Smoking cessation: progress, priorities, and prospectus

Cardiovascular Risk Reduction: We Have the Will, But Do We Have the Way?

As Rippe, Angelopoulos, and Zuckley pointed out, coronary heart disease “represents the quintessential lifestyle disease of developed countries,” offering both opportunities and challenges for the routine practice of lifestyle medicine. Although the empirical evidence provides a compelling rationale for the modification of preventable cardiovascular risks, their review prompts discussion of the continuing tendency for practice to lag behind knowledge, the persisting challenges to narrowing this knowledge-practice divide, and the emerging trends that may further advance cardiovascularrisk reduction efforts.

Practice Notes: Strategies in Health Education

The Practice Notes section is intended to keep readers informed about health education practice around the country. It is an attempt to spread the word about exemplary strategies, initiatives, and programs and share successes in overcoming obstacles or challenges. Periodically, articles presenting perspectives on practice-related issues are also included in Practice Notes.

Identifying effective intervention components for smoking cessation: a factorial screening experiment

AIMS

To identify promising intervention components intended to help smokers to attain and maintain abstinence in their quit smoking attempts.

DESIGN

A fully crossed, six-factor randomized fractional factorial experiment.

SETTING

Eleven primary care clinics in southern Wisconsin, USA.

PARTICIPANTS

A total of 637 adult smokers (55% women, 88% white) motivated to quit smoking who visited primary care clinics.

INTERVENTIONS

Six intervention components designed to prepare smokers to quit, and achieve and maintain abstinence (i.e. for the preparation, cessation and maintenance phases of smoking treatment): (1) preparation nicotine patch versus none; (2) preparation nicotine gum versus none; (3) preparation counseling versus none; (4) intensive cessation in-person counseling versus minimal; (5) intensive cessation telephone counseling versus minimal; and (6) 16 versus 8 weeks of combination nicotine replacement therapy (nicotine patch  +  nicotine gum).

MEASUREMENTS

Seven-day self-reported point-prevalence abstinence at 16 weeks.

FINDINGS

Preparation counseling significantly improved week 16 abstinence rates (P = .04), while both forms of preparation nicotine replacement therapy interacted synergistically with intensive cessation in-person counseling (P < 0.05). Conversely, intensive cessation phone counseling and intensive cessation in-person counseling interacted antagonistically (P < 0.05)-these components produced higher abstinence rates by themselves than in combination.

CONCLUSIONS

Preparation counseling and the combination of intensive cessation in-person counseling with preparation nicotine gum or patch are promising intervention components for smoking and should be evaluated as an integrated treatment package.

A behavioral smoking treatment based on perceived risks of quitting: A preliminary feasibility and acceptability study with female smokers

INTRODUCTION

Even treatments showing proven efficacy leave the majority of female smokers unable to quit. In response, there has been a special call for novel behavioral treatments, particularly those that target barriers to quitting faced by women. Significant barriers for women who smoke include perceived "risks" associated with cessation (e.g., managing stress and cravings). The purpose of this treatment development study is to test a novel, individualized smoking intervention for female smokers targeting risk perceptions.

METHODS

Twenty treatment-seeking female daily cigarette smokers were randomly assigned to receive either standard counseling based on the Mayo Clinic's "Smoke Free and Living It" manual or a new manualized treatment based on individual perceived risks of quitting. Primary outcomes were point prevalence smoking abstinence at the end of treatment and at a one month follow-up, and changes in smoking from baseline to one month follow-up.

RESULTS

The manualized perceived risk treatment demonstrated good acceptability and more participants receiving this treatment were abstinent at the end of the trial than participants in the standard counseling condition. Among participants who did not quit smoking, those receiving the perceived risk counseling reported a greater reduction in smoking at the one month follow up (Cohen's d=0.67).

CONCLUSIONS

This initial study demonstrated that an intervention targeting perceived risks of quitting was feasible to administer, acceptable to female smokers, and showed promise with regard to smoking outcomes, thus warranting further testing through Stage II clinical trials. Reducing perceived risks of quitting may represent a critical target for smoking treatment development.

A Review of the Literature Concerning HIV and Cigarette Smoking: Morbidity and Mortality, Associations with Individual- and Social-Level Characteristics, and Smoking Cessation Efforts

Cigarette smoking is endemic among many populations, but is especially prevalent among people living with HIV, and is consequently associated with a variety of types of morbidity as well as mortality. Despite this knowledge, relatively little research has been conducted among smokers living with HIV. Extant research has focused on examining individual-level characteristics associated with smoking behaviors, to the neglect of examining social-level factors. This manuscript represents a critical literature review of the intersecting research fields of HIV and cigarette smoking. Topics considered within this review include: morbidity, mortality, as well as treatment and medication adherence outcomes; individual- and social-level characteristics associated with various smoking behaviors; evidence-based smoking cessation interventions; and findings from cessation interventions among smokers living with HIV. Additionally, gaps in the existing literature, as well as directions for future research were identified and discussed.

Randomized trial on mindfulness training for smokers targeted to a disadvantaged population

We report the results of a randomized trial comparing a novel smoking cessation treatment Mindfulness Training for Smokers (MTS) to a usual care therapy (Controls), which included the availability of a tobacco quit line and nicotine patches. Data were collected from 196 low socioeconomic status smokers in 2010-2011 in Madison, Wisconsin. Participants were randomized to either MTS or a telephonic quit line. The primary outcome was 6-month smoking abstinence measured by carbon monoxide breath testing and Time-Line Follow-Back. Among treatment initiators (randomized participants who participated in the intervention), abstinence rates were significantly different between the MTS (38.7%) and control (20.6%, p = .05) groups. Study limitations are also discussed. Results suggest that further study is warranted.

Smokers who seek help in specialized cessation clinics: How special are they compared to smokers in general population?

Introduction: Patients of specialized nicotine dependence clinics are hypothesized to form a distinct subpopulation of smokers due to the features associated with treatment seeking. The aim of the study was to describe this subpopulation of smokers and compare it to smokers in general population.

Material and methods: A chart review of 796 outpatients attending a specialized nicotine dependence clinic, located in Toronto, Ontario, Canada was performed. Client smoking patterns and sociodemographic characteristics were compared to smokers in the general population using two Ontario surveys – the Ontario Tobacco Survey (n = 898) and the Centre for Addiction and Mental Health Monitor (n = 457).

Results: Smokers who seek treatment tend to smoke more and be more heavily addicted. They were older, had longer history of smoking and greater number of unsuccessful quit attempts, both assisted and unassisted. They reported lower education and income, had less social support and were likely to live with other smokers.

Conclusions: Smokers who seek treatment in specialized centers differ from the smokers in general population on several important characteristics. These same characteristics are associated with lower chances for successful smoking cessation and sustained abstinence and should be taken into consideration during clinical assessment and treatment planning.

Internet-based interventions for smoking cessation

BACKGROUND

The Internet is now an indispensable part of daily life for the majority of people in many parts of the world. It offers an additional means of effecting changes to behaviour such as smoking.

OBJECTIVES

To determine the effectiveness of Internet-based interventions for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register. There were no restrictions placed on language of publication or publication date. The most recent search was conducted in April 2013.

SELECTION CRITERIA

We included randomized and quasi-randomized trials. Participants were people who smoked, with no exclusions based on age, gender, ethnicity, language or health status. Any type of Internet intervention was eligible. The comparison condition could be a no-intervention control, a different Internet intervention, or a non-Internet intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed and extracted data. Methodological and study quality details were extracted using a standardized form. We extracted smoking cessation outcomes of six months follow-up or more, reporting short-term outcomes where longer-term outcomes were not available. We reported study effects as a risk ratio (RR) with a 95% confidence interval (CI). Clinical and statistical heterogeneity limited our ability to pool studies.

MAIN RESULTS

This updated review includes a total of 28 studies with over 45,000 participants. Some Internet programmes were intensive and included multiple outreach contacts with participants, whilst others relied on participants to initiate and maintain use.Fifteen trials compared an Internet intervention to a non-Internet-based smoking cessation intervention or to a no-intervention control. Ten of these recruited adults, one recruited young adult university students and two recruited adolescents. Seven of the trials in adults had follow-up at six months or longer and compared an Internet intervention to usual care or printed self help. In a post hoc subgroup analysis, pooled results from three trials that compared interactive and individually tailored interventions to usual care or written self help detected a statistically significant effect in favour of the intervention (RR 1.48, 95% CI 1.11 to 2.78). However all three trials were judged to be at high risk of bias in one domain and high statistical heterogeneity was detected (I² = 53%), with no obvious clinical explanation. Pooled results from two studies of an interactive, tailored intervention involving the Internet and automated phone contacts also detected a significant effect (RR 2.05, 95% CI 1.42 to 2.97, I² = 42%). Results from a sixth study comparing an interactive but non-tailored intervention to control did not detect a significant effect, nor did the seventh study, which compared a non-interactive, non-tailored intervention to control. Three trials comparing Internet interventions to face-to-face or phone counselling also did not detect evidence of an effect, nor did two trials evaluating Internet interventions as adjuncts to other behavioural interventions. A trial in college students increased point prevalence abstinence after 30 weeks but had no effect on sustained abstinence. Two small trials in adolescents did not detect an effect on cessation compared to control.Fourteen trials, all in adult populations, compared different Internet sites or programmes. Pooled estimates from three trials that compared tailored and/or interactive Internet programmes with non-tailored, non-interactive Internet programmes did not detect evidence of an effect (RR 1.12, 95% CI 0.95 to 1.32, I² = 0%). One trial detected evidence of a benefit from a tailored email compared to a non-tailored one, whereas a second trial comparing tailored messages to a non-tailored message did not detect evidence of an effect. Trials failed to detect a benefit of including a mood management component (three trials), or an asynchronous bulletin board.

AUTHORS' CONCLUSIONS

Results suggest that some Internet-based interventions can assist smoking cessation at six months or longer, particularly those which are interactive and tailored to individuals. However, the trials that compared Internet interventions with usual care or self help did not show consistent effects and were at risk of bias. Further research is needed despite 28 studies on the subject. Future studies should carefully consider optimising the interventions which promise most effect such as tailoring and interactivity.

Interventions to address chronic disease and HIV: strategies to promote smoking cessation among HIV-infected individuals

Tobacco use, especially cigarette smoking, is higher than average in persons living with HIV/AIDS (PLWHA). The Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence states that, during every medical encounter, all smokers should be offered smoking cessation counseling, along with approved medications. The Guideline also recognizes PLWHA as a priority population, given the scarcity of research on effective cessation treatments in this group. The scant evidence suggests that conventional treatments, though worthwhile, are not as successful as might be hoped for. The reasons for this are not entirely clear, but may have to do with the complex array of medical and psychosocial factors that complicate their lives. Clinicians should consider re-treatment strategies for those patients who encounter difficulty when quitting smoking with conventional approaches, switching or augmenting treatments as needed to minimize adverse experiences, and to maximize tolerability, adherence, and cessation outcomes.

Stress induces behavioral sensitization, increases nicotine-seeking behavior and leads to a decrease of CREB in the nucleus accumbens

Experimental evidence shows that exposure to stress engenders behavioral sensitization and increases drug-seeking and leads to intense drug taking. However the molecular mechanisms involved in these processes is not well known yet. The present experiments examined the effects of exposure to variable stress on nicotine-induced locomotor activation, cAMP-response element-binding protein (CREB) and extracellular signal-regulated kinase (ERK) activity and nicotine intravenous self-administration in rats. Male Wistar rats were exposed to variable stress that consisted of the exposure to different stressors twice a day in random order for 10 days. During this period the control group was left undisturbed except for cage cleaning. Ten days after the last stress episode, rats were challenged with either saline or nicotine (0.4 mg/kgs.c.) and the locomotor activity was recorded for 20 min. Immediately after behavioral recordings rats were sacrificed and their brains were removed to posterior western blotting analysis of CREB, phosphoCREB, ERK and phosphoERK in the nucleus accumbens. An independent set of control and stressed animals were subjected to an intravenous nicotine self-administration protocol. The break point during a progressive ratio schedule and nicotine intake patterns during a 24-hour binge was analyzed. Repeated variable stress caused a sensitized motor response to a single challenge of nicotine and decreased CREB in the nucleus accumbens. Furthermore, in the self-administration experiments previous stress exposure caused an increase in the break point and nicotine intake.

Fatherhood, smoking, and secondhand smoke in North America: an historical analysis with a view to contemporary practice

In the context of concerns about the effects of secondhand smoke on fetal health and the health of children, North American health promotion interventions have focused on reducing tobacco consumption among women to a greater extent than men. This is problematic when the health effects of men's secondhand smoke in family environments are considered. This article examines this gendered phenomenon in terms of a history of cigarette consumption that positions smoking as masculine. Furthermore, it demonstrates the value of addressing men's smoking using a gendered methodology, with an emphasis on fatherhood as an expression of masculine identity. Garnering health promotion programs to promote a culture of masculinity that is less individualistic, and defined in terms of responsibility and care for others, in addition to the self, has the potential to render men's smoking problematic and challenge the historic linkages between smoking and masculinity.

Does acceptance and relationship focused behavior therapy contribute to bupropion outcomes? A randomized controlled trial of functional analytic psychotherapy and acceptance and commitment therapy for smoking cessation

This study evaluated a treatment combining bupropion with a novel acceptance and relationship focused behavioral intervention based on the acceptance and relationship context (ARC) model. Three hundred and three smokers from a community sample were randomly assigned to bupropion, a widely used smoking cessation medication, or bupropion plus functional analytic psychotherapy (FAP) and acceptance and commitment therapy (ACT). Objective measures of smoking outcomes and self-report measures of acceptance and relationship processes were taken at pretreatment, posttreatment, 6-month, and 1-year follow-up. The combined treatment was significantly better than bupropion alone at 1-year follow-up with 7-day point prevalence quit rates of 31.6% in the combined condition versus 17.5% in the medication-alone condition. Acceptance and the therapeutic relationship at posttreatment statistically mediated 12-month outcomes. Bupropion outcomes were enhanced with an acceptance and relationship focused behavioral treatment.

Mindfulness training for smoking cessation: results from a randomized controlled trial

BACKGROUND

Cigarette smoking is the leading cause of preventable death in the world, and long-term abstinence rates remain modest. Mindfulness training (MT) has begun to show benefits in a number of psychiatric disorders, including depression, anxiety and more recently, in addictions. However, MT has not been evaluated for smoking cessation through randomized clinical trials.

METHODS

88 treatment-seeking, nicotine-dependent adults who were smoking an average of 20cigarettes/day were randomly assigned to receive MT or the American Lung Association's freedom from smoking (FFS) treatment. Both treatments were delivered twice weekly over 4 weeks (eight sessions total) in a group format. The primary outcomes were expired-air carbon monoxide-confirmed 7-day point prevalence abstinence and number of cigarettes/day at the end of the 4-week treatment and at a follow-up interview at week 17.

RESULTS

88% of individuals received MT and 84% of individuals received FFS completed treatment. Compared to those randomized to the FFS intervention, individuals who received MT showed a greater rate of reduction in cigarette use during treatment and maintained these gains during follow-up (F=11.11, p=.001). They also exhibited a trend toward greater point prevalence abstinence rate at the end of treatment (36% vs. 15%, p=.063), which was significant at the 17-week follow-up (31% vs. 6%, p=.012).

CONCLUSIONS

This initial trial of mindfulness training may confer benefits greater than those associated with current standard treatments for smoking cessation.

Effects of simultaneous exposure to stress and nicotine on nicotine-induced locomotor activation in adolescent and adult rats

Preclinical studies have shown that repeated stress experiences can result in an increase in the locomotor response to the subsequent administration of drugs of abuse, a phenomenon that has been termed behavioral cross-sensitization. Behavioral sensitization reflects neuroadaptive processes associated with drug addiction and drug-induced psychosis. Although cross-sensitization between stress- and drug-induced locomotor activity has been clearly demonstrated in adult rats, few studies have evaluated this phenomenon in adolescent rats. In the present study, we determined if the simultaneous exposure to stress and nicotine was capable of inducing behavioral sensitization to nicotine in adolescent and adult rats. To this end, adolescent (postnatal day (P) 28-37) and adult (P60-67) rats received nicotine (0.4 mg/kg, sc) or saline (0.9% NaCl, sc) and were immediately subjected to restraint stress for 2 h once a day for 7 days. The control group for stress was undisturbed following nicotine or saline injections. Three days after the last exposure to stress and nicotine, rats were challenged with a single dose of nicotine (0.4 mg/kg, sc) or saline and nicotine-induced locomotion was then recorded for 30 min. In adolescent rats, nicotine caused behavioral sensitization only in animals that were simultaneously exposed to stress, while in adult rats nicotine promoted sensitization independently of stress exposure. These findings demonstrate that adolescent rats are more vulnerable to the effects of stress on behavioral sensitization to nicotine than adult rats.

New methods for tobacco dependence treatment research

INTRODUCTION

Despite advances in tobacco dependence treatment in the past two decades, progress has been inconsistent and slow. This paper reviews pervasive methodological issues that may contribute to the lack of timely progress in tobacco treatment science including the lack of a dynamic model or framework of the cessation process, inefficient study designs, and the use of distal outcome measures that poorly index treatment effects. The authors then present a phase-based cessation framework that partitions the cessation process into four discrete phases based on current theories of cessation and empirical data. These phases include: (1) Motivation, (2) Precessation, (3) Cessation, and (4) Maintenance.

DISCUSSION

Within this framework, it is possible to identify phase-specific challenges that a smoker would encounter while quitting smoking, intervention components that would address these phase-specific challenges, mechanisms via which such interventions would exert their effects, and optimal outcome measures linked to these phase-specific interventions. Investigation of phase-based interventions can be accelerated by using efficient study designs that would permit more timely development of an optimal smoking cessation treatment package.

Knowledge, attitudes and practices regarding smoking cessation among Chinese affiliates of women's organisations in Hong Kong

Volunteers and staff of women's organisations who are highly active in engaging and providing community service can be recruited to motivate female smokers to quit. We described the knowledge and attitudes regarding tobacco control and smoking cessation among these affiliates in Hong Kong and identified factors associated with the practices of cessation interventions. Eight of 14 women's organisations joining the Women Against Tobacco Taskforce agreed to participate. All staff, volunteers, and members of the eight organisations were invited to complete a self-administered anonymous questionnaire during July and August 2006. A total of 623 out of 771 (80.8%) affiliates responded. Their knowledge on smoking and health (mean = 3.91, SD = 1.44 on a range of 0-7), smoking related diseases (mean = 2.91, SD = 0.97 on a range of 0-4), and women-specific diseases (mean = 2.93, SD = 1.87 on a range of 0-6), was considered to be inadequate. They had positive attitudes towards tobacco control (mean = 3.31, SD = 0.55) and their own role in smoking cessation counselling (mean = 3.19, SD = 0.56) on a 4-point Likert scale and 39.3% reported had attempted to offer quitting advice. Logistic regression analysis found that participants having direct contact with smokers who had a positive attitude towards their own role in smoking cessation counselling (OR = 2.57; 95% CI = 1.67-3.95) and better knowledge of smoking and smoking-related diseases (OR = 1.35; 95% CI = 1.06-1.71) were more likely to provide cessation counselling after controlling for gender; knowledge on smoking and health, and women-specific diseases; attitude towards tobacco control, negative and positive attitudes towards female smokers, and perceived self-efficacy in smoking cessation counselling. Women's organisations showed limited support towards tobacco control and their affiliates had a limited knowledge on smoking and health but had positive attitudes. Appropriate training, capacity building and establishing rapport with women's organisations are needed to promote smoking cessation and to support tobacco control in the community.

Role of sensitivity to anxiety symptoms in responsiveness to mindfulness versus suppression strategies for coping with smoking cravings

Mindfulness strategies for managing cravings involve present-moment, nonjudgmental awareness of cravings without acting on them, while suppression involves pushing cravings out of awareness. Few studies have investigated individual differences in responding to these strategies. The current study examined whether individual differences in anxiety sensitivity moderate responsiveness to mindfulness versus suppression for coping with smoking cravings. Participants (N=61) utilized a mindfulness or suppression strategy to manage cravings during cue exposure to cigarettes and were evaluated for self-efficacy 7 days later. Greater anxiety sensitivity after cue exposure was associated with increased self-efficacy in the suppression condition. This suggests that anxiety-sensitive individuals who utilize suppression may cope better with cravings, at least in the early days after learning these strategies.

Self-regulation of commitment to reduce cigarette consumption: mental contrasting of future with reality

The model of fantasy realisation (Oettingen, 2000) specifies mental contrasting of a positive future with negative reality as a strategy that creates strong goal commitments. We propose that fantasies about a positive and negative future produce strong goal commitments when contrasted with the respective reality. The present study supports this hypothesis in the area of reducing cigarette consumption. Mental contrasting of a positive future with negative reality as well as mental contrasting of a negative future with positive reality led to taking immediate action when participants had high expectations of success. Results indicate that both fantasies about a positive future and a negative future can be used to commit to goals that benefit health and prevent disease.

The Role of the Self in Smoking Initiation and Smoking Cessation: A Review and Blueprint for Research at the Intersection of Social-Cognition and Health

The self-concept is recognized as important to both smoking initiation and cessation. However, most of extant research has viewed the self-concept as a static, monolithic construct. It has not drawn on contemporary social-cognitive theories of the self-concept, which view the self-concept as a dynamic, multi-faceted cognitive structure that regulates behavior in context. This paper discusses a contemporary social cognitive framework that can be used to understand the role of the self-concept in smoking.

Internet-based interventions for smoking cessation

BACKGROUND

The Internet has become a regular part of daily life for the majority of people in many parts of the world. It now offers an additional means of effecting changes to behaviour such as smoking.

OBJECTIVES

To determine the effectiveness of Internet-based interventions for smoking cessation.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL, PsycINFO, and Google Scholar. There were no restrictions placed on language of publication or publication date. The most recent search was in June 2010.

SELECTION CRITERIA

We included randomized and quasi-randomized trials. Participants were people who smoked, with no exclusions based on age, gender, ethnicity, language or health status. Any type of Internet-based intervention was eligible. The comparison condition could be a no-intervention control or a different Internet site or programme.

DATA COLLECTION AND ANALYSIS

Methodological and study quality details were extracted using a standardised form. We selected smoking cessation outcomes at short term (one to three months) and long term (6 months or more) follow up, and reported study effects as a risk ratio with 95% confidence intervals. Only limited meta-analysis was performed, as the heterogeneity of the data for populations, interventions and outcomes allowed for very little pooling.

MAIN RESULTS

Twenty trials met the inclusion criteria. There were more female than male participants. Some Internet programmes were intensive and included multiple outreach contacts with participants, whilst others relied on participants to initiate and maintain use.Ten trials compared an Internet intervention to a non-Internet based smoking cessation intervention or to a no intervention control. Six of these recruited adults, one recruited young adult university students and three recruited adolescents. Two trials of the same intensive automated intervention in populations of adult who smoked showed significantly increased cessation compared to printed self-help materials at 12 months. In one of these, all trial participants were provided with nicotine replacement therapy (NRT). Three other trials in adults did not detect significant long term effects. One of these provided access to a website as an adjunct to counselling and bupropion, one compared web-based counselling, proactive telephone-based counselling or a combination of the two as an adjunct to varenicline. The third only provided a list of Internet resources. One further short-term trial did show a significant increase in quit rates at 3 months. A trial in college students increased point prevalence abstinence after 30 weeks but had no effect on sustained abstinence. Two small trials in adolescents did not detect an effect on cessation compared to control, whilst a third small trial did detect a benefit of a web-based adjunct to a group programme amongst adolescents.Ten trials, all in adult populations, compared different Internet sites or programmes. There was some evidence that sites that were tailored and interactive might be more effective than static sites, but this was not detected in all the trials that explored this factor. One large trial did not detect differences between different Internet sites. One trial of a tailored intervention as an adjunct to NRT use showed a significant benefit but only had a 3-month follow up. One trial detected evidence of a benefit from tailored email letter compared to a non-tailored one. Trials failed to detect a benefit of including a mood management component (three trials), or an asynchronous bulletin board. Higher abstinence rates were typically reported by participants who actively engaged with the programme (as reflected by the number of log-ins).

AUTHORS' CONCLUSIONS

Results suggest that some Internet-based interventions can assist smoking cessation, especially if the information is appropriately tailored to the users and frequent automated contacts with the users are ensured, however trials did not show consistent effects.

Changes in smoking expectancies in abstinent, reducing, and non-abstinent participants during a pharmacological trial for smoking cessation

INTRODUCTION

Smoking expectancies are related to smoking consumption and predict smoking cessation. Little is known about whether expectancies change during smoking treatments, consistent with changes in smoking behavior. This study examined reported changes in smoking beliefs during an 8-week smoking cessation trial, which evaluated the safety and efficacy of the monoamine oxidase B inhibitor selegiline hydrochloride versus placebo.

METHODS

Participants were classified as "Quit" (n = 18), "Reduced" (n = 34), or "Not Quit" (n = 49) by 7-day point prevalence abstinence at the end of treatment. Expectancies were assessed at randomization, 1 week after the target quit date, and at the end of treatment.

RESULTS

Beliefs about smoking assessed prior to the quit attempt were not associated with cessation outcomes. Participants who quit smoking reported a reduction in expectations that smoking would reduce negative affect, boredom, and cravings, and facilitate social interactions, while participants who did not quit smoking reported an increase in Negative Social Impression beliefs. There were gender differences in beliefs related to Negative Affect Reduction, Negative Physical Feelings, Social Facilitation, and Cravings and significant Gender X Smoking Status interactions for Health Risk and Weight Control beliefs. There were no significant effects of medication on expectancies.

DISCUSSION

Baseline expectancies were not associated with abstinence outcomes; however, expectancies changed over time with changes in smoking, and the greatest changes were seen with smoking abstinence. Information about the relationship between smoking beliefs and behaviors may be used to enhance or tailor smoking cessation treatments.

Therapeutic advances in the treatment of nicotine addiction: present and future

While the proportion of the adult population that smokes has declined steadily in several westernized societies, the rate of successful quit attempts is still low. This is because smokers develop nicotine dependence, a powerful addiction that may require multiple attempts and long-term treatment to achieve enduring abstinence. Currently available first-line agents for smoking cessation therapy include nicotine replacement therapy (available in several formulations, including transdermal patch, gum, nasal spray, inhaler, and lozenge), bupropion (an atypical antidepressant), and varenicline (a partial agonist of the α4β2 nicotinic acetylcholine receptor that was recently developed and approved specifically for smoking cessation therapy). Second-line agents are nortriptyline (a tricyclic antidepressant agent) and the antihypertensive agent clonidine. With the exception of varenicline, which has been shown to offer significant improvement in abstinence rates over bupropion, all of the available treatments appear similarly effective. The adverse event profiles of nortriptyline and clonidine make them more appropriate for second-line therapy, when first-line treatments have failed or are not tolerated. However, the currently marketed smoking cessation drugs reportedly lack high levels of efficacy, particularly in real-life settings. New medications and vaccines with significant clinical advantage are now in the advanced stage of development and offer promise. These include nicotine vaccines and monoamine type B inhibitors. In this review article we discuss current and emerging pharmacotherapies for tobacco dependence focusing on their mechanisms of action, efficacy and adverse event profiles.

Randomized controlled trial of an interactive internet smoking cessation program with long-term follow-up

BACKGROUND

Internet programs for smoking cessation are widely available but few controlled studies demonstrate long-term efficacy.

PURPOSE

To determine the 13-month effectiveness of an Internet program presenting a set sequence of interactive steps, and the role of depressed affect.

METHODS

In a randomized controlled trial sponsored by the American Cancer Society, a treatment condition (n = 1,106) was compared to a control site (n = 1,047).

RESULTS

More treatment condition participants were abstinent (30-day point prevalence) than control site participants (12.9% vs. 10.1%, p < .05) at 13 months. This effect was greater among participants not reporting depressed affect (15.0% vs. 10.1%, p < .01). Among smokers who reported depressed affect, there was no difference in abstinence between the treatment and control conditions.

CONCLUSIONS

Data support the long-term efficacy of an Internet intervention for cessation modeled on a structured, in-person treatment approach, especially for participants not experiencing daily depressed affect.

Are differences in guidelines for the treatment of nicotine dependence and non-nicotine dependence justified?

Despite the many similarities between nicotine dependence and other drug dependences, national guidelines for their treatment differ in several respects. The recent national guideline for the treatment of nicotine dependence has (i) less emphasis on detailed assessment; (ii) less emphasis on treatment of psychiatric comorbidity; (iii) less acceptance of reduction of use as an initial treatment goal; (iv) greater emphasis on pharmacological interventions; and (v) less emphasis on psychosocial treatment than national guidelines for non-nicotine dependences. These treatment differences may occur because (i) nicotine does not cause behavioral intoxication; (ii) psychiatric comorbidity is less problematic with nicotine dependence; (iii) psychosocial problems are less severe with nicotine dependence; and (iv) available pharmacotherapies for nicotine dependence are safer, more numerous and more easily available. However, it is unclear whether these treatment differences are, in fact, justifiable because of the scarcity of empirical tests. We suggest several possible empirical tests.

Development of a culturally targeted smoking cessation intervention for African American smokers

In this paper we describe the development a culturally targeted (CT) smoking cessation intervention for low-to-middle income African-American smokers. Based on theoretically based guidelines, modifications were made to a standard treatment manual for group-based smoking cessation counseling that incorporates cognitive-behavioral, motivational, and twelve step skills. Approximately 41% of the standard treatment materials were modified, and four new modules were developed. A pilot study was conducted to compare acceptability, feasibility and early outcome indicates in African American smokers randomized to the CT intervention compared with existing data from African American smokers treated using a non-targeted standard approach (ST). Outcomes from the CT pilot study were promising: results showed high levels of feasibility, acceptability and better adherence to nicotine replacement therapy, higher quit rates, and better retention and follow-up compared with the ST. Findings suggest that a culturally targeted and intensive group based smoking cessation treatment is plausibly effective in improving smoking cessation outcomes in African American smokers, warranting a larger randomized trial.

Brief motivational interventions for HIV/STI risk reduction among individuals receiving alcohol detoxification

This HIV/STI risk reduction clinical trial implemented in short-term alcohol detoxification employed a randomized block design to evaluate three intervention conditions for feasibility, safety, and potential for changing sexual risk attitudes, motivations, and behavior: (a) nonintervention control (standard HIV information dissemination), (b) brief motivational intervention (BMI) for resolution of ambivalence and sex risk reduction planning, and (c) BMI with biological feedback based on testing for sexually transmitted infections (STIs). Findings revealed that BMI can be feasibly implemented during detoxification treatment with individuals with significant substance impairment. BMI, whether coupled with biological feedback or not, enhanced motivation for increasing behaviors that protect from STI. Sexual risk behavior did not change in any of the groups to a statistically significant degree; however, additional analyses suggest negative biological feedback may have resulted in slightly increased level of sexual activity, undoing behavioral effects of increased motivation for sexual risk reduction, perhaps by distorting participants' perception of risk.

Evaluating mediators of the impact of the Linking the Interests of Families and Teachers (LIFT) multimodal preventive intervention on substance use initiation and growth across adolescence

Substance use outcomes were examined for 351 youth participating in a randomized controlled trial designed to assess the efficacy of a school-based multimodal universal preventive intervention, Linking the Interests of Families and Teachers (LIFT). Frequency of any use of tobacco, alcohol, and other drugs was assessed via self-report from grades 5 through 12. Latent variable growth models specified average level, linear growth and accelerated growth. The LIFT intervention had a significant effect on reducing the rate of growth in use of tobacco and illicit drugs, particularly for girls, and had an overall impact on average levels of use of tobacco, alcohol, and illicit drugs. Average tobacco use reductions were mediated by increases in family problem solving. The intervention had significant indirect effects on growth in substance use through intervention effects on reduced playground aggression and increased family problem solving. The intervention was also associated with roughly a 10% reduced risk in initiating tobacco and alcohol use. Implications for future studies of multimodal preventive interventions are discussed.

Cigarette smoking and HIV: more evidence for action

As many as 50-70% of persons infected with HIV are current smokers. Compelling evidence concerning the risks of cigarette smoking to persons living with HIV urges the inclusion of smoking treatment protocols in contemporary models of HIV care. Yet in spite of growing awareness of this problem, persons living with HIV are not being effectively treated for tobacco use. To further an understanding of contributing factors and define directions for evidenced-based intervention, factors associated with smoking behavior among persons living with HIV are examined.

A prospective examination of distress tolerance and early smoking lapse in adult self-quitters

INTRODUCTION

A significant percentage of smokers attempting cessation lapse to smoking within a matter of days, and current models of relapse devote insufficient attention to such early smoking lapse. Studies attempting to relate severity of nicotine withdrawal symptoms to short-term smoking cessation outcomes have yielded equivocal results. How one reacts to the discomfort of nicotine withdrawal and quitting smoking (i.e., distress tolerance) may be a more promising avenue of investigation with important treatment implications.

METHODS

The present investigation examined distress tolerance and early smoking lapse using a prospective design. Participants were 81 adult daily smokers recruited through newspaper advertisements targeted at smokers planning to quit smoking without assistance (i.e., no pharmacotherapy or psychosocial treatment; 42 males and 39 females; mean age = 42.6 years, SD = 12.20).

RESULTS

As hypothesized, both greater breath-holding duration and carbon dioxide-enriched air persistence were associated with a significantly lower risk of smoking lapse following an unaided quit attempt. These effects were above and beyond the risk associated with levels of nicotine dependence, education, and history of major depressive disorder, suggesting that distress tolerance and task persistence may operate independently of risk factors such as nicotine dependence and depressive history. In contrast to expectation, persistence on the Paced Auditory Serial Addition Test (a psychological challenge task) was not a significant predictor of earlier smoking lapse.

DISCUSSION

These results are discussed in relation to refining theoretical models of the role of distress tolerance in early smoking lapse and the utility of such models in the development of specialized treatment approaches for smoking cessation.

Comparing internet assistance for smoking cessation: 13-month follow-up of a six-arm randomized controlled trial

Background

Although many smokers seek Internet-based cessation assistance, few studies have experimentally evaluated long-term cessation rates among cigarette smokers who receive Internet assistance in quitting.

Objective

The purpose of this study is to describe long-term smoking cessation rates associated with 6 different Internet-based cessation services and the variation among them, to test the hypothesis that interactive and tailored Internet services yield higher long-term quit rates than more static Web-posted assistance, and to explore the possible effects of level of site utilization and a self-reported indicator of depression on long-term cessation rates.

Method

In 2004-05, a link was placed on the American Cancer Society (ACS) website for smokers who wanted help in quitting via the Internet. The link led smokers to the QuitLink study website, where they could answer eligibility questions, provide informed consent, and complete the baseline survey. Enrolled participants were randomly assigned to receive emailed access to one of five tailored interactive sites provided by cooperating research partners or to a targeted, minimally interactive ACS site with text, photographs, and graphics providing stage-based quitting advice and peer modeling.

Results

6451 of the visitors met eligibility requirements and completed consent procedures and the baseline survey. All of these smokers were randomly assigned to one of the six experimental groups. Follow-up surveys done online and via telephone interviews at approximately 13 months after randomization yielded 2468 respondents (38%) and found no significant overall quit rate differences among those assigned to the different websites (P = .15). At baseline, 1961 participants (30%) reported an indicator of depression. Post hoc analyses found that this group had significantly lower 13-month quit rates than those who did not report the indicator (all enrolled, 8% vs 12%, P < .001; followed only, 25% vs 31%, P = .003). When the 4490 participants (70%) who did not report an indicator of depression at baseline were separated for analysis, the more interactive, tailored sites, as a whole, were associated with higher quitting rates than the less interactive ACS site: 13% vs 10% (P = .04) among 4490 enrolled and 32% vs 26% (P = .06) among 1798 followed.

Conclusions

These findings show that Internet assistance is attractive and potentially cost-effective and suggest that tailored, interactive websites may help cigarette smokers who do not report an indicator of depression at baseline to quit and maintain cessation.

The effectiveness of covering smoking cessation services for medicare beneficiaries

OBJECTIVE

To examine whether reimbursement for Provider Counseling, Pharmacotherapies, and a telephone Quitline increase smoking cessation relative to Usual Care.

STUDY DESIGN

Randomized comparison trial testing the effectiveness of four smoking cessation benefits.

SETTING

Seven states that best represented the national population in terms of the proportion of those > or = 65 years of age and smoking rate.

PARTICIPANTS

There were 7,354 seniors voluntarily enrolled in the Medicare Stop Smoking Program and they were followed-up for 12 months.

INTERVENTION(S)

(1) Usual Care, (2) reimbursement for Provider Counseling, (3) reimbursement for Provider Counseling with Pharmacotherapy, and (4) telephone counseling Quitline with nicotine patch.

MAIN OUTCOME MEASURE

Seven-day self-reported cessation at 6- and 12-month follow-ups.

PRINCIPAL FINDINGS

Unadjusted quit rates assuming missing data=smoking were 10.2 percent (9.0-11.5), 14.1 percent (11.7-16.5), 15.8 percent (14.4-17.2), and 19.3 percent (17.4-21.2) at 12 months for the Usual Care, Provider Counseling, Provider Counseling + Pharmacotherapy, and Quitline arms, respectively. Results were robust to sociodemographics, smoking history, motivation, health status, and survey nonresponse. The additional cost per quitter (relative to Usual Care) ranged from several hundred dollars to $6,450.

CONCLUSIONS

A telephone Quitline in conjunction with low-cost Pharmacotherapy was the most effective means of reducing smoking in the elderly.

Smoking cessation intervention for female prisoners: addressing an urgent public health need

OBJECTIVES

We tested the efficacy of a combined pharmacologic and behavioral smoking cessation intervention among women in a state prison in the southern United States.

METHODS

The study design was a randomized controlled trial with a 6-month waitlist control group. The intervention was a 10-week group intervention combined with nicotine replacement therapy. Two hundred and fifty participants received the intervention, and 289 were in the control group. Assessments occurred at baseline; end of treatment; 3, 6, and 12 months after treatment; and at weekly sessions for participants in the intervention group.

RESULTS

The intervention was efficacious compared with the waitlist control group. Point prevalence quit rates for the intervention group were 18% at end of treatment, 17% at 3-month follow-up, 14% at 6-month follow-up, and 12% at 12-month follow-up, quit rates that are consistent with outcomes from community smoking-cessation interventions.

CONCLUSIONS

Female prisoners are interested in smoking cessation interventions and achieved point-prevalence quit rates similar to community samples. Augmenting tobacco control policies in prison with smoking cessation interventions has the potential to address a significant public health need.

Outcome from a community-based smoking cessation program for persons with serious mental illness

Six and 12-month outcomes are reported on 79 mentally ill persons attending either a 4- or 8-session community-based smoking cessation group. Quit rates at post, 3-, 6-, and 12-month follow-ups were 16, 19, 16, and 19%, respectively, with no significant effect of program length. These success rates are comparable to outcomes reported following group-based treatment with mentally healthy smokers. The majority of quitters used nicotine replacement therapy. Psychotropic medication dosages did not vary over time in quitters or non-quitters. No reductions in smoking were observed among non-quitters. Quitting smoking had no untoward effects on symptoms of mental illness or general functioning.

Nonpharmacologic therapy for smoking cessation: characteristics and efficacy of current approaches

This article reviews the most common nonpharmacologic approaches used to support smoking cessation and, where possible, provides estimates of their efficacy in controlled clinical trials. Virtually all of the approaches that have been systematically evaluated to date have demonstrated modest efficacy in increasing quit rates. A cornerstone of effective treatment is tobacco dependence counseling, for which there is a dose-response relation between the intensity of counseling (total minutes of contact) and its effectiveness. New approaches in which treatment is tailored to individual patient characteristics appear promising for the future but require further study. Also, new technologies that permit delivery of smoking interventions to a wider range of patients could have a significant impact on reducing smoking prevalence worldwide in the future. Overall, the clinical literature strongly endorses combining nonpharmacologic interventions with pharmacotherapy to optimize support for smokers who are trying to quit.

An algorithm for choosing among smoking cessation treatments

Currently, there are nine validated medications, four validated psychosocial strategies, and three validated ways to deliver psychosocial treatments for smoking cessation. This article presents an algorithm based on a literature review and the author's clinical experience. The algorithm integrates the recommendations of the major guidelines and meta-analyses and provides rationales for its treatment decisions. The algorithm suggests a brief assessment followed by use of one to two medications and counseling in most smokers. Because all treatments appear equally effective and have few adverse events, the algorithm suggests clinicians inform smokers of the pros and cons of the different treatments, and recommend use of one or more of each. If a smoker fails to quit, the algorithm suggests an assessment of why relapse occurred and then a more intense treatment, a new treatment, or both.

Are emergency chest pain patients ready to quit smoking?

This study examined predictors of readiness to quit smoking among emergency chest pain patients admitted to the observation unit (OU) to rule out myocardial infarction. While in the OU, patients (n=543) completed surveys assessing smoking history, nicotine dependence, readiness to quit, and other relevant variables. Participants smoked an average of 18.8 (SD=12.6) cigarettes per day. More than half (58%) had made at least 1 serious quit attempt > or = 24 hours) in the past year. Most had never used nicotine replacement medications. Nicotine dependence, perceived risk from smoking, and patient perceptions that smoking might be related to their chest pain were significantly associated with readiness to quit (P<.05). Results indicate that a significant proportion of OU patients think they are at relatively low risk from smoking and, although motivated to quit, are not using medications appropriately to assist quit attempts. There is a need for intervention and education with this population of patients.

Evaluating social-cognitive mechanisms that regulate self-efficacy in response to provocative smoking cues: an experimental investigation

Smokers' self-efficacy appraisals strongly predict smoking outcomes. However, the cognitive structures that regulate smokers' self-efficacy appraisals have not yet been identified. Knowledge of such structures could assist in designing treatments that target self-efficacy appraisals to improve smoking outcomes. This study evaluated whether 2 abstinence-related self-schemas, the abstainer ideal- and abstainer ought-possible selves, regulated self-efficacy to resist smoking when smokers were exposed to provocative smoking cues. Craving responses to the cues were a secondary outcome. Cognitively priming both of these abstainer selves increased self-efficacy and decreased craving compared with when a smoking-related self-schema was cognitively primed under the same provocative cue conditions. Higher levels of self-efficacy were consistently associated with decreased craving. These results have both theoretical and clinical implications for smoking cessation.

Effect of bupropion on physiological measures of stress in smokers during nicotine withdrawal

Studies suggest that among cigarette smokers trying to quit, stress undermines abstinence. Little research has assessed if therapies that increase smoking cessation rates impact physiological measures of stress response. Forty-three subjects completed this repeated-measures study in which a laboratory assessment was completed at baseline and after 17 days of treatment with either placebo (n=15), bupropion sustained release (150 mg twice daily) (n=14) or bupropion with stress reduction counseling (n=14). All subjects quit smoking 3 days prior to the second laboratory assessment. At each laboratory assessment physiological measures of stress (i.e. blood pressure, heart rate, plasma epinephrine, norepinephrine and cortisol concentrations) were measured during rest periods and in response to a speech, a math and a cold pressor task. Among subjects taking placebo, physiological measures of stress were generally lower at rest and during the stressors after smoking cessation. In those taking bupropion these measures were equivalent at the two assessments. Additionally, compared to placebo, those on bupropion had a greater diastolic blood pressure response to the speech stressor and greater systolic blood pressure response to the math stressor during the second laboratory session. This study suggests that bupropion may be maintaining physiological measures of stress during the nicotine withdrawal period.

Do behavioral smoking reduction approaches reach more or different smokers? Two studies; similar answers

There is a need for innovative approaches capable of reaching smokers who would not otherwise participate in efforts to modify their smoking. This paper reports on two studies to determine whether a smoking reduction intervention would appeal to additional or different types of smokers than do cessation interventions. Study 1 attempted to contact 160 HMO smokers scheduled for outpatient surgeries. In Study 2, actual pilot reduction and cessation programs were offered to 531 smokers about to undergo out-patient surgeries or procedures. In Study 1, 39% of those eligible elected smoking reduction; and 38% selected cessation. In Study 2 of those eligible, 22% began participation in the smoking reduction program; 12% preferred a cessation approach; and 65% declined. There were few demographic or smoking history differences among those who elected smoking reduction, cessation, or declined. Among this understudied population, a sizable proportion in both studies agreed to participate in smoking reduction. If replicated, this suggests that comprehensive programs that include a smoking reduction component could substantially increase their reach.

Posttraumatic stress disorder and late-onset smoking in the Vietnam era twin registry

Epidemiological and clinical studies have consistently reported associations between smoking and posttraumatic stress disorder (PTSD). This study analyzed diagnostic interview data on 6,744 members of the Vietnam Era Twin Registry to clarify the PTSD-smoking relation and to examine whether genetic liability for smoking moderated this relation. Preexisting active (unremitted) PTSD increased risk of late-onset daily smoking. Remitted PTSD decreased risk. Active PTSD increased risk of smoking at all levels of genetic liability; the effect was strongest for those with least genetic liability. This suggests PTSD represents a nongenetic pathway to late-onset smoking among individuals who were nonsmokers prior to developing PTSD. If replicated, these results identify PTSD as a risk factor for smoking that should lead to early tobacco control treatment in this population.

Distress tolerance and early smoking lapse

A significant percentage of smokers attempting cessation lapse to smoking within a matter of days and very few of these individuals recover to achieve abstinence. Current models of relapse devote insufficient attention to this phenomenon of early smoking lapse. Furthermore, studies attempting to relate severity of nicotine withdrawal symptoms to short-term smoking cessation outcomes have yielded equivocal results. The authors argue that how one reacts to the discomfort of nicotine withdrawal is a more promising avenue of investigation than severity of withdrawal and that inability to tolerate the distress of nicotine withdrawal and associated negative affect is a key factor in early smoking lapse and subsequent relapse. Theoretical and clinical implications of distress tolerance in smoking cessation are discussed and the development of a specialized and novel behavioral distress tolerance treatment for early smoking lapsers is proposed.

Relapse to smoking

Relapse is by far the most likely outcome of any smoking cessation attempt, even those made with the benefit intensive psychosocial treatment and pharmacotherapy. The present article briefly reviews the epidemiology of smoking and self-quitting, the outcome data for major forms of behavioral and pharmacologic smoking cessation treatments, and what is known about the natural history of relapse and recovery among treated smokers. A recent trend in smoking relapse research has been to study the dynamics of key motivational processes, such as withdrawal symptoms, negative affect, and craving, in the laboratory and in smokers' natural environments. This literature is also briefly reviewed, with an emphasis on how such investigations may reveal the limitations of current cessation treatments. Finally, three significant research themes that are likely to be important in future relapse research are highlighted--the possible "hardening" of the smoking population, the potential for developmental research to deepen our understanding of smoking motivation, and the promise of molecular genetic studies for advancing treatment and our understanding of relapse.

Comparative efficacy of rapid-release nicotine gum versus nicotine polacrilex gum in relieving smoking cue-provoked craving

AIMS

Most relapse episodes occur when smokers are confronted with craving provoked by situational cues. Current nicotine gum can help relieve cue-provoked cravings, but faster effects may result in more rapid relief. We tested a prototype formulation of a new rapid-release nicotine gum (RRNG) that provides more rapid release and absorption of nicotine, for its ability to provide faster and better craving relief compared to current nicotine polacrilex gum (NPG).

DESIGN

Random assignment to RRNG or NPG, used during a smoking cue provocation procedure. Participants and setting A total of 319 smokers were exposed to a smoking cue in the laboratory by being asked to light but not smoke a cigarette of their preferred brand. Subjects then chewed a piece of 2 mg RRNG (n = 159) or 2 mg NPG (n = 160) according to randomized assignment.

MEASUREMENTS

Craving assessments were completed at regular intervals before and after cue exposure (baseline, pre-cue, and 3, 6, 9, 12, 15, 18, 21, 25, 30 and 35 minutes after the cue).

FINDINGS

Smokers chewing RRNG showed significantly lower craving than NPG subjects starting with the first assessment at 3 minutes (P < 0.025). Repeated-measures ANOVA revealed a significant treatment x time interaction (P < 0.05)-craving scores dropped more rapidly in RRNG subjects compared to NPG subjects. Survival analyses also indicated superiority of RRNG in achieving more rapid self-reported meaningful relief (P < 0.05) and complete relief (P < 0.05) of craving.

CONCLUSIONS

Rapid-release nicotine gum reduced cue-provoked craving more rapidly compared to NPG, and thus merits further study in cessation efficacy trials.

The feasibility of smoking reduction: an update

AIM

To update conclusions of a previous review of smoking reduction on the extent to which (1) smokers spontaneously reduce their smoking, (2) smokers who try to quit and fail return to smoking less, (3) smokers can substantially reduce and maintain reductions via pharmacological and behavioral treatments and (4) smokers compensate when they reduce.

METHOD

Qualitative systematic review.

DATA SOURCES

Systematic computer searches and other methods.

STUDY SELECTION

Published and unpublished studies of smokers not trying to stop smoking. We located 13-26 studies for each of the four aims.

DATA EXTRACTION

The first author entered data with confirmation by second author.

DATA SYNTHESIS

Due to the heterogeneity of methods and necessity of extensive recalculation, a meta-analysis was not feasible.

RESULTS

Few daily smokers spontaneously reduce. Among those who try to stop smoking and relapse, some return to reduced smoking but whether they maintain this reduction is unclear. Nicotine replacement (and perhaps behavior therapies) can induce smokers not interested in quitting to make significant reductions in their smoking and maintain these over time. Some compensatory smoking occurs with reduction but significant declines in smoke exposure still occur.

CONCLUSIONS

These results indicate that reduction is feasible when aided by treatment. Whether reduction should be promoted will depend on the effect of reduction on health outcomes and future cessation.

Initial evaluation of a real-world Internet smoking cessation system

To significantly reduce smoking prevalence, treatments must balance reach, efficacy, and cost. The Internet can reach millions of smokers cost-effectively. Many cessation Web sites exist, but few have been evaluated. As a result, the potential impact of the Internet on smoking prevalence remains unknown. The present study reports the results, challenges, and limitations of a preliminary, large-scale evaluation of a broadly disseminated smoking cessation Web site used worldwide (QuitNet). Consecutive registrants (N=1,501) were surveyed 3 months after they registered on the Web site to assess 7-day point prevalence abstinence. Results must be interpreted cautiously because this is an uncontrolled study with a 25.6% response rate. Approximately 30% of those surveyed indicated they had already quit smoking at registration. Excluding these participants, an intention-to-treat analysis yielded 7% point prevalence abstinence (for the responders only, abstinence was 30%). A range of plausible cessation outcomes (9.8%-13.1%) among various subgroups is presented to illustrate the strengths and limitations of conducting Web-based evaluations, and the tensions between clinical and dissemination research methods. Process-to-outcome analyses indicated that sustained use of QuitNet, especially the use of social support, was associated with more than three times greater point prevalence abstinence and more than four times greater continuous abstinence. Despite its limitations, the present study provides useful information about the potential efficacy, challenging design and methodological issues, process-to-outcome mechanisms of action, and potential public health impact of Internet-based behavior change programs for smoking cessation.

Assisting with tobacco cessation

Tobacco use is the primary preventable cause of morbidity and mortality in the United States today. The consequences of smoking are well documented, and it is the responsibility of every health care provider to routinely screen and offer treatment to their patients who smoke. Nurses are no exception; we are uniquely qualified to provide practical skills training to our patients. Irrefutable data exist that even 3 minutes of counseling can have a positive influence that moves the patient who smokes further along the continuum toward quitting. The treatment recommendations and strategies that will be discussed are found in the Agency for Health Care Policy and Research guideline entitled "Treating Tobacco Use and Dependence." The algorithm will be broken down into practical interview questions and activities that every nurse can implement with his or her patients, regardless of practice setting.

Cigarette smoking and nicotine dependence

Tobacco use is the single most preventable cause of death, disability, and disease in the United States and is projected to be the leading cause of death and disability across all developed countries by the year 2020. Understanding nicotine dependence, its causes, consequences, and effective treatments is critical to the nation's public health agenda. This article presents a brief overview of nicotine dependence with particular emphasis placed on understanding what nicotine dependence is, why it occurs, how it is measured, and how it can be managed through effective treatments.