Comparison of two approaches in achieving smoking abstinence among patients in an outpatient clinic: A Phase 2 randomized controlled trial

An integrated smoking cessation and alcohol intervention among Hong Kong Chinese young people: Study protocol for a feasibility randomized controlled trial

INTRODUCTION

Young smokers always partake in both smoking and drinking. However, drinking undermines their likelihood to attempt quitting smoking or to successfully abstain from smoking. Hence, this trial will examine the feasibility of implementing an integrated smoking cessation and alcohol intervention in young Hong Kong Chinese people. Effect sizes of the integrated intervention (II) on self-reported and biochemically validated quit rates will also be calculated.

METHODS

The study will be a three-arm randomized controlled trial in a convenience sample of 150 smokers aged 18-25 years with alcohol drinking. Participants will be randomized into a standard treatment (ST), II, or control arm. The ST group will receive a brief smoking cessation intervention based on the 5A (Ask, Assess, Advice, Assist, Arrange) and 5R (Relevance, Risks, Rewards, Roadblocks, Repetition) models. The II group will receive brief advice on alcohol use based on the FRAMES (Feedback, Responsibility, Advice, Menu, Empathy, Efficacy) model in addition to the brief smoking cessation intervention. Both the ST and II groups will receive booster interventions at 1-week, 1-month, 3-month, and 6-month follow-up. The control group will receive leaflets on smoking cessation and alcohol reduction. Self-reported quitters at 6-month follow-up will be invited for biochemical validation. The primary outcomes are feasibility measures. The secondary outcomes are effect size of II on self-reported and biochemically validated quit rates at 6 months relative to control and ST. Outcomes will be assessed at baseline and at 1-week, 1-month, 3-month, and 6-month follow-ups.

ANALYSIS

Descriptive statistics will be used to calculate the feasibility measures. The three arms will be compared using analysis of variance for continuous variables and chi-square test for categorical variables. Effect sizes of II for self-reported and biochemically validated quit rates at 6 months will be determined using the generalized estimating equation model.

Effect of quitting immediately vs progressively on smoking cessation for smokers at emergency department in Hong Kong: A posteriori analysis of a randomized controlled trial

BACKGROUND

A progressive approach to quitting smoking has been a popular strategy for motivating smokers who are reluctant to quit. However, whether this strategy can effectively achieve complete cessation or is as successful as quitting immediately remains unresolved. This study aimed to determine whether quitting immediately or progressively was more effective in achieving complete cessation among smokers in Hong Kong who presented at emergency departments.

METHODS AND FINDINGS

A posteriori analysis of a single-blinded, multicenter, randomized controlled trial was performed. The original trials was conducted at emergency departments of four major acute hospitals in different districts of Hong Kong. In total, 1571 smokers 18 years or older who presented at 4 major emergency departments between July 4, 2015 and March 17, 2017 were randomized into an intervention group (n = 787) and a control group (n = 784). The intervention group received brief advice (about 1 minute) and could choose their own quit schedules (immediate or progressive, labeled QI and QP, respectively). The control group received a smoking cessation leaflet. Follow-ups were conducted at 1, 3, 6 and 12 months. The primary outcomes, by intention-to-treat, were biochemically validated abstinence between the QI subgroup and control group; between the QP subgroup and control group, and between the QI subgroup and QP subgroup at 6 months. After the propensity sore matching, the biochemically validated abstinence was statistically significantly higher in the QI subgroup than the control group at 6 months (12.1% vs 3.4%, P = 0.003; adjusted odds ratio [aOR] 4.34, 95% CI 1.63-11.52) and higher in the QP subgroup than the control group at 6 months (9.8% vs 3.4%, P = 0.02; aORs 2.95, 95% CI: 1.04-8.39). No statistically significant differences of biochemically validated abstinence at both 6 month (12.1% vs 9.8%, P = 0.49; aORs 1.50, 95% CI: 0.71-3.19) were found in the comparison between QI and QP subgroups.

CONCLUSIONS

This study demonstrates that the strategy of quitting progressively is effective, especially for smokers who lack motivation or find it difficult to quit. If adopted routinely, such an approach can help achieve a greater level of smoking abstinence in the community.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02660957.

Effectiveness of a video-based smoking cessation intervention focusing on maternal and child health in promoting quitting among expectant fathers in China: A randomized controlled trial

BACKGROUND

Secondhand smoke can cause adverse pregnancy outcomes, yet there is a lack of effective smoking cessation interventions targeted at expectant fathers. We examined the effectiveness of a video-based smoking cessation intervention focusing on maternal and child health in promoting quitting among expectant fathers.

METHODS AND FINDINGS

A single-blind, 3-arm, randomized controlled trial was conducted at the obstetrics registration centers of 3 tertiary public hospitals in 3 major cities (Guangzhou, Shenzhen, and Foshan) in China. Smoking expectant fathers who registered with their pregnant partners were invited to participate in this study. Between 14 August 2017 to 28 February 2018, 1,023 participants were randomized to a video (n = 333), text (n = 322), or control (n = 368) group. The video and text groups received videos or text messages on the risks of smoking for maternal and child health via instant messaging. The control group received a leaflet with information on smoking cessation. Follow-up visits were conducted at 1 week and at 1, 3, and 6 months. The primary outcome, by intention to treat (ITT), was validated abstinence from smoking at the 6-month follow-up. The secondary outcomes included 7-day point prevalence of abstinence (PPA) and level of readiness to quit at each follow-up. The mean age of participants was 32 years, and about half of them were first-time expectant fathers. About two-thirds of participants had completed tertiary education. The response rate was 79.7% (815 of 1,023) at 6 months. The video and text groups had higher rates of validated abstinence than the control group (video group: 22.5% [75 of 333], P < 0.001; text group: 14.9% [48 of 322], P = 0.02; control group: 9.2% [34 of 368]) with adjusted odds ratios (ORs) of 2.80 (95% confidence interval [CI]: 1.79-4.37, P < 0.001) in the video group and 1.70 (95% CI: 1.06-2.74, P = 0.03) in the text group. The video and text groups differed in the rates of validated abstinence (22.5% versus 14.9%, P = 0.008; adjusted OR: 1.64, 95% CI: 1.10-2.46, P = 0.02). The video and text groups had higher rates of 7-day PPA than the control group at 6 months (video group: 24.6% [82 of 333] versus 11.4% [42 of 368], P < 0.001; text group: 17.4% [56 of 333] versus 11.4% [42 of 368], P = 0.02). The video and text groups also differed in the rates of 7-day PPA (24.6% versus 17.4%, P = 0.02). Excluding the quitters, the video and text groups had higher levels of readiness to quit than the control group at 6 months (video group: 43.5% [109 of 251] versus 31.6% [103 of 326], P = 0.002; text group: 40.6% [108 of 266] versus 31.6% [103 of 326], P = 0.01), No such difference was detected between the video and text groups (43.5% versus 40.6%, P = 0.29). The study was limited in that the long-term effectiveness of the intervention is uncertain.

CONCLUSIONS

This smoking cessation intervention for expectant fathers that focused on explaining the ramifications of smoking on maternal and child health was effective and feasible in promoting quitting, and video messages were more effective than texts in delivering the information.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03236025.

Effectiveness of a Brief Self-determination Theory-Based Smoking Cessation Intervention for Smokers at Emergency Departments in Hong Kong: A Randomized Clinical Trial

IMPORTANCE

Clinicians have an opportunity to provide smoking cessation interventions to smokers who present to emergency departments (EDs). The effectiveness of a brief intervention based on self-determination theory for smoking cessation is uncertain.

OBJECTIVE

To examine the effectiveness of a brief intervention based on self-determination theory for smoking cessation (immediate or progressive) among Chinese smokers presenting at EDs in Hong Kong.

DESIGN, SETTING, AND PARTICIPANTS

This single-blind, multicenter intent-to-treat randomized clinical trial was conducted at the EDs of 4 major acute care hospitals in different districts of Hong Kong. In total, 1571 smokers 18 years or older who presented at 4 major EDs between July 4, 2015, and March 17, 2017, were randomized into an intervention group (n = 787) and a control group (n = 784).

INTERVENTIONS

The intervention group received brief advice (about 1 minute) and could choose their own quit schedules (immediate or progressive). The control group received a smoking cessation leaflet.

MAIN OUTCOMES AND MEASURES

Follow-up visits were conducted at 1, 3, 6, and 12 months. The primary outcome measure, by intent to treat, was biochemically validated abstinence at 6 months.

RESULTS

Participants (N = 1571) included 1381 men (87.9%); the mean (SD) age at baseline was 47.4 (16.4) years. Among participants who self-reported abstinence at 6 months, 50.3% (85 of 169) had biochemical validation by both an exhaled carbon monoxide test and a saliva cotinine test. Compared with the control group, the intervention group had statistically higher biochemically validated abstinence at 6 months: 6.7% (53 of 787) vs 2.8% (22 of 784) (P < .001), with an adjusted relative risk of 3.21 (95% CI, 1.74-5.93; P < .001). The intervention group also had higher self-reported quit rates at 6 months (12.2% [96 of 787] vs 9.3% [73 of 784], P = .04) and 12 months (13.0% [102 of 787] vs 8.5% [67 of 784], P < .01), as well as higher biochemically validated abstinence at 12 months (7.0% [55 of 787] vs 3.7% [29 of 784], P < .001). The additional cost for each intervention group participant was US $0.47, with an estimated gain of 0.0238 quality-adjusted life-year. The incremental cost per quality-adjusted life-year (US $19.53) fell within acceptable thresholds.

CONCLUSIONS AND RELEVANCE

This brief, low-cost self-determination theory-based intervention for smokers presenting at EDs effectively increased the biochemically validated quit rate at 6 months. If delivered routinely, such a simple intervention may offer a cost-effective and sustainable approach to help many smokers quit smoking.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02660957.

Smoking reduction interventions for smoking cessation

BACKGROUND

The standard way most people are advised to stop smoking is by quitting abruptly on a designated quit day. However, many people who smoke have tried to quit many times and may like to try an alternative method. Reducing smoking behaviour before quitting could be an alternative approach to cessation. However, before this method can be recommended it is important to ensure that abrupt quitting is not more effective than reducing to quit, and to determine whether there are ways to optimise reduction methods to increase the chances of cessation.

OBJECTIVES

To assess the effect of reduction-to-quit interventions on long-term smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, Embase and PsycINFO for studies, using the terms: cold turkey, schedul*, cut* down, cut-down, gradual*, abrupt*, fading, reduc*, taper*, controlled smoking and smoking reduction. We also searched trial registries to identify unpublished studies. Date of the most recent search: 29 October 2018.

SELECTION CRITERIA

Randomised controlled trials in which people who smoked were advised to reduce their smoking consumption before quitting smoking altogether in at least one trial arm. This advice could be delivered using self-help materials or behavioural support, and provided alongside smoking cessation pharmacotherapies or not. We excluded trials that did not assess cessation as an outcome, with follow-up of less than six months, where participants spontaneously reduced without being advised to do so, where the goal of reduction was not to quit altogether, or where participants were advised to switch to cigarettes with lower nicotine levels without reducing the amount of cigarettes smoked or the length of time spent smoking. We also excluded trials carried out in pregnant women.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison (no smoking cessation treatment, abrupt quitting interventions, and other reduction-to-quit interventions) and carried out meta-analyses where appropriate, using a Mantel-Haenszel random-effects model. We also extracted data on quit attempts, pre-quit smoking reduction, adverse events (AEs), serious adverse events (SAEs) and nicotine withdrawal symptoms, and meta-analysed these where sufficient data were available.

MAIN RESULTS

We identified 51 trials with 22,509 participants. Most recruited adults from the community using media or local advertising. People enrolled in the studies typically smoked an average of 23 cigarettes a day. We judged 18 of the studies to be at high risk of bias, but restricting the analysis only to the five studies at low or to the 28 studies at unclear risk of bias did not significantly alter results.We identified very low-certainty evidence, limited by risk of bias, inconsistency and imprecision, comparing the effect of reduction-to-quit interventions with no treatment on cessation rates (RR 1.74, 95% CI 0.90 to 3.38; I2 = 45%; 6 studies, 1599 participants). However, when comparing reduction-to-quit interventions with abrupt quitting (standard care) we found evidence that neither approach resulted in superior quit rates (RR 1. 01, 95% CI 0.87 to 1.17; I2 = 29%; 22 studies, 9219 participants). We judged this estimate to be of moderate certainty, due to imprecision. Subgroup analysis provided some evidence (P = 0.01, I2 = 77%) that reduction-to-quit interventions may result in more favourable quit rates than abrupt quitting if varenicline is used as a reduction aid. Our analysis comparing reduction using pharmacotherapy with reduction alone found low-certainty evidence, limited by inconsistency and imprecision, that reduction aided by pharmacotherapy resulted in higher quit rates (RR 1. 68, 95% CI 1.09 to 2.58; I2 = 78%; 11 studies, 8636 participants). However, a significant subgroup analysis (P < 0.001, I2 = 80% for subgroup differences) suggests that this may only be true when fast-acting NRT or varenicline are used (both moderate-certainty evidence) and not when nicotine patch, combination NRT or bupropion are used as an aid (all low- or very low-quality evidence). More evidence is likely to change the interpretation of the latter effects.Although there was some evidence from within-study comparisons that behavioural support for reduction to quit resulted in higher quit rates than self-help resources alone, the relative efficacy of various other characteristics of reduction-to-quit interventions investigated through within- and between-study comparisons did not provide any evidence that they enhanced the success of reduction-to-quit interventions. Pre-quit AEs, SAEs and nicotine withdrawal symptoms were measured variably and infrequently across studies. There was some evidence that AEs occurred more frequently in studies that compared reduction using pharmacotherapy versus no pharmacotherapy; however, the AEs reported were mild and usual symptoms associated with NRT use. There was no clear evidence that the number of people reporting SAEs, or changes in withdrawal symptoms, differed between trial arms.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that neither reduction-to-quit nor abrupt quitting interventions result in superior long-term quit rates when compared with one another. Evidence comparing the efficacy of reduction-to-quit interventions with no treatment was inconclusive and of low certainty. There is also low-certainty evidence to suggest that reduction-to-quit interventions may be more effective when pharmacotherapy is used as an aid, particularly fast-acting NRT or varenicline (moderate-certainty evidence). Evidence for any adverse effects of reduction-to-quit interventions was sparse, but available data suggested no excess of pre-quit SAEs or withdrawal symptoms. We downgraded the evidence across comparisons due to risk of bias, inconsistency and imprecision. Future research should aim to match any additional components of multicomponent reduction-to-quit interventions across study arms, so that the effect of reduction can be isolated. In particular, well-conducted, adequately-powered studies should focus on investigating the most effective features of reduction-to-quit interventions to maximise cessation rates.

A study protocol for a randomised controlled trial evaluating the use of information communication technology (WhatsApp/WeChat) to deliver brief motivational interviewing (i-BMI) in promoting smoking cessation among smokers with chronic diseases

Background

The recent development of smoking cessation interventions for smokers with chronic diseases has focused heavily on brief interventions. However, these interventions are too brief to make an impact on these smokers, especially when most of them are without any intention to quit. Previous studies showed that smokers who did not want to quit might be interested in changing other health behaviours. Also, once people engage in a health behaviour, they are found more likely to change other unhealthy habits. Hence, a general health promotion approach could be a feasible approach to motivate smokers who do not want to quit to first engage in any desirable health behaviour, and later quit smoking when they intend to do so. This study aims to determine the potential efficacy and effect size of such intervention approach in promoting smoking cessation for smokers with chronic diseases.

Methods

This is a randomized controlled trial. A convenience sample of 60 smokers with chronic diseases will be randomly assigned into either experimental (n = 30) or control group (n = 30). Smokers in the experimental group will receive an individual face-to-face brief motivational interviewing (MI) with generic advice on selected health behaviour. More brief MI messages will be delivered to them via WhatsApp/WeChat for 6 months. For subject in the control group, they will be asked to indicate their desirable health-related practice. However, no MI and booster interventions will be given. All subjects will complete a questionnaire at 1, 3, 6 and 12 months. Subjects abstinent from cigarettes at 12 months will perform a biochemical validation. The primary outcome is biochemically validated smoking abstinence at 12 months. Effect size of the intervention will be estimated by the odd ratios using intention-to-treat.

Discussion

This is the first study to determine the potential efficacy for the use of a personalized general health promotion approach in promoting smoking cessation for smokers with chronic diseases. If our proposed intervention is effective, we will able to assist smokers with chronic disease to quit smoking and change their health behaviour simultaneously.

Trial registration

CinicalTrials.gov NCT03983330 (Prospectively registered), registered on June 12, 2019.

Self-initiated gradual smoking reduction among community correction smokers

INTRODUCTION

Smoking remains the leading cause of preventable death in the United States. Many smoking cessation guidelines advise smokers to quit precipitately; however, most quit attempts involve a more gradual cessation. Characteristics of individuals who tend to reduce prior to quitting and the effectiveness of pre-quit reduction are not well understood. This study examined individual differences and smoking cessation outcomes between individuals who self-initiated gradual reduction in cigarettes per day (CPD) and those who did not reduce prior to quit date.

METHODS

This study is a secondary analysis from a randomized clinical trial of smoking cessation with pharmacotherapy among individuals under community corrections supervision. We compared participants who self-initiated smoking reduction by at least 25% between baseline and the first treatment session (n = 128) to participants who either increased or did not reduce smoking between baseline and the first treatment session (n = 354).

RESULTS

African American race, no previous cigar smoking, no previous use of pharmacotherapy for smoking cessation, less withdrawal symptoms at baseline, and older age at first smoking were associated with being a self-initiated gradual reduction in univariate analyses. Individuals who self-initiated gradual reduction also had a had a greater likelihood of achieving at least one quit during the one-year study period as compared to those who did not reduce prior to the intervention.

CONCLUSIONS

Individuals who self-initiate gradual reduction differ from those who increase or do not change their smoking prior to a quit date. Gradual reduction also increased success in quitting.

Smoking behaviours of Hong Kong Chinese hospitalised patients and predictors of smoking abstinence after discharge: a cross-sectional study

OBJECTIVES

Patients admitted to hospitals represent an excellent teachable moment for smoking cessation, as they are required to abstain from tobacco use during hospitalisation. Nevertheless, smoking behaviours of hospitalised patients, and factors that lead to smoking abstinence thereafter, remain relatively underexplored, particularly in a Hong Kong Chinese context. This study aimed to examine the smoking behaviours of hospitalised patients and explore factors leading to their abstaining from cigarette use after being hospitalised.

DESIGN

A cross-sectional design was employed.

SETTING

This study was conducted in three outpatient clinics in different regions in Hong Kong.

PARTICIPANTS

A total of 382 recruited Chinese patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

The patients were asked to complete a structured questionnaire that assessed their smoking behaviours before, during and after hospitalisation.

RESULTS

The results indicated 23.6% of smokers smoked secretly during their hospital stay, and about 76.1% of smokers resumed smoking after discharge. Multivariate logistic regression analysis found that number of days of hospitalisation admission in the preceding year (OR 1.02; 95% CI 1.01 to 1.27; p=0.036), patients' perceived correlation between smoking and their illness (OR 1.08; 95% CI 1.01 to 1.17; p=0.032), withdrawal symptoms experienced during hospitalisation (OR 0.75; 95% CI 0.58 to 0.97; p=0.027) and smoking cessation support from healthcare professionals (OR 1.18; 95% CI 1.07 to 1.36; p=0.014) were significant predictors of smoking abstinence after discharge.

CONCLUSIONS

The results of this study will aid development of appropriate and innovative smoking cessation interventions that can help patients achieve more successful smoking abstinence and less relapse.

TRIAL REGISTRATION NUMBER

NCT02866760.