It is possible to help smokers in early motivational stages to quit. The Inter99 study

Using a Family Systems Approach to Treat Tobacco Use among Cancer Patients

Tobacco use treatment is an essential component of cancer care. Family members play a significant role in smoking behavior, but more research is needed regarding the development, implementation, and impact of family-based interventions in cancer care. The UNC Tobacco Treatment Program conducted an 18-month pilot study to examine the feasibility of implementing a family systems approach to treat tobacco use among patients at the North Carolina Cancer Hospital and to measure the impact of such an approach on patient abstinence. Implementation included four phases: (1) modifying the electronic health record and monthly report generated from the electronic health record; (2) training Tobacco Treatment Specialists to provide family counseling; (3) integrating family members into patients' treatment; and (4) conducting six-month follow-up calls. During the course of the study, 42% (N = 221/532) of patients had family members integrated into their tobacco use treatment. Only 21 patients (4%) had family members present but not integrated into the treatment plan. At the six-month follow up time point, the seven-day point-prevalence quit rate for patients with family integration was 28% (N = 56/200), compared to 23% (N = 67/291) (p = 0.105) for patients without family integration. Integration of family members is clearly possible in an academic medical center's oncology tobacco treatment program. Although pilot results were not statistically significant at 6 months, a potentially higher quit rate suggests a need for expanded research on methods to integrate family members in oncology settings for patients with tobacco-related cancers.

Smokers with bipolar disorder, other affective disorders, and no mental health conditions: Comparison of baseline characteristics and success at quitting in a large 12-month behavioral intervention randomized trial

BACKGROUND

The extent to which smokers with bipolar disorder (BD) differ from other smokers on cessation-related characteristics and outcomes is unknown and could improve knowledge of treatment needs for this group. These analyses compared smokers with BD versus smokers with other affective disorders (ADs; anxiety and unipolar depression) and smokers with no mental health conditions (MHCs).

METHOD

Participants (n = 2570) were a subsample of those enrolled in a smoking cessation trial comparing two web-delivered intervention approaches: acceptance and commitment therapy (ACT) and cognitive behavioral therapy. Those included in this analysis self-reported having BD (n = 221), other ADs (n = 783) or no major MHCs (n = 1566). Surveys assessed baseline characteristics and self-reported abstinence at 3, 6, and 12-months post-randomization. Treatment utilization was tracked via page views.

RESULTS

Smokers with BD were distinct from both AD and no MHC smokers on the majority of baseline characteristics. At 12-months, quit rates were lower for smokers with BD (20%) than no MHCs (29%; p = 0.01), but no different than other ADs (20%; p =  .467). Interactions between treatment assignment and diagnostic group were non-significant for cessation outcome. The number of logins was higher for smokers with BD than AD in the ACT arm only (p = .001), but this finding was not replicated across other utilization indicators.

CONCLUSIONS

Smokers with BD and other ADs had similar long-term quit rates despite numerous differences in baseline characteristics. Despite being lower than for smokers without MHCs, long-term quit rates from web-based treatment are promising for smokers with BD as well as other ADs.

Effectiveness of the Gold Standard Programme (GSP) for smoking cessation on smokers with and without a severe mental disorder: a Danish cohort study

OBJECTIVES

We compared the effectiveness of an intensive smoking cessation intervention among smokers with and without a severe mental disorder (SMD) and identified factors associated with successful quitting. The main hypothesis was that smokers with an SMD would be less likely to stay continuously smoke-free for 6 months.

DESIGN

A prospective cohort study.

SETTING

In all, 302 smoking cessation clinics in Denmark from municipal clinics, pharmacies, hospitals, midwives, primary care facilities and other private providers who reported data to the national Danish Smoking Cessation Database from 2006 to 2016 participated in this study.

PARTICIPANTS

A total of 38 293 patients from the Danish Smoking Cessation Database. Patients with an SMD were identified by linking data to the Danish National Patient Register. Diagnoses of organic mental disorders (F0 chapter) or intellectual disabilities (F7 chapter) were not included. Smokers ≥18 years old who were attending a Gold Standard Programme (GSP) with planned follow-up were included. Smokers not wanting contact after 6 months were excluded.

INTERVENTIONS

A comprehensive manual-based smoking cessation intervention comprising five meetings over a 6-week period (the GSP).

MAIN OUTCOME MEASURES

Self-reported continuous abstinence at the 6-month follow-up.

RESULTS

In all, 69% of the participants participated in the follow-up after 6 months. The overall rate of successful quitting was high but significantly lower in SMD smokers (29% vs 38%; OR 0.74; 95% CI 0.68 to 0.80). Variables associated with successful quitting were compliance (defined as attending ≥75% of the planned meetings), older age and male gender as well as not being disadvantaged, heavy smoking or recommendation of intervention by health professionals.

CONCLUSIONS

Only 29% of smokers with an SMD successfully quit smoking which was significantly lower than the 38% of smokers without an SMD. Compliance was the most important predictor for successful quitting.

Changing the default for tobacco-cessation treatment in an inpatient setting: study protocol of a randomized controlled trial

BACKGROUND

Most health care providers do not treat tobacco dependence routinely. This may in part be due to the treatment "default." Current treatment guidelines recommend that providers (1) ask patients if they are willing to quit and (2) provide cessation-focused medications and counseling only to smokers who state that they are willing to quit. The default is that patients have to "opt in" to receive cessation assistance: providers ask smokers if they are willing to quit, and only offer medications and cessation support to those who say "yes." This drastically limits the reach of cessation services because, at any given encounter, only one in three smokers say that they are ready to quit. The objective of this study is to determine the impact of providing all smokers with tobacco-cessation treatment unless they refuse it (OPT OUT) versus current practice-screening for readiness and only offering treatment to smokers who say they are ready to quit (OPT IN).

METHODS

This individually randomized clinical trial is conducted in a tertiary-care hospital. We will conduct the trial among up to 1000 randomly selected hospitalized smokers to determine the population impact of changing the treatment default, identify mediators of outcome, and determine the cost-effectiveness of this new, highly proactive approach. This is a population-based study that targets an endpoint of vital interest; applies minimal eligibility criteria to broaden generalizability; and utilizes hospital staff for interventions to ensure long-term sustainability. The study employs delayed consent and an innovative Bayesian adaptive design to evaluate a major shift in our approach to care. If effective, this change would expand the reach of tobacco-cessation treatment from 30% to 100% of smokers.

DISCUSSION

Regardless of outcome, the trial will provide a model of how to alter and evaluate the impact of health care defaults. If OPT OUT proves to be more effective, it will expand the population eligible for cessation treatment by over 300%. It will also simplify the tobacco-cessation treatment algorithm, and relieve busy health care providers of the burden of evaluating readiness to quit.

TRIAL REGISTRATION

Clinical Trials Registration, ID: NCT02721082 . Registered on 22 March 2016.

Group behaviour therapy programmes for smoking cessation

BACKGROUND

Group therapy offers individuals the opportunity to learn behavioural techniques for smoking cessation, and to provide each other with mutual support.

OBJECTIVES

To determine the effect of group-delivered behavioural interventions in achieving long-term smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, using the terms 'behavior therapy', 'cognitive therapy', 'psychotherapy' or 'group therapy', in May 2016.

SELECTION CRITERIA

Randomized trials that compared group therapy with self-help, individual counselling, another intervention or no intervention (including usual care or a waiting-list control). We also considered trials that compared more than one group programme. We included those trials with a minimum of two group meetings, and follow-up of smoking status at least six months after the start of the programme. We excluded trials in which group therapy was provided to both active therapy and placebo arms of trials of pharmacotherapies, unless they had a factorial design.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data in duplicate on the participants, the interventions provided to the groups and the controls, including programme length, intensity and main components, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months follow-up in participants smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically-validated rates where available. We analysed participants lost to follow-up as continuing smokers. We expressed effects as a risk ratio for cessation. Where possible, we performed meta-analysis using a fixed-effect (Mantel-Haenszel) model. We assessed the quality of evidence within each study and comparison, using the Cochrane 'Risk of bias' tool and GRADE criteria.

MAIN RESULTS

Sixty-six trials met our inclusion criteria for one or more of the comparisons in the review. Thirteen trials compared a group programme with a self-help programme; there was an increase in cessation with the use of a group programme (N = 4395, risk ratio (RR) 1.88, 95% confidence interval (CI) 1.52 to 2.33, I2 = 0%). We judged the GRADE quality of evidence to be moderate, downgraded due to there being few studies at low risk of bias. Fourteen trials compared a group programme with brief support from a health care provider. There was a small increase in cessation (N = 7286, RR 1.22, 95% CI 1.03 to 1.43, I2 = 59%). We judged the GRADE quality of evidence to be low, downgraded due to inconsistency in addition to risk of bias. There was also low quality evidence of benefit of a group programme compared to no-intervention controls, (9 trials, N = 1098, RR 2.60, 95% CI 1.80 to 3.76 I2 = 55%). We did not detect evidence that group therapy was more effective than a similar intensity of individual counselling (6 trials, N = 980, RR 0.99, 95% CI 0.76 to 1.28, I2 = 9%). Programmes which included components for increasing cognitive and behavioural skills were not shown to be more effective than same-length or shorter programmes without these components.

AUTHORS' CONCLUSIONS

Group therapy is better for helping people stop smoking than self-help, and other less intensive interventions. There is not enough evidence to evaluate whether groups are more effective, or cost-effective, than intensive individual counselling. There is not enough evidence to support the use of particular psychological components in a programme beyond the support and skills training normally included.

Does Motivation Matter? Analysis of a Randomized Trial of Proactive Outreach to VA Smokers

BACKGROUND

Current guidelines advise providers to assess smokers' readiness to quit, then offer cessation therapies to smokers planning to quit and motivational interventions to smokers not planning to quit.

OBJECTIVES

We examined the relationship between baseline stage of change (SOC), treatment utilization, and smoking cessation to determine whether the effect of a proactive smoking cessation intervention was dependent on smokers' level of motivation to quit.

DESIGN

Secondary analysis of a multicenter randomized controlled trial.

PARTICIPANTS

A total of 3006 current smokers, aged 18-80 years, at four Veterans Affairs (VA) medical centers.

INTERVENTIONS

Proactive care included proactive outreach (mailed invitation followed by telephone outreach), offer of smoking cessation services (telephone or face-to-face), and access to pharmacotherapy. Usual care participants had access to VA smoking cessation services and state telephone quitlines.

MAIN MEASURES

Baseline SOC measured with Readiness to Quit Ladder, and 6-month prolonged abstinence self-reported at 1 year.

KEY RESULTS

At baseline, 35.8 % of smokers were in preparation, 38.2 % in contemplation, and 26.0 % in precontemplation. The overall interaction between SOC and treatment arm was not statistically significant (p = 0.30). Among smokers in preparation, 21.1 % of proactive care participants achieved 6-month prolonged abstinence, compared to 13.1 % of usual care participants (OR, 1.8 [95 % CI, 1.2-2.6]). Similarly, proactive care increased abstinence among smokers in contemplation (11.0 % vs. 6.5 %; OR, 1.8 [95 % CI, 1.1-2.8]). Smokers in precontemplation quit smoking at similar rates (5.3 % vs. 5.6 %; OR, 0.9 [95 % CI, 0.5-1.9]). Within each stage, uptake of smoking cessation treatments increased with higher SOC and with proactive care as compared with usual care.

LIMITATIONS

Mostly male participants limits generalizability. Randomization was not stratified by SOC.

CONCLUSIONS

Proactive care increased treatment uptake compared to usual care across all SOC. Proactive care increased smoking cessation among smokers in preparation and contemplation but not in precontemplation. Proactively offering cessation therapies to smokers at all SOC will increase treatment utilization and population-level smoking cessation.

A systematic review and narrative summary of family-based smoking cessation interventions to help adults quit smoking

BACKGROUND

Smoking is the most significant preventable cause of morbidity and early mortality in the world. The family is an influential context in which smoking behaviour occurs.

METHODS

A systematic review and narrative summary of family-based interventions to help adults quit smoking was conducted.

RESULTS

Eight controlled trials were included. Risk of bias was high. The smoking-related outcome of the intervention was self-reported smoking status/abstinence, validated by objective measures (including saliva thiocynate or breath carbon monoxide). Follow-up ranged from 6 weeks to 5 years. The main target groups were: pregnant women (1), pregnant women who smoked (2), men at risk of cardiovascular disease (2), adult smokers (1), parents who smoked (1) and couples who both smoked (1). Interventions included family members but most did not go further by drawing on family, systemic or relational theories to harness the influence of family on smoking behaviour. Only three studies directly compared the effects on smoking behaviour of a family-based (i.e., interventions that involve a member of the family) versus an individual-based (i.e., interventions that use behaviour change techniques that focus on the individual) intervention. None of these studies found significant differences between groups on the smoking behaviour of the main target group.

CONCLUSIONS

We have yet to develop family-based smoking cessation interventions that harness or re-direct the influence of family members on smoking behaviour in a positive way. Thus, it is likely that individualised-approaches to smoking cessation will prevail.

"Tobacco dependence treatment makes no sense because"…: rebuttal of commonly-heard arguments against providing tobacco dependence treatment in the hospital setting

BACKGROUND

The provision of tobacco dependence treatment in health care settings, particularly in countries lacking a history of strong tobacco control policy implementation, is limited by continued misconceptions on the part of health professionals and decision-makers regarding its worth and efficacy. In this paper, we rebut 9 arguments against the provision of tobacco dependence treatment that we have encountered in our experiences implementing and maintaining a dedicated smoking cessation service at a large university hospital in southern Germany.

DISCUSSION

Broadly, the arguments relate to the nature of addiction, the efficacy and safety of stop-smoking medication and behavioural support, and the benefits and challenges of quitting. They include: (a) If smokers really want to quit, they will be able to do it alone (without help); (b) You can't forbid patients from doing what they want; (c) Patients will be upset if you talk to them about their smoking; (d) Stop-smoking medication has side effects that are more dangerous than smoking; (e) You have to be well trained to help smokers to quit (otherwise you can do more harm than good); (f) If you smoke yourself, you lack credibility; (g) If you have cancer, it is too late to quit; (h) Nicotine withdrawal is dangerous for heavy smokers; and (i) Smokers die earlier, thus reducing costs to the health system.

SUMMARY

It is hoped that the counter-arguments presented here arm tobacco control advocates and practitioners working in health care settings, particularly in countries which have not prioritised tobacco control, to respond appropriately and convincingly to those opposed to the provision of tobacco dependence treatment.

Gold standard program for heavy smokers in a real-life setting

Background: High-intensity smoking cessation programs generally lead to more continuous abstinence, however, lower rates of success have been reported among heavy smokers. The aim was to evaluate continuous abstinence among heavy smokers during the intensive 6-week Gold Standard Program (GSP) and to identify modifiable factors associated with continuous abstinence. Methods: In this nationwide clinical study based on 36,550 smokers attending an intensive cessation program in Denmark. Heavy smoking was defined as ≥7 points in the Fagerström Nicotine Dependency Test, smoking ≥20 cigarettes daily or ≥20 pack-years. Results: Overall, 28% had a Fagerström score ≥7 points, 58% smoked ≥20 cigarettes daily and 68% smoked ≥20 pack-years. Continuous abstinence was 33% in responders (6-months response rate: 78%); however, abstinence was approximately 1–6% lower in the heavy smokers than the overall population. Attending GSP with an individual format (vs. group/other, OR 1.23–1.44); in a hospital setting (vs. pharmacy/municipality services, OR 1.05–1.11); and being compliant (attending the planned meetings OR 4.36–4.89) were associated with abstinence. Abstinence decreased in a dose-dependent manner with increasing smoking severity. Conclusions: Abstinence after GSP was 1–6% lower in the heavy smokers than in the overall study population. Modifiable factors may be used for small improvements in continued abstinence. However attempts to improve compliance seemed especially promising.

Evaluating the effectiveness of using personal tailored risk information and taster sessions to increase the uptake of smoking cessation services: study protocol for a randomised controlled trial

BACKGROUND

Although government-funded specialist smoking cessation services in England offer advice and support to smokers motivated to quit, only a small proportion of smokers make use of this service. Evidence suggests that if smokers are proactively and personally invited to use services, use will be higher than with a standard referral made by health professionals. Computer-based systems generating personalised tailored communications also have the potential to engage with a larger proportion of the smoking population. In this study smokers are proactively invited to use the NHS Stop Smoking Service (SSS), with a personal computer-tailored letter and the offer of a no-commitment introductory session designed to give more information about the service. The primary objective is to assess the relative effectiveness on attendance at the NHS SSS, of proactive recruitment by a brief personal letter, tailored to individual characteristics, and invitation to a taster session, over a standard generic letter advertising the service.

METHOD/DESIGN

This randomised controlled trial will recruit smokers from general practice who are motivated to quit and have not recently attended the NHS SSS. Smokers aged 16 years and over, identified from medical records in participating practices, are sent a brief screening questionnaire and cover letter from their GP. Smokers giving consent are randomised to the Control group to receive a standard generic letter advertising the local service, or to the Intervention group to receive a brief personal, tailored letter with risk information and an invitation to attend a 'Come and Try it' taster session. The primary outcome, assessed 6 months after the date of randomisation, is the proportion of people attending the NHS SSS for at least one session. Planned recruitment is to secure 4,500 participants, from 18 regions in England served by an NHS SSS.

DISCUSSION

Personal risk information generated by computer, with the addition of taster sessions, could be widely replicated and delivered cost effectively to a large proportion of the smoking population. The results of this trial will inform the potential of this method to increase referrals to specialised smoking cessation services and prompt more quit attempts.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN76561916.

The protocol for the Be Our Ally Beat Smoking (BOABS) study, a randomised controlled trial of an intensive smoking cessation intervention in a remote Aboriginal Australian health care setting

BACKGROUND

Australian Aboriginal peoples and Torres Strait Islanders (Indigenous Australians) smoke at much higher rates than non-Indigenous people and smoking is an important contributor to increased disease, hospital admissions and deaths in Indigenous Australian populations. Smoking cessation programs in Australia have not had the same impact on Indigenous smokers as on non-Indigenous smokers. This paper describes the protocol for a study that aims to test the efficacy of a locally-tailored, intensive, multidimensional smoking cessation program.

METHODS/DESIGN

This study is a parallel, randomised, controlled trial. Participants are Aboriginal and Torres Strait Islander smokers aged 16 years and over, who are randomly allocated to a 'control' or 'intervention' group in a 2:1 ratio. Those assigned to the 'intervention' group receive smoking cessation counselling at face-to-face visits, weekly for the first four weeks, monthly to six months and two monthly to 12 months. They are also encouraged to attend a monthly smoking cessation support group. The 'control' group receive 'usual care' (i.e. they do not receive the smoking cessation program). Aboriginal researchers deliver the intervention, the goal of which is to help Aboriginal peoples and Torres Strait Islanders quit smoking. Data collection occurs at baseline (when they enrol) and at six and 12 months after enrolling. The primary outcome is self-reported smoking cessation with urinary cotinine confirmation at 12 months.

DISCUSSION

Stopping smoking has been described as the single most important individual change Aboriginal and Torres Strait Islander smokers could make to improve their health. Smoking cessation programs are a major priority in Aboriginal and Torres Strait Islander health and evidence for effective approaches is essential for policy development and resourcing. A range of strategies have been used to encourage Aboriginal peoples and Torres Strait Islanders to quit smoking however there have been few good quality studies that show what approaches work best. More evidence of strategies that could work more widely in Indigenous primary health care settings is needed if effective policy is to be developed and implemented. Our project will make an important contribution in this area.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12608000604303).

A qualitative exploration of smokers' views regarding aspects of a community-based mobile stop smoking service in the United Kingdom

Background

Developing more accessible stop smoking services (SSS) is important, particularly for reaching smokers from socio-economically deprived groups who are more likely to smoke and less likely to quit in comparison to their more affluent counterparts. A drop-in mobile SSS (MSSS) was piloted across 13 locations in socio-economically deprived areas of Nottingham.

Methods

Semi-structured telephone interviews were conducted to explore the views of 40 smokers who registered with the MSSS.

Results

The MSSS appeared to trigger quit attempts. For some of the participants the attempt was totally unplanned; for others, it built on pre-existing thoughts about quitting which had not yet been acted upon. Smokers interested in quitting were comfortable about approaching the MSSS, whilst acknowledging that they did not feel pressured to register with the service. The drop-in format of the MSSS was found to be more appealing than making an appointment. In addition, several participants articulated that they may not have utilised other SSS had they not come across the MSSS.

Conclusions

A MSSS may be an effective way to prompt quit attempts for smokers not planning to quit and also reach smokers who would not engage with SSS.

Brief assessment of readiness to change tobacco use in treated youth

This study examined the concurrent and predictive validity of four brief measures of readiness to change tobacco use for use with adolescents in clinical practice (Readiness Ruler, Thoughts About Abstinence, motivation to abstain, and confidence to abstain) and a single-item measure of difficulty to abstain. Participants were 154 adolescent smokers recruited from outpatient addictions treatment, who completed assessments shortly after admission and at 6- and 12-month follow-up. Concurrent validity analyses indicated that the four readiness measures were moderately correlated at each time point. Predictive validity analyses indicated that the Ruler and the motivation to abstain ratings predicted number of cigarettes smoked at 6 and 12 months. Perceived difficulty to abstain predicted cigarette use over and above the readiness to change measures. Results support the clinical utility of the Ruler and motivation to abstain as brief measures of readiness to change, and perceived difficulty to abstain as a tool to aid adolescent tobacco cessation.

A group-randomized tobacco trial among 30 Pacific Northwest colleges: results from the Campus Health Action on Tobacco study

INTRODUCTION

We conducted a group-randomized trial to increase smoking cessation and decrease smoking onset and prevalence in 30 colleges and universities in the Pacific Northwest.

METHODS

Random samples of students, oversampling for freshmen, were drawn from the participating colleges; students completed a questionnaire that included seven major areas of tobacco policies and behavior. Following this baseline, the colleges were randomized to intervention or control. Three interventionists developed Campus Advisory Boards in the 15 intervention colleges and facilitated intervention activities. The freshmen cohort was resurveyed 1 and 2 years after the baseline. Two-years postrandomization, new cross-sectional samples were drawn, and students were surveyed.

RESULTS

At follow-up, we found no significant overall differences between intervention and control schools when examining smoking cessation, prevalence, or onset. There was a significant decrease in prevalence in private independent colleges, a significant increase in cessation among rural schools, and a decrease in smoking onset in urban schools.

DISCUSSION

Intervention in this college population had mixed results. More work is needed to determine how best to reach this population of smokers.

Parent quit attempts after counseling to reduce children's secondhand smoke exposure and promote cessation: main and moderating relationships

INTRODUCTION

This study explored predictors of smoking quit attempts in a sample of low-income smoking mothers who participated in a randomized trial of a 6-month, 14-session counseling intervention to decrease their children's secondhand smoke exposure (SHSe) and eliminate smoking.

METHODS

Measures were taken at baseline and at 3, 6, 12, and 18 months on 150 mothers who exposed their children (aged <4 years) to > or = 10 cigarettes/week in the home. Reported 7-day quits were verified by saliva cotinine or urine anabasine and anatabine levels.

RESULTS

There were few quits longer than 6 months. Mothers in the counseling group reported more 24-hr quits (p = .019) and more 7-day quits (p = .029) than controls. Multivariate modeling revealed that having quit for at least 24 hr in the year prior to baseline and the number of alternative cessation methods ever tried were predictive of the longest quit attempt during the 18-month study. Mothers in the counseling group who at baseline felt SHSe posed a health risk for their children or who at baseline had more permissive home smoking policies had longer quit attempts.

DISCUSSION

Results confirm that attempts to quit smoking predict additional quit attempts. This suggests that practice may be necessary for many people to quit smoking permanently. Findings of interaction analyses suggest that participant factors may alter the effects of treatment procedures. Failure to account for or employ such factors in the analysis or design of community trials could confound the results of intervention trials.

Clinical utility of varenicline for smokers with medical and psychiatric comorbidity

Chronic obstructive pulmonary disease (COPD) is a costly and deadly disease afflicting an estimated 210 million people and accounting for 5% of all global deaths. Exposure to cigarette smoke is the greatest risk factor for COPD in the developed world. Smoking cessation improves respiratory symptoms and lung function and reduces mortality among patients with COPD. Cigarette smokers with COPD and other co-morbid conditions such as cardiovascular disease and psychiatric illnesses should receive comprehensive tobacco treatment interventions incorporating efficacious pharmacotherapies. Varenicline, an α₄β₂ nicotinic acetylcholine receptor partial agonist, is the newest and most effective drug currently available to promote smoking cessation. In conjunction with behavioral interventions and clinical monitoring for potential side effects, varenicline offers great hope for reducing smoking-attributable death and disability.

The role of nicotine replacement therapy in early quitting success

INTRODUCTION

Nicotine replacement therapy (NRT) is an effective but underutilized smoking cessation aid despite being available over the counter. This exploratory study examined whether voluntary early use of NRT predicted cessation in a self-initiated quit attempt better than other commonly studied variables.

METHODS

Data were collected from 99 adult smokers desiring to quit smoking in the near future over a 10-day baseline period prior to the implementation of a contingency management intervention. NRT use was neither encouraged nor discouraged during the study. Initial abstinence, biochemically verified using a criterion of CO level <4 ppm, was conceptualized in 2 ways: (a) any day of baseline abstinence and (b) the sum of baseline days abstinent. We examined the predictive value of NRT use as well as demographics, self-efficacy, motivational readiness, and nicotine dependence.

RESULTS

While greater self-efficacy was predictive of initial abstinence, NRT use was the most consistent predictor. The odds of abstaining at least 1 day during baseline were 16.8 times greater for those who used NRT on Day 1 than nonusers. Self-efficacy and "any baseline NRT use" contributed significant amounts of variance to the "sum of days abstinent," with the overall model explaining 29% of the variance (p < .001). The sum of baseline days of NRT use and use of NRT on Day 1 also predicted the "sum of days abstinent."

DISCUSSION

Given NRT's effectiveness, but underutilization in real-world settings, the data support the need for interventions or strategies encouraging people to use NRT in their quit attempts.

Tobacco smoking cessation management: integrating varenicline in current practice

Tobacco smoking is widespread and is one of the world’s most prevalent modifiable risk factors for morbidity and mortality. It is important to facilitate smoking cessation better in order to reduce the health consequences of tobacco use. The most effective approach assisting smokers in their quit attempts combines both pharmacotherapy and nonpharmacological interventions. This review summarizes the latest international epidemiological data available on tobacco use, considers the associated effects on health, and reviews existing policies against tobacco use. Among the interventions for smoking cessation, the three major pharmacotherapies (which have demonstrated efficacy when combined with behavioral support) are discussed: nicotine replacement therapy (NRT), bupropion, and varenicline. As the newest pharmacotherapy made available in this area, particular consideration is given to varenicline, and a review of our clinical experience is offered.

Health decision making: lynchpin of evidence-based practice

Health decision making is both the lynchpin and the least developed aspect of evidence-based practice. The evidence-based practice process requires integrating the evidence with consideration of practical resources and patient preferences and doing so via a process that is genuinely collaborative. Yet, the literature is largely silent about how to accomplish integrative, shared decision making.

IMPLICATIONS

for evidence-based practice are discussed for 2 theories of clinician decision making (expected utility and fuzzy trace) and 2 theories of patient health decision making (transtheoretical model and reasoned action). Three suggestions are offered. First, it would be advantageous to have theory-based algorithms that weight and integrate the 3 data strands (evidence, resources, preferences) in different decisional contexts. Second, patients, not providers, make the decisions of greatest impact on public health, and those decisions are behavioral. Consequently, theory explicating how provider-patient collaboration can influence patient lifestyle decisions made miles from the provider's office is greatly needed. Third, although the preponderance of data on complex decisions supports a computational approach, such an approach to evidence-based practice is too impractical to be widely applied at present. More troublesomely, until patients come to trust decisions made computationally more than they trust their providers' intuitions, patient adherence will remain problematic. A good theory of integrative, collaborative health decision making remains needed.

Reasons for not using smoking cessation aids

Background

Few smokers use effective smoking cessation aids (SCA) when trying to stop smoking. Little is known why available SCA are used insufficiently. We therefore investigated the reasons for not using SCA and examined related demographic, smoking behaviour, and motivational variables.

Methods

Data were collected in two population-based studies testing smoking cessation interventions in north-eastern Germany. A total of 636 current smokers who had never used SCA and had attempted to quit or reduce smoking within the last 12 months were given a questionnaire to assess reasons for non-use. The questionnaire comprised two subscales: "Social and environmental barriers" and "SCA unnecessary."

Results

The most endorsed reasons for non-use of SCA were the belief to be able to quit on one's own (55.2%), the belief that help is not necessary (40.1%), and the belief that smoking does not constitute a big problem in one's life (36.5%). One quarter of all smokers reported that smoking cessation aids are not helpful in quitting and that the aids cost too much. Smokers intending to quit agreed stronger to both subscales and smokers with lower education agreed stronger to the subscale "Social and environmental barriers".

Conclusion

Main reasons for non-use of SCA are being overly self-confident and the perception that SCA are not helpful. Future interventions to increase the use of SCA should address these reasons in all smokers.

Smoking cessation at the workplace: 1 year success of short seminars

OBJECTIVES

In search of less time-consuming methods of smoking cessation Allen Carr' seminars performed at workplaces in Austria were evaluated.

METHODS

Of all the 357 smokers attending a seminar in summer 2002, 308 (86%), consented to participate in a repeated health survey, including the SF-36 questionnaire. After 3 months 268 (87%) gave computer-aided telephone interviews and 223 (72%) after 1 year. Analysis by logistic regression was done separately for males and females.

RESULTS

The 1-year quit rate was 40% (worst case assumption) to 55% (best estimate). In 96% of quitters an intensive counseling for 6 h without pharmaceutical aid thereafter was sufficient to maintain abstinence for 12 months. A long smoking history or many earlier unsuccessful attempts to quit did not predict failure. The risk of relapse was found higher in young men with a high number of pack-years and in women with good physical fitness but high Fagerstroem score and financial reasons for the intention to quit smoking. While an average weight gain of 3 kg in males was not associated with failure to quit smoking, we found the highest weight gain (4 kg) in females in the group abstinent at 3 months but smoking again at 12 months. In all participants subjective life quality scored by SF-36 improved. In quitters perception of general health improved more.

CONCLUSIONS

Group counseling at the workplace was found to be an efficient method of smoking cessation, capable of increasing subjective life quality and health and to smooth the way to smoke-free enterprises.