Nicotine dependence treatment: perceived health status improvement with 1-year continuous smoking abstinence

Smoking cessation for improving mental health

BACKGROUND

There is a common perception that smoking generally helps people to manage stress, and may be a form of 'self-medication' in people with mental health conditions. However, there are biologically plausible reasons why smoking may worsen mental health through neuroadaptations arising from chronic smoking, leading to frequent nicotine withdrawal symptoms (e.g. anxiety, depression, irritability), in which case smoking cessation may help to improve rather than worsen mental health.

OBJECTIVES

To examine the association between tobacco smoking cessation and change in mental health.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, and the trial registries clinicaltrials.gov and the International Clinical Trials Registry Platform, from 14 April 2012 to 07 January 2020. These were updated searches of a previously-conducted non-Cochrane review where searches were conducted from database inception to 13 April 2012.  SELECTION CRITERIA: We included controlled before-after studies, including randomised controlled trials (RCTs) analysed by smoking status at follow-up, and longitudinal cohort studies. In order to be eligible for inclusion studies had to recruit adults who smoked tobacco, and assess whether they quit or continued smoking during the study. They also had to measure a mental health outcome at baseline and at least six weeks later.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Our primary outcomes were change in depression symptoms, anxiety symptoms or mixed anxiety and depression symptoms between baseline and follow-up. Secondary outcomes  included change in symptoms of stress, psychological quality of life, positive affect, and social impact or social quality of life, as well as new incidence of depression, anxiety, or mixed anxiety and depression disorders. We assessed the risk of bias for the primary outcomes using a modified ROBINS-I tool.  For change in mental health outcomes, we calculated the pooled standardised mean difference (SMD) and 95% confidence interval (95% CI) for the difference in change in mental health from baseline to follow-up between those who had quit smoking and those who had continued to smoke. For the incidence of psychological disorders, we calculated odds ratios (ORs) and 95% CIs. For all meta-analyses we used a generic inverse variance random-effects model and quantified statistical heterogeneity using I2. We conducted subgroup analyses to investigate any differences in associations between sub-populations, i.e. unselected people with mental illness, people with physical chronic diseases. We assessed the certainty of evidence for our primary outcomes (depression, anxiety, and mixed depression and anxiety) and our secondary social impact outcome using the eight GRADE considerations relevant to non-randomised studies (risk of bias, inconsistency, imprecision, indirectness, publication bias, magnitude of the effect, the influence of all plausible residual confounding, the presence of a dose-response gradient).

MAIN RESULTS

We included 102 studies representing over 169,500 participants. Sixty-two of these were identified in the updated search for this review and 40 were included in the original version of the review.  Sixty-three studies provided data on change in mental health, 10 were included in meta-analyses of incidence of mental health disorders, and 31 were synthesised narratively.  For all primary outcomes, smoking cessation was associated with an improvement in mental health symptoms compared with continuing to smoke: anxiety symptoms (SMD -0.28, 95% CI -0.43 to -0.13; 15 studies, 3141 participants; I2 = 69%; low-certainty evidence); depression symptoms: (SMD -0.30, 95% CI -0.39 to -0.21; 34 studies, 7156 participants; I2 = 69%' very low-certainty evidence);  mixed anxiety and depression symptoms (SMD -0.31, 95% CI -0.40 to -0.22; 8 studies, 2829 participants; I2 = 0%; moderate certainty evidence).  These findings were robust to preplanned sensitivity analyses, and subgroup analysis generally did not produce evidence of differences in the effect size among subpopulations or based on methodological characteristics. All studies were deemed to be at serious risk of bias due to possible time-varying confounding, and three studies measuring depression symptoms were judged to be at critical risk of bias overall. There was also some evidence of funnel plot asymmetry. For these reasons, we rated our certainty in the estimates for anxiety as low, for depression as very low, and for mixed anxiety and depression as moderate. For the secondary outcomes, smoking cessation was associated with an improvement in symptoms of stress (SMD -0.19, 95% CI -0.34 to -0.04; 4 studies, 1792 participants; I2 = 50%), positive affect (SMD 0.22, 95% CI 0.11 to 0.33; 13 studies, 4880 participants; I2 = 75%), and psychological quality of life (SMD 0.11, 95% CI 0.06 to 0.16; 19 studies, 18,034 participants; I2 = 42%). There was also evidence that smoking cessation was not associated with a reduction in social quality of life, with the confidence interval incorporating the possibility of a small improvement (SMD 0.03, 95% CI 0.00 to 0.06; 9 studies, 14,673 participants; I2 = 0%). The incidence of new mixed anxiety and depression was lower in people who stopped smoking compared with those who continued (OR 0.76, 95% CI 0.66 to 0.86; 3 studies, 8685 participants; I2 = 57%), as was the incidence of anxiety disorder (OR 0.61, 95% CI 0.34 to 1.12; 2 studies, 2293 participants; I2 = 46%). We deemed it inappropriate to present a pooled estimate for the incidence of new cases of clinical depression, as there was high statistical heterogeneity (I2 = 87%).

AUTHORS' CONCLUSIONS

Taken together, these data provide evidence that mental health does not worsen as a result of quitting smoking, and very low- to moderate-certainty evidence that smoking cessation is associated with small to moderate improvements in mental health.  These improvements are seen in both unselected samples and in subpopulations, including people diagnosed with mental health conditions. Additional studies that use more advanced methods to overcome time-varying confounding would strengthen the evidence in this area.

Factors Associated with Successful Smoking Cessation According to Age Group: Findings of an 11-Year Korea National Survey

Previous studies suggest that factors related to smoking cessation may vary with age. This study examined the factors affecting smoking cessation by age among Korean adult male smokers using data from the Korea National Health and Nutrition Examination Survey from 2007 to 2018 (excluding 2013). Logistic regression analyses were used to investigate various factors associated with smoking cessation in three different age groups. Out of a total of 15,492 individuals, 31.5% of the 3523 individuals aged 19-39 years (young adult), 54.7% of the 7390 individuals aged 40-64 years (middle-aged), and 78.6% of the 4589 individuals aged ≥65 years (older adults) succeeded in quitting. In the young adult and middle-aged groups, being married was associated with successful quitting, and lifetime smoking was associated with unsuccessful quitting. Willpower and several comorbidities were related to successful cessation in the middle-aged and older adult groups. Skipping any meal, which suggests unhealthy behavior, was negatively related to quitting in the young adult group. We observed that factors associated with smoking cessation success or failure differed by age, which should be considered when developing smoking cessation policies and programs.

Improvements in health-related quality of life among smokers who quit after hospitalization

Few rigorous longitudinal assessments have examined health-related quality of life (HRQoL) changes after smoking cessation, especially among recently-hospitalized smokers. We compared the change in HRQoL between those who did or did not quit smoking 6 months after hospital discharge. Participants were 1357 smokers recruited for a cessation trial between 2012 and 2014 while hospitalized at two hospitals in Massachusetts and one in Pennsylvania. Cessation was defined as biochemically confirmed 7-day point prevalence abstinence at 6 months or as self-reported continuous abstinence at 1, 3, or 6 months post discharge. HRQoL measures included a single-item global health measure (SF1); the Patient Health Questionnaire for Depression and Anxiety (PHQ-4) screening tool for psychological distress; and the EQ-5D-5L health utilities measure. Multivariable models controlled for age, sex, race, education, insurance, study site, study arm, discharge diagnoses, and baseline HRQoL. Improvements in HRQoL were evident in the first month after discharge among those achieving abstinence compared to continuing smokers. At 6 months post-discharge, those with biochemically confirmed cessation were 30% more likely to report at least good health by the SF1 (aRR 95% CI 1.14-1.45), 19% less likely to screen positive for psychological distress (aRR, 95% CI 0.68-0.93), and had EQ-5D-5L health utility scores 0.05 points (95% CI 0.02-0.08) higher than continuing smokers. Results were similar when assessed as a function of self-reported cessation. Hospital-initiated smoking cessation is associated with rapid statistically and clinically significant improvements in a range of HRQoL measures, providing an additional tool clinicians and health systems could use to encourage smoking cessation.

Do tobacco smoking and illicit drug/alcohol dependence increase the risk of mental disorders among men? Evidence from a national urban Bangladeshi sample

PURPOSE

This study sought to examine the relationship between tobacco consumption or illicit drug/alcohol use and mental disorders.

DESIGN AND METHODS

We used data from the 2006 Bangladesh Urban Health Survey. The analyses were based on the responses of 13,819 men aged 15-59 years.

FINDINGS

Smoking of any type was associated with an increased risk of mental disorders as were current cigarette smoking, heavy cigarette, or bidi smoking status. Ever and current use of illicit drugs/alcohol was also associated with a greater risk of mental disorders among the participants.

PRACTICE IMPLICATIONS

The present findings indicate that preventing tobacco smoking and illicit drug/alcohol dependence may help reduce the burden caused by mental disorders among urban Bangladeshi men. Reducing the risk of common mental health problems may also help reduce the prevalence of tobacco consumption and illicit drug/alcohol dependence.

Impact of smoking cessation therapy on health-related quality of life

BACKGROUND

Smoking is associated with poor health-related quality of life (HRQL); however, there are few data regarding effects of smoking cessation treatment on HRQL. The purpose of this study was to describe changes in HRQL after smoking cessation treatment and to elucidate factors influencing this improvement in HRQL.

SETTING

Smoking cessation clinic at a 358-bed community teaching hospital in Japan.

METHODS

We conducted a prospective cohort study of cigarette smokers who participated in a 3-month smoking cessation programme. HRQL was assessed at baseline and at the end of the programme using the St. George's Respiratory Questionnaire (SGRQ). The abstinence was subjected to verification by an exhaled CO level of ≤10 ppm.

RESULTS

Of 570 participants in the programme, 277 (mean age: 60.9±12.2 y, male/female=180/97) were eligible; excluded were 277 participants who dropped out of the programme and 16 for whom SGRQs were not available or were incomplete. Initial prescribed pharmacotherapy was transdermal nicotine patches in 160 participants and varenicline in 117. At 12 weeks, SGRQ scores improved significantly as follows (mean±SD): Δ symptoms score, -5.7±16.0; Δ activity score, -4.4±18.3; Δ impact score, -5.3±13.5 and Δ total score, -5.1±12.2 (p<0.0001 in all cases). There were no significant differences in changes in SGRQ scores between quitters (n=183) and continuous smokers (n=94). In a multivariate analysis, only the average nicotine addiction level according to the Tobacco Dependence Screener test was associated with a clinically significant improvement in the SGRQ (OR 1.35 (95% CI 1.15 to 1.59)). Marked reduction in number of cigarettes smoked with a corresponding low median exhaled CO level of 7 ppm in continuous smokers following therapy was observed.

CONCLUSIONS

Smoking cessation treatment improved HRQL regardless of quit status. Baseline nicotine addiction level was predictive of that improvement.

Assessment of perceived health status among primary care patients in Southern Italy: findings from a cross-sectional survey

Background

The primary aim of this study was to measure HRQOL of primary care patients in one of the poorest areas of Italy, using SF-12, whereas the secondary aim was to identify subgroups of this population, according to socio-demographics, clinical characteristics, behavioural risk factors, and health services utilization, that manifest poorer HRQOL. These data may be helpful to policy makers to implement health care policies and social interventions for improving HRQOL.

Methods

A cross-sectional survey was conducted in Southern Italy on primary care patients aged 18 and over. SF-12 was used to measure perceived health status. Physical component and mental summary scores were obtained. We performed univariate and multivariate analysis to evaluate eventual significant differences of mean PCS-12 and MCS-12 according to various characteristics (demographics, presence of chronic diseases, behavioral risk factors, and utilization of health services).

Results

Of the 1467 participating in our survey, more than one third evaluated their health as unsatisfactory, noted significant limitations and reported problems on all SF-12-scales. Physical and mental summary scores showed an overall mean of 45.9 (SD ± 10.8) and 44.9 (SD ± 11.6), respectively. Statistical analysis showed significant differences in perceived health status by socio-demographic characteristics, such as gender, age, education level and employment status, by behavioral risk factors, chronic diseases and health services utilization.

Conclusions

Our findings seem to indicate that primary care patients in Southern Italy have a poor HRQOL and this perception is even poorer in subgroups of the population, according to several sociodemographic, clinical characteristics, and behavioural risk factors. These results may have significant implications for health care policymakers, since they emphasize the need of developing effective and targeted strategies to improve HRQOL in Southern Italy.

Spiritual well-being in lung cancer survivors

PURPOSE

Spiritual well-being (SWB) among lung cancer survivors has not been well-delineated. Additionally, little is known about how SWB is affected over the trajectory of the disease process. The aims of this study were to examine the SWB of individuals with a diagnosis of lung cancer, to assess the stability of SWB over time, and to identify the factors associated with SWB.

METHODS

A prospective cohort of patients with lung cancer first seen at the Mayo Clinic over a 10-year period of time was included in this study. Study entry was at the time of diagnosis or referral to the Mayo Clinic, and participation involved annual survey using the Functional Assessment in Chronic Illness Therapy-Spiritual Well-being, Medical Outcome Short Form 8, and Quality of Life (QOL) Linear Analog Scale Assessment. Associations were explored using Fisher's exact test, chi-squared test, Kruskal-Wallis test, and Spearman correlations. Linear regression was used to explore multivariate relationships.

RESULTS

There were 1,578 participants over a 10-year period of time. Group SWB scores were relatively high and stable over a 10-year period of time ([Formula: see text], standard deviation = 14.47-18.46, possible scale of 0-100). However, individual scores varied widely across almost the entire scale (2.1-100) and revealed a chaotic trajectory for SWB. Males, current smokers, and those with higher pack-years experienced lower SWB compared to females, nonsmokers, and those with lower pack-years (p < 0.0001, 0.0455, and 0.0004, respectively). SWB was strongly associated with overall QOL.

CONCLUSIONS

SWB is an individualistic experience that can change dramatically over time for cancer survivors. Ongoing assessments are important.

Smoking characteristics of adults with selected lifetime mental illnesses: results from the 2007 National Health Interview Survey

OBJECTIVES

We estimated smoking prevalence, frequency, intensity, and cessation attempts among US adults with selected diagnosed lifetime mental illnesses.

METHODS

We used data from the 2007 National Health Interview Survey on 23 393 noninstitutionalized US adults to obtain age-adjusted estimates of smoking prevalence, frequency, intensity, and cessation attempts for adults screened as having serious psychological distress and persons self-reporting bipolar disorder, schizophrenia, attention deficit disorder or hyperactivity, dementia, or phobias or fears.

RESULTS

The age-adjusted smoking prevalence of adults with mental illness or serious psychological distress ranged from 34.3% (phobias or fears) to 59.1% (schizophrenia) compared with 18.3% of adults with no such illness. Smoking prevalence increased with the number of comorbid mental illnesses. Cessation attempts among persons with diagnosed mental illness or serious psychological distress were comparable to attempts among adults without mental illnesses or distress; however, lower quit ratios were observed among adults with these diagnoses, indicating lower success in quitting.

CONCLUSIONS

The prevalence of current smoking was higher among persons with mental illnesses than among adults without mental illnesses. Our findings stress the need for prevention and cessation efforts targeting adults with mental illnesses.

Smoking cessation: an integral part of lung cancer treatment

Lung cancer is the leading cause of cancer death in the US. About 50% of lung cancer patients are current smokers at the time of diagnosis and up to 83% continue to smoke after diagnosis. A recent study suggests that people who continue to smoke after a diagnosis of early-stage lung cancer almost double their risk of dying. Despite a growing body of evidence that continued smoking by patients after a lung cancer diagnosis is linked with less effective treatment and a poorer prognosis, the belief prevails that treating tobacco dependence is useless. With improved cancer treatments and survival rates, smoking cessation among lung cancer patients has become increasingly important. There is a pressing need to clarify the role of smoking cessation in the care of lung cancer patients.

OBJECTIVE

This paper will report on the benefits of smoking cessation for lung cancer patients and the elements of smoking cessation treatment, with consideration of tailoring to the needs of lung cancer patients.

RESULTS

Given the significant benefits of smoking cessation and that tobacco dependence remains a challenge for many lung cancer patients, cancer care providers need to offer full support and intensive treatment with a smoking cessation program that is tailored to lung cancer patients' specific needs.

CONCLUSION

A tobacco dependence treatment plan for lung cancer patients is provided.

The effect of stopping smoking on perceived stress levels

AIMS

Many smokers believe that smoking helps them to cope with stress, and that stopping smoking would deprive them of an effective stress management tool. Changes in stress levels following long-term smoking cessation are not well mapped. This longitudinal project was designed to provide more robust data on post-cessation changes in perceived stress levels by following a cohort of smokers admitted to hospital after myocardial infarction (MI) or for coronary artery bypass (CAB) surgery, as such patients typically achieve higher continuous abstinence rates than other comparable samples.

DESIGN

A total of 469 smokers hospitalized after MI or CAB surgery and wanting to stop smoking were seen in the hospital and completed 1-year follow-ups. Ratings of helpfulness of smoking in managing stress at baseline, smoking status (validated by salivary cotinine concentration) and ratings of perceived stress at baseline and at 1-year follow-up were collected.

FINDINGS

Of the patients, 41% (n = 194) maintained abstinence for 1 year. Future abstainers and future smokers did not differ in baseline stress levels or in their perception of coping properties of smoking. However, abstainers recorded a significantly larger decrease in perceived stress than continuing smokers, and the result held when possible confounding factors were controlled for (P < 0.001).

CONCLUSIONS

In highly dependent smokers who report that smoking helps them cope with stress, smoking cessation is associated with lowering of stress. Whatever immediate effects smoking may have on perceived stress, overall it may generate or aggravate negative emotional states. The results provide reassurance to smokers worried that stopping smoking may deprive them of a valuable coping resource.

Cost-effectiveness of a smoking cessation program implemented at the time of surgery for lung cancer

BACKGROUND

Many patients are active smokers at the time of a diagnosis of surgically resectable lung cancer. Perioperative smoking cessation is associated with improved survival, but the cost-effectiveness of a smoking cessation program initiated immediately before surgery is unknown.

METHODS

We developed a decision analytic Markov model to evaluate the incremental cost-effectiveness of a formal smoking cessation program. The parameter estimates were taken from the available literature. The model included the cost and effectiveness of the smoking cessation program, cost and incidence of perioperative complications, postoperative mortality, and utility measured in quality adjusted life years (QALY). Dollars per QALY and life year were calculated and one-way sensitivity analyses were performed.

RESULTS

The cost/QALY and cost/life year were $16,415 and $45,629 at 1 year after surgery and $2609 and $2703 at 5 years, respectively. Most sensitivity analyses showed the 1 year postsurgery cost/QALY estimates were less than $50,000, and all were less than $12,000 at 5 years. Cost-effectiveness estimates were most sensitive to the frequency of perioperative complications and the estimated short-term utility estimates.

CONCLUSION

A smoking cessation program initiated before surgical lung resection is cost-effective at both 1 and 5 years postsurgery. Providers should encourage patients who are still smoking to engage in formal smoking cessation programs.

The impact of smoking cessation on patient quality of life

OBJECTIVE: To evaluate changes in health-related quality of life (HRQoL) after twelve months of smoking cessation. METHODS: This was a prospective study to evaluate the effectiveness of a smoking cessation program on the quality of life of 60 self-referred subjects, at a public hospital, during the period of August 2006 to December 2007. The program consisted of 2-h group sessions once a week during the first month and then every 15 days over six months, followed by monthly phone contacts for another six months. The treatment was based on behavior modification and the use of bupropion in combination with nicotinic replacement therapy. Abstinence was verified by exhaled CO measurements. Patient HRQoL was quantified using the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) questionnaire. Differences in quality of life scores between quitters and non-quitters at twelve months after the initial intervention were evaluated using analysis of covariance with baseline characteristics as covariates. RESULTS: Self-reported quality of life scores were significantly higher among the 40 quitters than among the 20 non-quitters. The following SF-36 domains were most affected: role-emotional (p = 0.008); general health (p = 0.006); vitality (p < 0.001); and mental health (p = 0.002). At twelve months after the smoking cessation intervention, the SF-36 mental component and physical component summary scores were higher among quitters than among non-quitters (p = 0.004 and p = 0.001, respectively). CONCLUSIONS: Our findings illustrate that smoking abstinence is related to better HRQoL, especially in aspects of mental health.

Effect of smoking status on productivity loss

OBJECTIVE

The objective of this study was to describe health-related productivity losses in nonsmokers, former smokers, and current smokers using a large, cross-sectional database of U.S. employees.

METHODS

Volunteers completed the Wellness Inventory, an instrument measuring productivity losses related to 11 health conditions affecting employee health. Results are aggregated, dollarized, and reported by smoking group.

RESULTS

Current smokers missed more days of work and experienced more unproductive time at work compared with former smokers and nonsmokers. The average annual cost for lost productivity for nonsmokers was 2623 dollars/year compared with 3246 dollars/year for former smokers and 4430 dollars/year for current smokers. More than half the costs were due to unproductive time at work.

CONCLUSION

Current smokers incurred the highest productivity losses, which translated into higher costs to employers for current smokers. Costs were lower for former smokers and nonsmokers.

Smoking, smoking cessation, and risk of cardiovascular disease

Cigarette smoking increases the risk of atherothrombotic clinical events such as myocardial infarction and the effect is dose dependent for persons who continue to smoke. Reductions in smoking habit and smoking cessation are important ways to improve cardiovascular risk and favorably affect primary and secondary prevention of clinical disease. Therapeutic methods to improve smoking reduction and cessation include nicotine replacement, behavioral interventions, and medications (bupropion, clonidine). Improved cessation rates are under active study and include behavioral methods, targeting smokers immediately after myocardial infarction, consideration of depression in smokers, pharmacogenomics to identify persons who may respond more favorably to specific interventions, and newer medications that affect endocannabinoid receptors.