Factors Associated with Adherence to Transdermal Nicotine Patches within a Smoking Cessation Effectiveness Trial

Association of anxiety and depression symptoms with perceived health risk of nicotine vaping products for smoking cessation

As tobacco smoking prevalence is unacceptably high for the one in five Australians reporting a mental health condition in the past year, multiple cessation supports are needed to reduce tobacco-related disease. Nicotine vaping product (NVP)-facilitated smoking cessation is one option requiring a medical prescription in Australia. Yet, people easily obtain NVPs via non-prescription channels. As mental health impacts quitting intentions and health system engagement, this study examined how presence of anxiety and depression symptoms may be associated with perceived health risk of using NVPs from prescription or non-prescription sources for smoking cessation. We used cross-sectional South Australian (15 years +) 2022 survey data on vaping, smoking, anxiety, and depression. Robust linear regression was used to examine the association of anxiety and depression symptoms and nicotine addiction concern on perceived health risk of using NVPs from prescription or non-prescription sources. For prescription NVPs, vaping was associated with lower perceived health risk (b=-0.732). Higher perceived addiction risk was associated with higher perceived health risk from prescription NVPs (b=0.784). For non-prescription NVPs, vaping (b=-0.661) or smoking (b=-0.310) was associated with lower perceived health risk, and higher perceived addiction risk (b=0.733) was associated with a higher perceived health risk. Although anxiety and depression were not directly associated with NVP health risk perceptions, vaping while having depression symptoms was associated with higher perceived health risk ratings for prescription (b=0.700) but not non-prescription sources. People with depression who vape may see health risk barriers in NVP prescription access for smoking cessation, a smoking cessation support gap.

Treatment adherence in a smoking cessation clinical trial for individuals with current or past major depressive disorder: Predictors and association with cessation

INTRODUCTION

Individuals with major depressive disorder (MDD) exhibit high rates of tobacco use and lower responsiveness to tobacco cessation treatments. Treatment adherence is a strong predictor of treatment outcomes in the general population but has not been evaluated in this under-served community of smokers with MDD.

METHODS

We used data from a randomized clinical trial on smoking cessation treatment among 300 smokers with MDD to examine the rate of adherence (medication and counseling), the association of adherence with cessation outcomes, and factors associated with adherence, including demographic and smoking characteristics, psychiatric characteristics, smoking cessation processes (e.g., withdrawal, reinforcers), and treatment-related side effects (e.g., nausea).

RESULTS

Overall, 43.7% of participants were adherent with medication and 63.0% were adherent with counseling. Medication adherence was significantly associated with cessation, with 32.1% of adherent vs. 13.0% of non-adherent participants quitting smoking at EOT. Counseling adherence was also significantly associated with cessation, with 32.3% of adherent vs. 2.7% of non-adherent participants quitting smoking. Multivariate regression models showed that medication adherence was associated with higher engagement in complementary reinforcers and higher baseline smoking reward, while counseling adherence was associated with identifying as female, lower alcohol use and nicotine dependence, higher baseline smoking reward, and higher engagement in substitute and complementary reinforcers within the first weeks of medication use.

CONCLUSIONS

As with the general population of smokers, non-adherence to treatment in smokers experiencing depression is widespread and a significant barrier to cessation. Interventions that target reinforcers may improve rates of treatment adherence.

Exenatide as an adjunct to nicotine patch for smoking cessation and prevention of postcessation weight gain among treatment-seeking smokers with pre-diabetes and/or overweight: study protocol for a randomised, placebo-controlled clinical trial

INTRODUCTION

Obesity and smoking are the two leading causes of preventable death in the USA. Unfortunately, most smokers gain weight after quitting. Postcessation weight gain (PCWG) is frequently cited as one of the primary barriers to a quit attempt and a common cause of relapse. Further, excessive PCWG may contribute to the onset or progression of metabolic conditions, such as hyperglycaemia and obesity. The efficacy of the current treatments for smoking cessation is modest, and these treatments have no clinically meaningful impact on mitigating PCWG. Here, we outline a novel approach using glucagon-like peptide 1 receptor agonists (GLP-1RA), which have demonstrated efficacy in reducing both food and nicotine intake. This report describes the design of a double-blind, placebo-controlled, randomised clinical trial that evaluates the effects of the GLP-1RA exenatide as an adjunct to nicotine patches on smoking abstinence and PCWG.

METHODS AND ANALYSIS

The study will be conducted at two university-affiliated research sites in Houston, Texas, the UTHealth Center for Neurobehavioral Research on Addiction and Baylor College of Medicine Michael E. DeBakey VA Medical Centre. The sample will consist of 216 treatment-seeking smokers with pre-diabetes (haemoglobin A1c of 5.7%-6.4%) and/or overweight (body mass index of 25 kg/m² or above). Participants will be randomised (1:1) to receive subcutaneous injections of placebo or 2 mg exenatide, once weekly for 14 weeks. All participants will receive transdermal nicotine replacement therapy and brief smoking cessation counselling for 14 weeks. The primary outcomes are 4-week continuous abstinence and changes in body weight at the end of treatment. The secondary outcomes are (1) abstinence and changes in body weight at 12 weeks post end of treatment and (2) changes in neuroaffective responses to cigarette-related and food-related cues as measured by electroencephalogram.

ETHICS AND DISSEMINATION

The study has been approved by the UTHealth Committee for the Protection of Human Subjects (HSC-MS-21-0639) and Baylor College of Medicine Institutional Review Board (H-50543). All participants will sign informed consent. The study results will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05610800.

The Use of Biomarkers to Guide Precision Treatment for Tobacco Use

This review summarizes the evidence to date on the development of biomarkers for personalizing the pharmacological treatment of combustible tobacco use. First, the latest evidence on FDA-approved medications is considered, demonstrating that, while these medications offer real benefits, they do not contribute to smoking cessation in approximately two-thirds of cases. Second, the case for using biomarkers to guide tobacco treatment is made based on the potential to increase medication effectiveness and uptake and reduce side effects. Next, the FDA framework of biomarker development is presented along with the state of science on biomarkers for tobacco treatment, including a review of the nicotine metabolite ratio, electroencephalographic event-related potentials, and other biomarkers utilized for risk feedback. We conclude with a discussion of the challenges and opportunities for the translation of biomarkers to guide tobacco treatment and propose priorities for future research.

Lasered Graphene Microheaters Modified with Phase-Change Composites: New Approach to Smart Patch Drug Delivery

The combination of paraffin wax and O,O'-bis(2-aminopropyl) polypropylene glycol-block-polyethylene glycol-block-polypropylene glycol was used as a phase-change material (PCM) for the controlled delivery of curcumin. The PCM was combined with a graphene-based heater derived from the laser scribing of polyimide film. This assembly provides a new approach to a smart patch through which release can be electronically controlled, allowing repetitive dosing. Rather than relying on passive diffusion, delivery is induced and terminated through the controlled heating of the PCM with transfer only occurring when the PCM transitions from solid to liquid. The material properties of the device and release characteristics of the strategy under repetitive dosing are critically assessed. The delivery yield of curcumin was found to be 3.5 µg (4.5 µg/cm2) per 3 min thermal cycle.

Predictors of Adherence to Smoking Cessation Medications among Current and Ex-Smokers in Australia: Findings from a National Cross-Sectional Survey

Background: Adherence to smoking cessation medications (SCMs) improve the rate of successful quitting. This study aimed to evaluate the level of adherence to SCMs and associated factors among smokers and ex-smokers in Australia. Method: A cross-sectional study using an online survey was conducted in Australia. Descriptive statistics were used to present the overall characteristics of participants. Cross-tabulation with Pearson’s chi-square test was performed to evaluate the possible associations between factors. To explore barriers and facilitators of adherence to SCMs, logistic regressions were conducted. Results: Among 201 participants, 57 (28.4%) were found to be adherent to SCMs. The odds of being adherent were found to be higher among participants with good social support (AOR = 3.28, 95% CI of 2.30–6.27). Participants who did not experience anxiety symptoms had higher odds of being adherent to SCMs as compared to smokers who had anxiety symptoms (AOR = 4.41, 95% CI of 3.64–14.68). Having previous experience of using SCMs improved adherence four-fold (AOR = 3.87, 95% CI of 1.11–13.44). Level of nicotine dependence showed a direct association with adherence (AOR = 3.53, 95% CI of 1.40–8.95). Not relapsing while on the medications improved adherence (AOR = 2.88, 95% CI of 1.21–6.88). Conclusion: In a study of smokers and ex-smokers in Australia, the self-reported level of adherence to SCMs was found to be low. Adherence was associated with social, psychological, and medication-related factors. Smoking cessation interventions are recommended to include strategies that can address medication adherence.

Medicaid-Insured Client Characteristics and Quit Outcomes at the Arizona Smokers' Helpline

Medicaid-insured individuals who smoke experience disparities in quitting and are a priority population for assistance. This retrospective cohort study of Arizona Smokers' Helpline clients (Jan 2014-Mar 2019) examined the association between insurance status, treatment, and smoking cessation. When compared to clients with non-Medicaid insurance or no insurance, clients with Medicaid (26%) were more likely to be female, referred directly to the ASHLine by a healthcare or community partner, smoke in the home, and report having a mental health condition. They also were less likely to utilize cessation medication and reported receiving less social support to quit. Controlling for these and other theoretically relevant variables, insurance status was stratified (Medicaid, non-Medicaid, and uninsured), and quit outcomes were compared by level of treatment (4 treatment groups: more and less than 3 coaching sessions and cessation medication use yes/no). Compared to clients who received 3+ coaching sessions, those who had less than 3 coaching sessions had significantly lower adjusted odds of quitting. Results were similar regardless of cessation medication use or insurance status. There is no indication that treatment effects differ by insurance status. While insurance status appears to proxy for other important factors like low social and economic status and higher comorbidity prevalence, in a quitline setting, quitting is associated with additional, high-quality coaching. Where coaching sessions may offset social and economic barriers to quitting, quitlines may consider focusing on assisting Medicaid-insured clients to connect and engage with treatment.

Barriers and Facilitators of Adherence to Nicotine Replacement Therapy: A Systematic Review and Analysis Using the Capability, Opportunity, Motivation, and Behaviour (COM-B) Model

BACKGROUND

Poor adherence to nicotine replacement therapy (NRT) is associated with low rates of smoking cessation. Hence, this study aims to identify and map patient-related factors associated with adherence to NRT using the capability, opportunity, motivation, and behaviour (COM-B) model.

METHODS

A systematic review was conducted by searching five databases (MEDLINE, Scopus, EMBASE, CINAHL, and PsycINFO) and grey literature on 30 August 2020. Data were extracted, thematically analysed, and mapped to the COM-B model. The Joanna Briggs Institute (JBI) critical appraisal tool was utilised to assess the quality of studies.

RESULTS

A total of 2929 citations were screened, and 26 articles with a total of 13,429 participants included. Thirty-one factors were identified and mapped to COM-B model: psychological capability (forgetfulness, education), physical capability (level of nicotine dependence, withdrawal symptoms), reflective motivation (perception about NRT and quitting), automatic motivation (alcohol use, stress, depression), physical opportunity (cost), and social opportunity (social support). The most prominent element associated with adherence was reflective motivation followed by physical capability and automatic motivation.

CONCLUSIONS

Multiple personal, social, and environmental factors affect NRT adherence. Hence, it is recommended to implement a multifaceted behavioural intervention incorporating factors categorised under the COM-B model, which is the hub of the behaviour change wheel (BCW) to improve adherence and quitting.

Extended Nicotine Patch Treatment Among Smokers With and Without Comorbid Psychopathology

INTRODUCTION

Individuals with psychiatric conditions smoke at higher rates than the general population and may need more intensive treatment to quit. We examined whether or not extended treatment with nicotine patch, combined with behavior counseling, would disproportionally benefit smokers with versus without a lifetime psychiatric condition.

METHODS

We conducted a secondary analysis of data from an effectiveness trial of treatment with 12 counseling sessions (48 weeks) and 21-mg nicotine patch (8, 24, or 52 weeks) among 525 adult daily smokers. A structured clinical interview assessed past and current psychiatric disorders (major depression, generalized anxiety disorder, alcohol abuse and/or dependence, and substance abuse and/or dependence), as described in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Abstinence was bioverified at week 52. Logistic regression evaluated the effect of the psychiatric status × treatment duration interaction on abstinence at week 52, covarying for sociodemographics, baseline psychological symptoms, and treatment adherence.

RESULTS

At baseline, 115 (21.9%) participants were diagnosed with one or more psychiatric conditions. The psychiatric status × treatment duration interaction was significant for week 52 abstinence (p = .027). Abstinence rates between smokers with versus without a psychiatric condition in the 24-week treatment arm (9.3% vs. 31.5% abstinent) significantly differed from the 8-week treatment arm (18.8% vs. 22.3%), p = .017. Abstinence rates for smokers with (22.5%) versus without a psychiatric condition (19.7%) in the 52-week treatment arm did not differ from those in the 8-week arm.

CONCLUSIONS

Targeted smoking cessation treatment, rather than extending treatment duration, may be especially warranted to optimize treatment for smokers with comorbid mood, anxiety, and substance use disorders.

IMPLICATIONS

Individuals with psychiatric conditions smoke at higher rates and have greater difficulty quitting compared to those in the general population, but little is known about how to best optimize treatment for this high tobacco burden population. The present study found that cessation response to extended duration treatment with the transdermal nicotine patch did not differ for smokers with versus without comorbid anxiety, mood, and substance use disorders in a large-scale clinical effectiveness trial. Development of targeted behavioral treatments may be required to optimize abstinence outcomes for this high-risk population, rather than simply extending the duration of pharmacotherapy treatments.

Evaluation of nicotine patch adherence measurement using self-report and saliva cotinine among abstainers in a smoking cessation trial

BACKGROUND

Adherence to nicotine patches relates to cessation. This is the first study to examine the validity of self-reported nicotine patch adherence relative to saliva cotinine.

METHODS

We used data from 198 clinical trial participants who received 11 weeks of nicotine patches, self-reported patch use, had saliva cotinine 1-week after the start of treatment assessed, and were not smoking when saliva was collected (CO < 6). Self-reported patch adherence was defined as: 3-day (before saliva collection), 7-day (before saliva collection), 3-week use (7 days before, and 14 days after, saliva collection), and 11-week use (7 days before, and 10 weeks after, saliva collection). Analyses, including receiver operating characteristic curves, considered differences in nicotine metabolism. Sensitivity, specificity and positive (PPV) and negative predictive value (NPV) assessed optimal cotinine cut-point for adherence.

RESULTS

Self-reported 7-day (r = 0.13) and 3-week (r = 0.13) patch use marginally correlated with week 1 cotinine (p's = 0.08) but not 3-day or 11-week. Significant area under the curve (AUC) values of 0.67 (95 %CI: 0.55-0.79) and 0.72 (95 %CI: 0.57-0.88) were found using 7-day self-report for the overall sample and for slow metabolizers (p's<0.01), but not for normal metabolizers. Optimal 1-week cotinine cut-points using 7-day self-report were 170 ng/mL (overall) and 184 ng/mL (slow), with sensitivity = 0.56-0.62, specificity = 0.69-0.78, PPV = 0.96-0.97, and NPV = 0.13-0.14.

CONCLUSIONS

Among CO-confirmed abstainers, self-reported patch use and saliva cotinine assessed 1-week into treatment, were modestly correlated and optimal cotinine cut-point differed by rate of nicotine metabolism. Seven-day patch use may be a more valid self-report measure of patch adherence based on cotinine than 3-day, 3-week, or 11-week. Rate of nicotine metabolism may affect this relationship.