Smoking cessation: How compelling is the evidence? A review

Cognitive Distortions as Barriers to Seeking Smoking Cessation Treatment: A Comparative Study

Background/Objectives: Despite the availability of effective pharmacotherapy and evidence-based treatments, a substantial proportion of smokers do not seek treatment. This study aims to explore the cognitive distortions associated with not seeking evidence-based smoking cessation treatment and to identify cognitive barriers. Methods: The research conducted in Istanbul between October and December 2017 employs a cross-sectional design and includes two groups: a treatment-seeking group comprising 156 patients diagnosed with tobacco use disorder and a non-treatment seeking group of 78 patients with tobacco use disorder who had never sought professional help for smoking cessation. A comprehensive data collection process was used, including sociodemographic information, cognitive distortion assessment using the cognitive distortions scale, a smoking-related cognitive distortions interview and the Fagerström Test for Nicotine Dependence. Results: While no significant sociodemographic differences were observed between the treatment-seeking and non-treatment-seeking groups, the study found that higher nicotine dependence was associated with a higher likelihood of seeking treatment. The treatment-seeking group displayed significantly higher levels of "all-or-nothing thinking" cognitive distortions related to smoking and smoking cessation. Conversely, the non-treatment-seeking group exhibited elevated levels of cognitive distortions such as "labeling", "mental filtering", "should statements" and "minimizing the positive" regarding receiving smoking cessation treatment. Conclusions: Understanding the cognitive distortions associated with treatment-seeking behavior for tobacco use disorder is crucial for developing targeted public-based interventions, public service announcements for tobacco use prevention and encouraging individuals to seek evidence-based treatment. Addressing these cognitive distortions can also potentially enhance the effectiveness of smoking cessation programs and reduce the global burden of tobacco-related diseases and mortality.

Effectiveness and feasibility of the self-administered and repeated episodic future thinking exercises in smoking cessation

Delay discounting (DD) is associated with smoking behavior and relapses. Episodic future thinking (EFT) is one of the leading interventions shown to reduce DD. The 1-month follow-up study with 60 participants that employed EFT as active intervention and episodic recent thinking (ERT) as control intervention was conducted in participants receiving smoking cessation treatment. In EFT group, there was significant decrease in DD rates from pre-intervention to post-intervention (p = 0.009), whereas no significant change was observed in ERT group (p = 0.497). DD rates in EFT group did not change significantly over 1 month (p = 0.059), while decrease was detected in ERT group (p = 0.011). Smoking cessation rates between groups were similar (p = 0.486). Adherence with completing follow-up evaluation forms and performing relevant exercises was higher in EFT group (p = 0.038, p = 0.006). Adding EFT to usual smoking cessation treatment did not increase smoking cessation rates, however feasibility of the self-administered exercises needs to be improved to clarify clinical effects.

A pilot survey of clinicians' experiences, attitudes, and interests in hypnosis

Growing evidence supports the use of clinical hypnosis for medical and mental health applications. Most health care professionals lack training in hypnosis, and this may impact their readiness to recommend it. This study examined experiences, attitudes, and interests in hypnosis among health care professionals from a variety of disciplines. Thirty-seven health care professionals completed an online survey prior to attending a talk on hypnosis. Half of survey respondents were physicians or nurses. Most reported no training in hypnosis (70.3%), but half had previously experienced hypnosis. Participants displayed an understanding of common myths and misconceptions regarding hypnosis and felt hypnosis could be useful in health care settings. Despite this, the majority indicated they are rarely or never asked about hypnosis by their patients. A significant majority of survey participants believed individuals providing hypnosis should have both training and certification.

Is it Time to Quit? Smoking Persistence and Self-Rated Health

This study evaluates the impact of smoking on self-rated health using a British cohort born in 1970 that was followed through adult life. Records were taken for this dataset many times; individual self-rated health was first recorded in 1996 at age 26, and afterward at ages 30, 34, and 42. The smoking rate over time determined membership in the groups of current-smokers, never-smokers, and former-smokers. Estimates showed that the current-smokers group produced an increase in the probability of being in poor health with respect to never-smokers of about 10 percentage points in the long term. This result was also consistent when we used former-smokers as the control group, or other model specifications. The baseline estimates were not contradicted by robustness checks and policy implications of these results were discussed.

Smoker motivations and predictors of smoking cessation: lessons from an inpatient smoking cessation programme

INTRODUCTION

Our study aimed to review the quit rates of smokers from our inpatient smoking cessation programme in relation to habits and sociodemographic factors, and also to explore the potential usefulness of electronic cigarettes (ECs) by reviewing smoking motivations.

METHODS

This was a retrospective study of patients recruited into our inpatient smoking cessation programme from June 2008 to June 2015. Sociodemographic factors and information on smoking habits were collected using a counsellor-administered questionnaire. Patients were given intensive counselling followed by a phone interview at one, three and six months to assess smoking status.

RESULTS

A total of 2,722 patients were enrolled. 27.6% of patients were abstinent at six months' follow-up. Patients who quit smoking were older, married, initiated smoking at a later age and had lower Fagerström Test for Nicotine Dependence scores. There was a trend towards successful quitting in those with higher education levels and Chinese ethnicity, but this was not statistically significant. Patients who planned to quit cold turkey and those who quit because of social pressures were more successful. Of the smoking motivations, only nicotine dependence was an independent predictor of smoking cessation.

CONCLUSION

Smoking motivations such as habitual use and psychological dependence did not influence quit rates and therefore do not support the use of ECs. Instead, a cold turkey method of quitting was shown in our study to contribute to cessation success. We recommend an increased focus on the use of pharmacologic aids as well as involvement of peer/spousal support to aid in such quit attempts.

A Multifaceted Hypnosis Smoking-Cessation Program: Enhancing Motivation and Goal Attainment

Smoking cessation remains a major health priority. Despite public campaigns against smoking and widespread availability of smoking-cessation treatments, many people continue to smoke. The authors argue that the "problem of motivation," that is, suboptimal or fluctuating motivation to resist smoking urges and to comply with the demands of treatment, commonly undermines treatment seeking and adherence, appreciably reducing the success rates of smoking-cessation programs. The authors describe the history of the Winning Edge smoking-cessation program and discuss ways to enhance motivation before, during, and after formal treatment. They illustrate how hypnotic suggestions, administered in the context of their program, can promote cognitive, behavioral, and emotional commitment to treatment and enhance motivation to live a smoke-free life.

Combination Extended Smoking Cessation Treatment Plus Home Visits for Smokers With Schizophrenia: A Randomized Controlled Trial

INTRODUCTION

The majority of people with schizophrenia have a diagnosis of tobacco dependence during their lifetime. A major obstacle to reducing the burden of cigarette smoking in this population is that these smokers have lower quit rates when undergoing standard treatment compared to smokers with no mental illness. We sought to determine if combination extended treatment (COMB-EXT) and home visits (HV) would lead to improved outcomes in smokers with schizophrenia.

METHODS

Thirty-four cigarette smokers with schizophrenia completed either COMB-EXT with HV, COMB-EXT without HV, or treatment as usual (TAU) (random assignment). COMB-EXT consisted of group cognitive-behavioral therapy (CBT), bupropion, nicotine patch, and nicotine lozenge, which were initiated within 2 weeks and continued for 26 weekly visits. HV consisted of biweekly visits to the home with assessment of secondhand smoke (SHS) exposure and brief behavioral therapy with participants and others in the home environment. TAU consisted of group CBT plus serial single or combination medication trials as per standard care.

RESULTS

Smokers with schizophrenia who received COMB-EXT (with or without HV) had greater reductions in cigarettes per day than those treated with TAU (both ps < .01). In addition, 7-day point prevalence abstinence rates for the three groups were 45%, 20%, and 8%, respectively, which was significantly higher for COMB-EXT plus HV than TAU (χ²(1) = 4.8, p = .03). Groups did not differ significantly in the number of adverse events, and HV were easily scheduled.

CONCLUSION

COMB-EXT improves outcomes for smokers with schizophrenia. HV appeared to provide additional benefit for smoking cessation in this treatment-resistant population.

IMPLICATIONS

The clear benefit found here of rapidly initiated, combination, extended treatment over TAU suggests that aggressive and extended treatment should be considered in clinical practice for smokers with schizophrenia. Furthermore, HV to address SHS exposure showed initial promise for assisting smokers with schizophrenia in maintaining abstinence, indicating that this intervention may be worthy of future research.

If at first you don't succeed: characterization of smokers with late smoking abstinence onset

INTRODUCTION

Most cigarette smoking cessation research has aimed to clarify characteristics associated with initial and sustained abstinence, with less attention paid to predictors of gaining abstinence following an initial failure.

METHODS

The current investigation explored pre-treatment demographic, smoking, and psychiatric characteristics related to gaining abstinence among smokers who failed to attain initial abstinence. Participants were 809 individuals enrolled in extended, 52-week, smoking cessation interventions. Of these, 287 (62.4%) failed to achieve initial abstinence. Gaining abstinence following initial abstinence failure was defined as achieving seven-day point prevalent abstinence at any post-initial abstinence assessment.

RESULTS

Those who gained abstinence (Gainers) were more likely to have a live-in partner (χ(2)(1, N=283)=3.8, p=.05, Cramér's V=.12), identify as Hispanic (χ(2)(1, N=281)=7.8, p<.01, Cramér's V=.17), evidence lower baseline expired breath carbon monoxide (F(1, 284)=5.7, p=.02, η(2)=.02), report less cigarette dependence (F(1, 278)=7.1, p<.01, η(2)=.03), and report past week cannabis use (χ(2)(1, N=284)=5.6, p=.02, Cramér's V=.14). A logistic regression model suggested that having a live-in partner (OR=5.14, 95% CI=1.09-3.02, p=.02) and identifying as Hispanic (OR=4.93, 95% CI=1.20-18.77, p=.03) increased the odds of gaining abstinence.

DISCUSSION

Having a live-in partner, Hispanic status, greater cigarette dependence, and recent cannabis use were associated with gaining abstinence. These findings provide insight into an understudied area, contributing an initial framework toward understanding gaining abstinence following initial failure.

Nicotine administration in healthy non-smokers reduces appetite but does not alter plasma ghrelin

OBJECTIVE

We studied whether suppressed secretion of the orexigenic peptide ghrelin might be involved in the anorexigenic effects of nicotine.

METHODS

Fifty healthy non-smokers chewed gums containing 2 mg nicotine, or no nicotine in a double-blind randomised crossover design in two independent studies.

RESULTS

Plasma nonacylated ghrelin was not significantly affected by nicotine after 30 and 60 min. Increased blood pressure and decreased appetite ratings confirmed a biological nicotine effect.

CONCLUSIONS

These results do not support a key role of peripheral ghrelin secretion in weight changes related to smoking or smoking cessation, but do not rule out that central nervous system ghrelin is involved.

Ear acupressure for smoking cessation: a randomised controlled trial

This study investigated the efficacy and safety of ear acupressure (EAP) as a stand-alone intervention for smoking cessation and the feasibility of this study design. Adult smokers were randomised to receive EAP specific for smoking cessation (SSEAP) or a nonspecific EAP (NSEAP) intervention which is not typically used for smoking cessation. Participants received 8 weekly treatments and were requested to press the five pellets taped to one ear at least three times daily. Participants were followed up for three months. Primary outcome measures were a 7-day point-prevalence cessation rate confirmed by exhaled carbon monoxide and relief of nicotine withdrawal symptoms (NWS). Intention-to-treat analysis was applied. Forty-three adult smokers were randomly assigned to SSEAP (n = 20) or NSEAP (n = 23) groups. The dropout rate was high with 19 participants completing the treatments and 12 remaining at followup. One participant from the SSEAP group had confirmed cessation at week 8 and end of followup (5%), but there was no difference between groups for confirmed cessation or NWS. Adverse events were few and minor.

Ear acupressure for smoking cessation: study protocol for a randomised controlled trial

BACKGROUND

Smoking is the largest preventable cause of death and disease worldwide but smokers often fail to quit due to nicotine withdrawal symptoms. Current available pharmaceutical therapies may assist with smoking cessation but may have side effects. Ear acupressure (EAP) and ear acupuncture have been used for smoking cessation, and some positive results have been reported. The aim of the study is to assess the efficacy and safety of EAP in assisting individuals to quit smoking and/or support them in the management of nicotine withdrawal symptoms.

METHODS

This study will be a randomised, single-blind, sham-controlled study conducted at RMIT University in Melbourne, Australia. Adult smokers will be randomly assigned to receive EAP specifically for smoking cessation or nonspecific EAP treatments. After a 2-week run-in, participants will be treated once a week for 8 weeks and followed up for 12 weeks. The primary outcome measures will be 7 day point-prevalence cessation rate by self-report validated by expired carbon monoxide and nicotine withdrawal symptoms measured by the Mood and Physical Symptoms Score questionnaire. Secondary outcomes will be self-reported usage of nicotine replacement therapies, cigarette consumption, body weight change and quality of life. The safety end point will be self-reported adverse events associated with EAP. Intention-to-treat analysis will be applied.

DISCUSSION

Findings from this study will determine if this EAP intervention alone can be an effective and safe therapy to assist with smoking cessation and the management of nicotine withdrawal symptoms.

Behavioral interventions associated with smoking cessation in the treatment of tobacco use

Tobacco smoke is the leading cause of preventable premature death worldwide. While the majority of smokers would like to stop, the habitual and addictive nature of smoking makes cessation difficult. Clinical guidelines suggest that smoking cessation interventions should include both behavioural support and pharmacotherapy (e.g. nicotine replacement therapy). This commentary paper focuses on the important role of behavioural interventions in encouraging and supporting smoking cessation attempts. Recent developments in the field are discussed, including ‘cut-down to quit’, the behaviour change techniques taxonomy (BCTT) and very brief advice (VBA) on smoking. The paper concludes with a discussion of the important role that health professionals can and should play in the delivery of smoking cessation interventions.

Predictors of success in smoking cessation among Italian adults motivated to quit

We examined the role of sexual gender, age, working status, education, cigarettes per day, Fagerström test, age of onset, pharmacologic intervention (bupropion or varenicline), 10 sessions of cognitive-behavioral group counseling therapy (GCT) conducted over 6 weeks, and level of attendance of the counseling program as predictors of smoking cessation on 1282 Italian adult smokers. Results of a multi-variate forward stepwise conditional logistic analysis, at the first step, indicate that subjects who attended the program from 4 to 6 sessions and from 1 to 3 sessions, respectively, resulted about 3 times and 24 times more likely to smoke than those attending from 7 to 10 sessions; at the second step, subjects with high Fagerström score were 2 times more likely to smoke than subjects with low/middle Fagerström; at the third step, subjects treated only with GCT were 2 times more likely to smoke than subjects with combined pharmacologic interventions and GCT; at the fourth step, subjects with age of onset less than 17 years were 1.5 times more likely to smoke than subjects with a higher age of onset; eventually, at the fifth step women resulted 1.5 times more likely to smoke than men. In conclusion, we found that a steady attendance of the cognitive behavioral program, as well as the addition of pharmacologic interventions to counseling, remarkably increased the probability of the smoking cessation behavior to be determined. Nevertheless, FTQ was a valid measure in predicting the smoking cessation, and women revealed to be more likely to keep the smoking behavior, as well as subjects who declared an age of onset less than 17 years.

Medications for substance use disorders

In this article, the authors briefly review the pharmacotherapeutic agents that are currently available for the treatment of substance use disorders. Nicotine replacement therapies are most effective for tobacco cessation. Naltrexone, acamprosate, and disulfiram are effective for reducing alcohol use. The most effective pharmacotherapies for opiate use disorders are agonist therapies, including methadone and buprenorphine. The authors also examine recent advances in medication development for other substance use disorders such as stimulant addiction. The role of medication adherence and behavioral treatments and the integration of behavioral and pharmacotherapeutic interventions are also discussed.

Efficacy of a nicotine mouth spray in smoking cessation: a randomised, double-blind trial

A nicotine mouth spray has advantages over other acute forms of nicotine replacement therapy, such as a faster uptake of nicotine and faster relief of craving.

This multicentre, randomised (2:1), double-blind, placebo-controlled efficacy and safety study evaluated self-reported, carbon monoxide-verified continuous abstinence from smoking from week 2 until weeks 6, 24, and 52 in 479 smokers (≥1 cigarette per day) who were treated with either active (n=318) or placebo (n=161) spray for 12 weeks and low-intensity counselling at three smoking cessation clinics in Denmark and Germany.

Active treatment yielded significantly higher continuous abstinence rates than placebo from week 2 until week 6 (26.1% versus 16.1%; relative success rate (RR) 1.62, 95% CI 1.09–2.41), week 24 (15.7% versus 6.8%; RR 2.30, 95% CI 1.23–4.30), and week 52 (13.8% versus 5.6%; RR 2.48, 95% CI 1.24–4.94). Most adverse events were mild to moderate, and 9.1% of subjects on active spray withdrew due to adverse events, compared to 7.5% on placebo. The overall rate of treatment-related adverse events was 87.4% with active spray versus 71.4% with placebo spray.

Nicotine mouth spray delivered significantly higher 6-, 24- and 52-week continuous abstinence rates than placebo.

Brain β2*-nicotinic acetylcholine receptor occupancy after use of a nicotine inhaler

The Nicotrol® (Pfizer, USA) nicotine inhaler reduces craving by mimicking the behavioural component of cigarettes and delivering controlled doses of nicotine, which binds to the beta-2 subunit-containing nicotinic acetylcholine receptors (β2*-nAChRs). Previous studies examined β2*-nAChR occupancy after administration of regular and low-nicotine cigarettes. Here, we measured occupancy of β2*-nAChRs after administration of nicotine via inhaler, and the relationship between occupancy and changes in craving for tobacco smoking and withdrawal symptoms. Tobacco smokers participated in [123I]5-IA-85380 SPECT studies with either a nicotine inhaler (n=9) or tobacco cigarette (n=4) challenge. [123I]5-IA was administered as a bolus plus constant infusion. After equilibrium was achieved, three 30-min baseline scans were collected, and subjects either used the nicotine inhaler or a regular cigarette, and up to six additional scans were obtained. Receptor occupancy was determined based on the Lassen plot method. Craving for tobacco smoking and withdrawal symptoms were evaluated pre- and post-challenge. Use of the nicotine inhaler produced an average 55.9±6.4% occupancy of β2*-nAChRs 2-5 h post-challenge, whereas use of a cigarette produced significantly higher receptor occupancy (F=10.6, p=0.009) with an average 67.6±14.1% occupancy 1.5-5 h post-challenge. There was a significant decrease in withdrawal symptoms post-nicotine inhaler use (F=6.13, p=0.04). These results demonstrate significant differences in occupancy of β2*-nAChRs by nicotine after use of the inhaler vs. a cigarette and confirm the ability of the nicotine inhaler to relieve withdrawal symptoms.

Toxic effects of low alcohol and nicotine combinations in SH-SY5Y cells are apoptotically mediated

It is well established that combination of heavy drinking and smoking has severe health consequences. However, at relatively low concentrations, both alcohol and nicotine may have beneficial effects including neuroprotection. Thus, protective effects of low alcohol concentration against beta-amyloid-induced toxicity in organotypic hippocampal slices and protective effects of nicotine against salsolinol-induced toxicity in human-derived neuroblastoma cells (SH-SY5Y) have been reported. In this study, we sought to determine whether alcohol might also be protective against salsolinol-induced toxicity in SH-SY5Y cells and whether the combination of low doses of alcohol and nicotine might have an additive or synergistic effect. Pre-exposure of SH-SY5Y cells to either ethanol (1 or 10 mM) or nicotine (20 or 50 μM) significantly attenuated salsolinol-induced toxicity. However, contrary to the expectation the combination of low doses of alcohol and nicotine not only did not provide any synergistic or additive protective effect, but exacerbated salsolinol-induced toxicity. Indeed, simple combination of low alcohol and nicotine resulted in significant toxicity in SH-SY5Y cells. This toxicity, reflected in a reduction in cell viability was associated with an increase in apoptosis as determined by caspase-3 measurement. These in vitro results suggest that combination of even low concentrations of alcohol and nicotine may activate apoptotic mechanisms that can lead to cell toxicity and detrimental consequences.

Smoking cessation should have more emphasis within Tobacco Control? The case for

Smoking cessation is usually mentioned last in the chain of established measures to improve Tobacco Control. This seems logical, as smoking cessation is a secondary or tertiary preventative measure only. In the recently proposed Tobacco Control Scale (TCS) using 6 Tobacco Control measures pricing is considered most important, and smoking cessation least important. For current smokers secondary or tertiary preventative measures are necessary with smoking cessation being the most effective one as its impact on health is immediate. Pricing, on the other hand, is less effective in inciting current smokers to quit. Further, the vast majority of smokers would like to quit if they were able; so help in achieving this goal is welcome. Other Tobacco Control measures, on the other hand, are mostly negatively perceived by smokers because they perceive them as curtailment of their freedom. This is a psychological advantage the health professional active in this area has over other people involved in Tobacco Control and must be exploited. There is also strong evidence that smoking cessation is cost-effective, especially when comparing costs involved in addressing other important health risk factors, such as hyperlipidemia and arterial hypertension. Finally, the role of smoking cessation in helping to decrease social acceptability of smoking should not be underrated as every smoker who quits sets an example for other smokers to follow or for children not to start. In summary, smoking cessation continues to be of paramount importance among Tobacco Control measures, and should get more emphasis especially in health care settings.

Adverse events associated with nicotine replacement therapy (NRT) for smoking cessation. A systematic review and meta-analysis of one hundred and twenty studies involving 177,390 individuals

Background

Nicotine replacement therapy (NRT) is the most common form of smoking cessation pharmacotherapy and has proven efficacy for the treatment of tobacco dependence. Although expectations of mild adverse effects have been observed to be independent predictors of reduced motivation to use NRT, adverse effects associated with NRT have not been precisely quantified.

Objective

A systematic review and meta-analysis aimed to identify all randomized clinical trials (RCTs) of NRT versus inert controls and all observational studies to determine the magnitude of reported adverse effects with NRT.

Methods

Searches of 10 electronic databases from inception to November 2009 were conducted. Study selection and data extraction were carried out independently in duplicate. RCTs were pooled using a random effects method with Odds Ratio [OR] as the effect measure, while proportions were pooled from observational studies. A meta-regression analysis was applied to examine whether the nicotine patch is associated with different adverse effects from those common to orally administered NRT.

Results

Ninety-two RCTs involving 32,185 participants and 28 observational studies involving 145, 205 participants were identified. Pooled RCT evidence of varying NRT formulations found an increased risk of heart palpitations and chest pains (OR 2.06, 95% Confidence Interval [CI] 1.51-2.82, P < 0.001); nausea and vomiting (OR 1.67, 95% CI 1.37-2.04, P < 0.001); gastrointestinal complaints (OR 1.54, 95% CI, 1.25-1.89, P < 0.001); and insomnia (OR 1.42, 95% CI, 1.21-1.66, P < 0.001). Pooled evidence specific to the NRT patch found an increase in skin irritations (OR 2.80, 95% CO, 2.28-3.24, P < 0.001). Orally administered NRT was associated with mouth and throat soreness (OR 1.87, 95% CI, 1.36-2.57, P < 0.001); mouth ulcers (OR 1.49, 95% CI, 1.05-2.20, P < 0.001); hiccoughs (OR 7.68, 95% CI, 4.59-12.85, P < 0.001) and coughing (OR 2.89, 95% CI, 1.92-4.33, P < 0.001). There was no statistically significant increase in anxiety or depressive symptoms associated with NRT use. Non-comparative observational studies demonstrated the prevalence of these events in a broad population.

Conclusion

The use of NRT is associated with a variety of side effects. In addition to counseling and medical monitoring, clinicians should inform patients of potential side effects which are associated with the use of NRT for the treatment of tobacco dependence.