Comparison of Three Carbon Monoxide Monitors for Determination of Smoking Status in Smokers and Nonsmokers with and without COPD

Monday-Enhanced CEASE Program for Underserved Ethnic Minorities: a Mixed-Methods Study

BACKGROUND

Due to the persistence of tobacco-related health disparities in the U.S., there is a need for innovative strategies to reach the underserved ethnic minority populations who are most at risk. As contemplations for health behavior modification tend to surge on Mondays, we explored the feasibility and effect of a Monday-enhanced smoking cessation program on quitting outcomes in a low-income ethnic minority community.

AIMS

To compare a Monday-enhanced with a standard Communities Engaged and Advocating for a Smoke-free Environment (CEASE) program and understand the overall experiences of participants in the program.

METHODS

In this mixed-methods study, affordable housing complexes (n = 4) and a church were randomly assigned either a Monday-enhanced (n = 3) or standard (n = 2) CEASE smoking cessation program. CEASE comprised twelve weekly group counseling sessions facilitated by trained peer motivators plus nicotine replacement products. Participants in the Monday-enhanced arm were encouraged to pick Mondays as a quitting day. Quantitative and qualitative data were collected during the program and at 3-month post-graduation.

RESULTS

Seventy-seven participants were enrolled in the study arms. In both groups combined, tobacco consumption reduced from 7.7 to 5.6 cig/day (mean reduction, 2.1; 95% CI: 0.9 to 5.1, p = 0.08). Although no significant difference in quit rate was observed between the two arms, more participants completed the follow-up survey in the Monday-enhanced than standard CEASE program [82.4% vs. 36.0%, p < 0.05]. While qualitative data suggested an overall satisfaction of participants with the program, motivation for quitting was higher in the Monday-enhanced CEASE program compared to the standard CEASE program.

CONCLUSION

The Monday-enhanced program is promising and may enhance participants' engagement and willingness to quit smoking, particularly in low-income ethnic minority communities. Further research should include larger sample sizes to better assess the efficacy of a Monday-enhanced program across diverse populations.

Evaluating the impact of varying expired carbon monoxide thresholds on smoking relapse identification: insights from the E3 trial on e-cigarette efficacy for smoking cessation

OBJECTIVES

Expired carbon monoxide (ECO) is often used in smoking cessation trials to biochemically validate self-reported smoking status. The optimal ECO threshold to distinguish individuals who smoke from those who do not is debated.

DESIGN

The data from the 'Evaluating the Efficacy of E-Cigarette use for Smoking Cessation (E3) Trial' were used; the E3 trial was a randomised controlled trial that examined e-cigarettes efficacy for smoking cessation.

SETTINGS

Participants were recruited from 17 Canadian sites across 4 provinces.

PARTICIPANTS

This substudy included data from participants who returned for at least one of the clinical visits at week 4 (291), 12 (257) or 24 (218) and provided both self-reported smoking status and ECO measures. Analyses were based on 766 paired measures (ie, self-reported smoking status with corresponding ECO).

RESULTS

The ability of ECO measurements to discriminate between adults who reported smoking and those who reported abstinence varied with the threshold used. ECO thresholds of 6, 7, 8 and 9 parts per million (ppm) yielded the greatest area under the receiver operating characteristic curve (0.84). These thresholds produced sensitivities of 84%, 82%, 78% and 76% and specificities of 84%, 87%, 90% and 91%, respectively. However, at a threshold of 6 ppm, intersecting sensitivity (84%) and specificity (84%) were maximised with respect to each other. Biochemical validation had the highest agreement with self-report at an ECO threshold of 6 ppm (κ=0.57; 95% CI, 0.51 to 0.64).

CONCLUSION

The classification of participants' smoking status depends on the ECO threshold used for biochemical validation. We recommend that future smoking cessation trial investigators analyse and report the impact that varying ECO thresholds has on trial results.

TRIAL REGISTRATION NUMBER

NCT02417467.

Impact of text messages in a middle-income country to promote secondary prevention after acute coronary syndrome (IMPACS): A randomized trial

BACKGROUND

Studies that used short message service (SMS) programs as an intervention to promote health care have shown beneficial results in the control of risk factors for ischemic heart disease in patients of high-income countries, but evidence is lacking in low or middle-income countries.

AIMS

The purpose of this study is to evaluate whether the use of SMS increases risk factor control within 6 months after discharge by acute coronary syndrome (ACS) in a middle-income country.

METHODS

It will be a 2-arm, parallel, double-blind, randomized clinical trial of 160 patients discharged after an ACS from a single center with 6 months of follow-up. The intervention group will receive 4 SMS per week offering advice, motivation and information about medication adherence, increase of regular physical activity, adoption of healthy dietary measures, and smoking cessation (if appropriate). The primary outcome is achieving 4 or 5 points in a risk factor control score, which combines the cluster effect of 5 main modifiable risk factors for ACS [low-density lipoprotein cholesterol, LDL-C <70 mg/dL, blood pressure <140/90 mm Hg, regular exercise (≥5 days/week × 30 minutes of moderate exercise per session), nonsmoker status, and body mass index, BMI <25 kg/m]. Secondary outcomes are plasma LDL-C level, level of physical activity, blood pressure, medication adherence, proportion of nonsmokers, BMI, rehospitalization, cardiovascular death, and death from any cause. This study, as a randomized clinical trial protocol, followed the recommendations of the Standard Protocol Items (SPIRIT).

EXPECTED OUTCOMES

This study aims to provide evidence of whether SMS interventions are effective in improving cardiovascular disease risk factors control in post-ACS patients in a middle-income country. CLINICALTRIALS.

GOV IDENTIFIER

NCT03414190 (First posted on January 29, 2018; last update on May 14, 2018) - Retrospectively registered.

Salivary cotinine concentration and carbon monoxide levels in young adults smoking midwakh in comparison with cigarette smokers

Objectives

To estimate and compare the salivary cotinine levels using a semiquantitative method, called NicAlert, between three groups: non-smokers, daily smokers of cigarettes and daily smokers of midwakh, and to compare the carbon monoxide (CO) levels among these groups.

Materials and methods

A total of 159 adult male volunteers aged 20 and above were included, with 54 current cigarette smokers, 52 current midwakh smokers and 53 non-smokers. Estimate of breath carbon monoxide and salivary cotinine were collected, as well as sociodemographic characteristics and details of smoking habits and second-hand smoke exposure among participants. Institutional review board approval was obtained and data were analysed using SPSS V.21 with the Kruskal-Wallis test used to obtain differences in the distribution.

Results

There was no significant difference in the median breath CO and salivary cotinine levels between cigarette and midwakh smokers. Levels of breath CO were significantly higher in cigarette and midwakh smokers as compared with non-smokers (19.5, 17.5 and 6.0, respectively, p<0.05); the same relationship was observed for cotinine levels among cigarette and midwakh smokers as compared with non-smokers (4.0, 3.0 and 0.0, respectively, p≤0.05). Additionally, the values of both salivary cotinine and breath CO increased with the frequency of tobacco use.

Conclusion

These are the first data that we are aware of that demonstrate that in terms of at least two key biomarkers of tobacco use, there are comparable levels of exposure between cigarettes and midwakh users, demonstrating a need for intensified attention to the use of midwakh.

Smoking behaviour and sensations during the pre-quit period of an exercise-aided smoking cessation intervention

INTRODUCTION

Previous research has shown reductions in cigarette consumption during the pre-quit period of exercise-aided smoking cessation interventions. Smoking topography and sensation patterns during this period is unknown and may provide valuable insight into compensation and cessation readiness.

METHODS

Female smokers (N = 236, M age = 43, M cigarettes/day = 17.0) enrolled in an exercise-aided smoking cessation intervention self-reported daily cigarette use and cigarette sensory experiences. Breath carbon monoxide and smoking topography data were collected during the period leading up to the targeted quit date (i.e., baseline, week 1, and week 3), which was set for week 4.

RESULTS

Repeated measures ANOVAs revealed that cigarette consumption (p < 0.001, eta = 0.32), carbon monoxide (p < 0.001, eta = 0.14), puff duration (p = 0.01, eta = 0.05), smoking satisfaction (p < 0.001, eta = 0.34), psychological reward (p < 0.001, eta = 0.43), enjoyment of respiratory tract sensations (p < 0.001, eta = 0.29), and craving (p < 0.001, eta = 0.39) decreased, whereas average puff flow (p = 0.01, eta = 0.05) increased.

CONCLUSIONS

This is the first study to establish that regular exercise during the pre-quit period served as a conduit for facilitating behavioral and sensory harm reduction with cigarettes. Furthermore, the pattern of change observed between cigarette consumption and smoking topography does not support compensation. These findings imply that female smokers who exercise prior to a quit attempt are in a favourable state to achieve cessation.

Targeting Hypoxia to Improve Non-Small Cell Lung Cancer Outcome

Oxygen deprivation (hypoxia) in non-small cell lung cancer (NSCLC) is an important factor in treatment resistance and poor survival. Hypoxia is an attractive therapeutic target, particularly in the context of radiotherapy, which is delivered to more than half of NSCLC patients. However, NSCLC hypoxia-targeted therapy trials have not yet translated into patient benefit. Recently, early termination of promising evofosfamide and tarloxotinib bromide studies due to futility highlighted the need for a paradigm shift in our approach to avoid disappointments in future trials. Radiotherapy dose painting strategies based on hypoxia imaging require careful refinement prior to clinical investigation. This review will summarize the role of hypoxia, highlight the potential of hypoxia as a therapeutic target, and outline past and ongoing hypoxia-targeted therapy trials in NSCLC. Evidence supporting radiotherapy dose painting based on hypoxia imaging will be critically appraised. Carefully selected hypoxia biomarkers suitable for integration within future NSCLC hypoxia-targeted therapy trials will be examined. Research gaps will be identified to guide future investigation. Although this review will focus on NSCLC hypoxia, more general discussions (eg, obstacles of hypoxia biomarker research and developing a framework for future hypoxia trials) are applicable to other tumor sites.

Use of Expired Air Carbon Monoxide Testing in Clinical Tobacco Treatment Settings

Carbon monoxide (CO) testing is considered an easy, noninvasive, and objective contribution to the assessment of smoking behavior, as CO is rapidly absorbed into the bloodstream when lit cigarettes or cigars are inhaled. CO testing is a medically important billable outpatient service that can contribute to sustainability of face to face tobacco use treatment services by clinicians. This article reviews research on the clinical use of CO testing to provide biomedical feedback in assessing smoking behavior, educating smokers on tobacco health effects, assisting with treatment planning, and as a motivational tool to encourage people to become tobacco free. Further research can focus on how to best incorporate CO testing into clinical practice, including more research on outcomes and methods to ensure that insurers reimburse for testing and improved ways to use CO testing to initiate attempts to quit tobacco use, to maintain cessation, and to prevent relapse.

A randomized clinical trial to determine the effectiveness of CO-oximetry and anti-smoking brief advice in a cohort of kidney transplant patients who smoke: study protocol for a randomized controlled trial

Background

The cardiovascular risk in renal transplant patients is increased in patients who continue to smoke after transplantation.

The aim of the study is to measure the effectiveness of exhaled carbon monoxide (CO) measurement plus brief advisory sessions, in comparison to brief advice, to reduce smoking exposure and smoking behavior in kidney transplant recipients who smoke. The effectiveness will be measured by: (1) abandonment of smoking, (2) increase in motivation to stop smoking, and (3) reduction in the number of cigarettes smoked per day.

Methods/design

Design: a randomized, controlled, open clinical trial with blinded evaluation.

Scope: A Coruña Hospital (Spain), reference to renal transplantation in the period 2012–2015.

Inclusion criteria: renal transplant patients who smoke in the precontemplation, contemplation or preparation stages according to the Prochaska and DiClemente’s Stages of Change model, and who give their consent to participate.

Exclusion criteria: smokers attempting to stop smoking, patients with terminal illness or mental disability that prevents them from participating.

Randomization: patients will be randomized to the control group (brief advisory session) or the intervention group (brief advisory session plus measuring exhaled CO). The sample target size is n = 112, with 56 patients in each group. Allowing for up to 10 % loss to follow-up, this would provide 80 % power to detect a 13 % difference in attempting to give up smoking outcomes at a two-tailed significance level of 5 %. Measurements: sociodemographic characteristics, cardiovascular risk factors, treatment, rejection episodes, infections, self-reported smoking habit, drug use, level of dependence (the Fagerström test), stage of change (Prochaska and DiClemente’s Stages of Change model), and motivation to giving up smoking (the Richmond test).

Response: the effectiveness will be evaluated every 3, 6, 9 and 12 months as: pattern of tobacco use (self-reported tobacco use), smoking cessation rates, carbon monoxide (CO) levels in exhaled air measured by CO-oximetry, urinary cotinine tests, nicotine dependence (Fagerström test), motivational stages of change (Prochaska and DiClemente’s stages) and motivation to stop smoking (the Richmond test).

Analysis: descriptive statistics and linear/logistic multiple regression models will be performed. Clinical relevance will be measured as relative risk reduction, absolute risk reduction and the number needed to treat.

Ethics: informed consent of the patients and Ethical Review Board was obtained (code 2011/061).

Discussion

Tobacco is a modifiable risk factor that increase the risk of morbidity and mortality in kidney transplant recipients. If effectiveness of CO-oximetry is confirmed to reduce tobacco exposure, we would have an intervention that is easy to use, low cost and with great implications about cardiovascular risk prevention in these patients.

Trial registration

Current Controlled Trials ISRCTN16615772.

EudraCT number: 2015-002009-12.

Are Nurses and Auxiliary Healthcare Workers Equally Effective in Delivering Smoking Cessation Support in Primary Care?

Introduction:

Smoking cessation support is increasingly delivered in primary care by auxiliary healthcare workers in place of healthcare professionals. However, it is unknown whether this shift might affect the quality and impact of the support delivered.

Methods:

Data from the iQuit in Practice randomized control trial of cessation support in General Practice was used (N = 602). Analyses assessed whether cessation advisor type (nurse or healthcare assistant [HCA]) was associated with abstinence (primary outcome: self-reported 2-week point prevalence abstinence at 8 weeks follow-up), the advice delivered during the initial consultation, pharmacotherapies prescribed, patient satisfaction, initial consultation length, and the number and type of interim contacts.

Results:

There were no statistically significant differences in abstinence for support delivered by HCAs versus nurses at 8 weeks (HCAs 42.8%, nurses 42.6%; unadjusted odds ratio [OR] = 1.01, 95% confidence interval [CI] = 0.73 to 1.40), or at 4 weeks or 6 months follow-up. There were no statistically significant differences in advice delivered, the types of pharmacotherapies prescribed or patient satisfaction. Compared with nurses, HCA consultations were longer on average (HCAs 23.6 minutes, nurses 20.8 minutes; P = .002) and they undertook more interim contacts (HCAs median 2, nurses median 1; P < .001), with contact more likely to be face-to-face than phone call (HCAs 91.2%, nurses 70.9%; OR = 4.23, 95% CI = 2.86 to 6.26).

Conclusions:

HCAs appear equally effective as nurses in supporting smoking cessation, although they do this with greater patient contact. Using auxiliary practitioners to deliver cessation support could free up nurse time and reduce costs.

Implications:

This study found that primary care patients receiving smoking cessation support from auxiliary healthcare workers were just as likely to be abstinent up to 6 months later as those patients seen by nurses. While the auxiliary healthcare workers achieved this with slightly increased patient contact time, the advice delivered, pharmacotherapies provided and patient satisfaction were similar to that of nurses. Expanding the auxiliary healthcare worker role to include smoking cessation support could increase role satisfaction and reduce the costs of cessation support delivery in primary care.

Combining intensive practice nurse counselling or brief general practitioner advice with varenicline for smoking cessation in primary care: study protocol of a pragmatic randomized controlled trial

INTRODUCTION

Combining behavioural support and pharmacotherapy is most effective for smoking cessation and recommended in clinical guidelines. Despite that smoking cessation assistance from the general practitioner can be effective, dissemination of clinical practice guidelines and efforts on upskilling has not lead to the routine provision of smoking cessation advice among general practitioners. Intensive counselling from the practice nurse could contribute to better smoking cessation rates in primary care. However, the effectiveness of intensive counselling from a practice nurse versus usual care from a general practitioner in combination with varenicline is still unknown.

MATERIALS AND METHODS

A pragmatic randomized controlled trial was conducted comparing: (a) intensive individual counselling delivered by a practice nurse and (b) brief advice delivered by a general practitioner; both groups received 12-weeks of open-label varenicline. A minimum of 272 adult daily smoking participants were recruited and treated in their routine primary care setting. The primary outcome was defined as prolonged abstinence from weeks 9 to 26, biochemically validated by exhaled carbon monoxide. Data was analysed blinded according to the intention-to-treat principle and participants with missing data on their smoking status at follow-up were counted as smokers. Secondary outcomes included: one-year prolonged abstinence, short-term incremental cost-effectiveness, medication adherence, and baseline predictors of successful smoking cessation.

DISCUSSION

This trial is the first to provide scientific evidence on the effectiveness, cost-effectiveness, and potential mechanisms of action of intensive practice nurse counselling combined with varenicline under real-life conditions. This paper explains the methodology of the trial and discusses the pragmatic and/or explanatory design aspects.

TRIAL REGISTRATION

Dutch Trial Register NTR3067.

Smoking cessation-specific parenting and parental smoking as precursors of adolescent smoking cognitions and quitting

Relatively little is known about if and through which mechanisms parents influence adolescents' smoking cessation. The present study used Social Cognitive Theory as a theoretical framework to test whether parental smoking and smoking cessation-specific parenting (SCSP) predicted readiness to quit smoking and actual smoking cessation one year later. Both direct paths between parent factors and outcomes, and indirect paths via adolescents' smoking-specific cognitions (pros of smoking and quitting, and self-efficacy) were examined in a sample of 530 adolescents in the ages of 13 to 18 who smoked daily and weekly at baseline. The main findings show that although parental smoking and SCSP were significantly associated with cognitions (cross-sectionally), neither the parent factors nor cognitions predicted readiness to quit smoking or actual cessation one year later. Baseline SCSP did predict readiness to quit one year later. Parents may be more influential in shaping adolescents' beliefs and readiness to quit than in facilitating actual cessation.

Therapeutic education in cardiovascular diseases: state of the art and perspectives

OBJECTIVE

To assess the impact of therapeutic education programmes for Coronary Artery Disease (CAD) and Chronic Heart Failure (CHF), as well as patients' expectations and education needs, tips to improve adherence to lifestyle modifications, and education materials.

METHOD

We conducted a systematic review of the literature from 1966 to 2010 on Medline and the Cochrane Library databases using following key words: "counselling", "self-care", "self-management", "patient education" and "chronic heart failure", "CAD", "coronary heart disease", "myocardial infarction", "acute coronary syndrome". Clinical trials and randomized clinical trials, as well as literature reviews and practical guidelines, published in English and French were analysed.

RESULTS

Therapeutic patient education (TPE) is part of the non-pharmacological management of cardiovascular diseases, allowing patients to move from an acute event to the effective self-management of a chronic disease. Large studies clearly showed the efficacy of TPE programmes in changing cardiac patients' lifestyle. Favourable effects have been proved concerning morbidity and cost-effectiveness even though there is less evidence for mortality reduction. Numerous types of intervention have been studied, but there are no recommendations about standardized rules and methods to deliver information and education, or to evaluate the results of TPE. The main limit of TPE is the lack of results for adherence to long-term lifestyle modifications.

CONCLUSION

The efficacy of TE in cardiovascular diseases could be improved by optimal collaboration between acute cardiac units and cardiac rehabilitation units. The use of standardized rules and methods to deliver information and education and to assess their effects could reinforce this collaboration. Networks for medical and paramedical TPE follow-up in tertiary prevention could be organized to improve long-term results.

Assessing recent smoking status by measuring exhaled carbon monoxide levels

BACKGROUND

Cigarette smoke causes both acute and chronic changes of the immune system. Excluding recent smoking is therefore important in clinical studies with chronic inflammation as primary focus. In this context, it is common to ask the study subjects to refrain from smoking within a certain time frame prior to sampling. The duration of the smoking cessation is typically from midnight the evening before, i.e. 8 hours from sampling. As it has been shown that a proportion of current smokers underestimates or denies smoking, objective assessment of recent smoking status is of great importance. Our aim was to extend the use of exhaled carbon monoxide (CO(breath)), a well-established method for separating smokers from non-smokers, to assessment of recent smoking status.

METHODS AND FINDINGS

The time course of CO(breath) decline was investigated by hourly measurements during one day on non-symptomatic smokers and non-smokers (6+7), as well as by measurements on three separate occasions on non-smokers (n = 29), smokers with normal lung function (n = 38) and smokers with chronic obstructive pulmonary disease (n = 19) participating in a clinical study. We used regression analysis to model the decay, and receiver operator characteristics analysis for evaluation of model performance. The decline was described as a mono-exponential decay (r(2) = 0.7) with a half-life of 4.5 hours. CO decline rate depends on initial CO levels, and by necessity a generic cut-off is therefore crude as initial CO(breath) varies a lot between individuals. However, a cut-off level of 12 ppm could classify recent smokers from smokers having refrained from smoking during the past 8 hours with a specificity of 94% and a sensitivity of 90%.

CONCLUSIONS

We hereby describe a method for classifying recent smokers from smokers having refrained from smoking for >8 hours that is easy to implement in a clinical setting.