants. The mean time spent to complete the questionnaire varied between 15 and 30 minutes.

CONCLUSION

An understandable and easy-to-use questionnaire was developed with suitable content and it was well accepted by health professionals. Pre-testing provided a substantial enhancement of the questionnaire, minimizing difficulties in understanding the questions and perfecting the response options. This instrument will contribute to the process of assessing smoking cessation services.

Eicosapentaenoic acid/arachidonic acid ratio and smoking status in elderly patients with type 2 diabetes mellitus

BACKGROUND

A low ratio of eicosapentaenoic acid (EPA)/arachidonic acid (AA) is considered a risk factor for cardiovascular disease. Smoking is also a risk factor for cardiovascular disease even in an elderly population. This study investigated the relationship between EPA/AA ratio and smoking status among elderly patients with type 2 diabetes mellitus (T2DM).

FINDINGS

A total of 188 elderly patients with T2DM (men/women, 114/74; mean age, 65.0 ± 7.5 years) were studied in terms of their smoking status, diabetic conditions, and blood data, including EPA and AA. Current smokers showed a lower EPA/AA ratio than non-smokers (current smokers: 0.29, n = 49; non-smokers: 0.39, n = 139, p < 0.01). This relationship remained significant after adjusting for multiple variables.

CONCLUSIONS

Smoking may affect the EPA/AA ratio among elderly patients with T2DM, suggesting a possible mechanism of cardiovascular disease development and indicating the importance of smoking secession in such patients.

Is cancer risk still reduced if you give up smoking in later life?

SUMMARY This report summarizes the experimental and epidemiological evidence examining the ability of smoking cessation to influence cancer risk reduction in later life. Available evidence suggests that smoking cessation even in later years can significantly reduce mortality and yield risk reductions for many cancers including lung, oral, head and neck, and stomach cancer, among others. More research is necessary to accurately quantify the degree of cancer risk reduction for particular age groups and to calculate the minimum time of cessation necessary to produce a significant benefit for the patient. Smoking cessation is the only approach that has been shown to effectively reduce the risk of many cancers on a mass scale. Considering this, we recommend that healthcare providers communicate these benefits to patients at every opportunity and reinforce the notion that it is never too late to quit smoking.

A review of existing treatments for substance abuse among the elderly and recommendations for future directions

Background

With population aging, there is widespread recognition that the healthcare system must be prepared to serve the unique needs of substance using older adults (OA) in the decades ahead. As such, there is an increasingly urgent need to identify efficient and effective substance abuse treatments (SAT) for OA. Despite this need, there remains a surprising dearth of research on treatment for OA.

Aims of review

This review describes and evaluates studies on SAT applied to and specifically designed for OA over the last 30 years with an emphasis on methodologies used and the knowledge gained.

Methods

Using three research databases, 25 studies published in the last 30 years which investigated the impact of SAT on OA and met specific selection criteria were reviewed.

Results

A majority of the studies were methodologically limited in that they were pre-to-post or post-test only studies. Of the randomized controlled trials, many were limited by sample sizes of 15 individuals or less per group, making main effects difficult to detect. Thus, with caution, the literature suggests that among treatment seeking OA, treatment, whether age-specific or mixed-age, generally works yielding rates of abstinence comparable to general populations and younger cohorts. It also appears that with greater treatment exposure (higher dosage), regardless of level of care, OA do better. Finally, based on only two studies, age-specific treatment appears to potentiate treatment effects for OA. Like younger adults, OA appear to have a heterogeneous response to treatments, and preliminary evidence suggests a possibility of treatment matching for OA.

Conclusions

Expansion of research on SAT for OA is urgently needed for maximum effectiveness and efficiency of the healthcare system serving these individuals. Future research needs to include laboratory and community based randomized controlled trials with high internal validity of previously vetted evidenced-based practices, including Motivational Interviewing, cognitive behavioral therapy, and medications such as naltrexone, to determine the best fit for OA.