Reasons to quit and barriers to quitting smoking in US young adults

Implicit Theories of Smoking and Intention to Quit: A Serial Mediation Model

INTRODUCTION

There is growing evidence that implicit theories of smoking (ITS)-whether smokers perceive smoking behavior as malleable or fixed-are significant predictors of quitting intentions.

AIMS AND METHODS

This cross-sectional study aims to investigate the underlying mechanisms of implicit theories on smoking in predicting smokers' intentions to quit. We conducted multiple linear regression with quitting intentions as the dependent variable, ITS as the independent variable, and sociodemographic variables, quitting attempts in the past year, and receiving quitting advice in the past 12 months as the covariates. The mediating role of consideration of future consequences (CFC) and self-efficacy in the relationship between implicit theories of smoking and quitting intentions was evaluated by mediation analyses.

RESULTS

A total of 510 smokers were included in the final analyses. Smokers holding a higher incremental theory of smoking reported a higher likelihood of considering future consequences (β = 0.289, p < .001) and a weaker possibility of considering immediate results (β = -0.317, p < .001), which, in turn, enhanced their quitting self-efficacy and then led to stronger intentions to quit smoking (β = 0.261, p < .001).

CONCLUSIONS

The current study enriched our understanding of the underlying mechanisms that connect smokers' ITS and their likelihood of smoking cessation such that higher incremental theories of smoking predict stronger intention to quit smoking, and the effect was serially mediated by smokers' likelihood of considering future consequences of their behavior and their perceived self-efficacy for smoking cessation.

IMPLICATIONS

This study indicated the mediating role of CFC and self-efficacy for smoking cessation on the relationship between the ITS and quitting intentions. These two psychological factors and the pathways may be important points for understanding the model of implicit theories for smoking and improving the effectiveness of implicit theories-based intervention on smoking cessation.

An overview of systematic reviews on predictors of smoking cessation among young people

Understanding the factors that influence smoking cessation among young people is crucial for planning targeted cessation approaches. The objective of this review was to comprehensively summarize evidence for predictors of different smoking cessation related behaviors among young people from currently available systematic reviews. We searched six databases and reference lists of the included articles for studies published up to October 20, 2023. All systematic reviews summarizing predictors of intention to quit smoking, quit attempts, or smoking abstinence among people aged 10-35 years were included. We excluded reviews on effectiveness of smoking cessation intervention; smoking prevention and other smoking behaviors; cessation of other tobacco products use, dual use, and polysubstance use. We categorized the identified predictors into 5 different categories for 3 overlapping age groups. JBI critical appraisal tool and GRADE-CERqual approach were used for quality and certainty assessment respectively. A total of 11 systematic reviews were included in this study; all summarized predictors of smoking abstinence/quit attempts and two also identified predictors of intention to quit smoking. Seven reviews had satisfactory critical appraisal score and there was minimal overlapping between the reviews. We found 4 'possible' predictors of intention to quit smoking and 119 predictors of smoking abstinence/quit attempts. Most of these 119 predictors were applicable for ~10-29 years age group. We had moderate confidence on the 'probable', 'possible', 'insufficient evidence', and 'inconsistent direction' predictors and low confidence on the 'probably unrelated' factors. The 'probable' predictors include a wide variety of socio-demographic factors, nicotine dependence, mental health, attitudes, behavioral and psychological factors, peer and family related factors, and jurisdictional policies. These predictors can guide improvement of existing smoking cessation interventions or planning of new targeted intervention programs. Other predictors as well as predictors of intention to quit smoking need to be further investigated among adolescents and young adults separately.

Perceptions of health warnings on cigarette sticks among the adult population in Al-Madinah, Saudi Arabia: A cross-sectional survey

INTRODUCTION

Health warnings on cigarette sticks are emerging as a tool to control tobacco consumption; hence, understanding how they are perceived is valuable in determining their effectiveness. Our study aimed to evaluate the perception of health-related messages and warnings on individual cigarette sticks. It also aimed to evaluate the perceptions of the effectiveness of cigarette packaging warnings and the acceptance level for the inclusion of health warnings on cigarette sticks.

METHODS

This cross-sectional survey was conducted on 285 individuals in Al-Madinah, Saudi Arabia. The survey was distributed online using a non-probability convenience sampling technique. The chi-squared test and logistic regression analysis were used to determine the association of sociodemographic characteristics and smoking-related variables with participants' perceptions of health warnings on cigarette sticks and packaging. The responses were also assessed qualitatively using conceptual content analysis.

RESULTS

In all, 18.6% of participants perceived that the package warnings were either 'quite effective' or 'very effective' in prompting smokers to quit. For health warnings on cigarette sticks, 28.1% of participants perceived that the theme of statistics on mortality was either 'quite effective' or 'very effective' in prompting smokers to quit, compared to 35.0 % for the theme of social and financial consequences. Respondents who had secondary education and lower were almost two times more likely to support the inclusion of health warnings than those who had a university education and higher (OR=1.9; 95% CI: 1.02-3.7, p=0.042). Most of the comments were positive for the inclusion of health warnings on cigarette sticks.

CONCLUSIONS

Most participants perceived that package warnings were ineffective, but warnings on cigarette sticks were effective methods of dissuasion of cigarette use. Smokers were almost twice as likely to perceive as effective supportive messages to quit than non-smokers. The majority of participants 'agreed' or 'strongly agreed' to the inclusion of health warnings on cigarette sticks.

COVID-19-related stress response among adult females: Relevance of sociodemographics, health-related behaviors and COVID-19 contact

Women were more affected than men during the COVID-19 pandemic. This study aimed to investigate COVID-19-related stress response in adult women and its association with the relevant socioeconomic, lifestyle and COVID-19-related factors. This research was carried out in eight randomly chosen cities from September 2020 to October 2021. To examine stress, we distributed the COVID Stress Scales (CSS) and the Perceived Stress Scale (PSS). Women also fulfilled a general socio-epidemiologic questionnaire. The study included 1,264 women. Most women were healthy, highly educated, employed, married, nonsmokers who consumed alcohol. The average total CSS score suggested a relatively low COVID-19 related stress), while 1.7% of women had CSS ≥ 100. The mean PSS was around the mid-point value of the scale. Older women, who were not in a relationship, didn't smoke, didn't drink alcohol, but used immune boosters, had chronic illnesses and reported losing money during the pandemic had higher CSS scores. A higher level of stress was also experienced by women exposed to the intense reporting about COVID-19, had contact with COVID-19 positive people or took care of COVID-19 positive family members. In this sample of predominantly highly educated women few women experienced very high stress level, probably due to the study timing (after the initial wave) when the pandemic saw attenuated stress levels. To relieve women from stress, structural organization and planning in terms of health care delivery, offsetting economic losses, controlled information dissemination and psychological support for women are needed.

Motivations for continued tobacco smoking and reasons for quitting among youths in Wakiso district, Uganda: a qualitative study

BACKGROUND

Efforts have been invested towards cessation of tobacco use among youths aged 18-35 years, however, motivators for continued tobacco smoking and reasons for quitting are limited in Ugandan settings. Therefore, this study aimed to explore motivations for continued tobacco smoking and reasons for quitting in Wakiso district Uganda.

METHODS

This study used explanatory sequential method. Data from a Population-based survey collected from October 2019 to September 2020 was used to select participants for this qualitative study. Twenty-three in-depths interviews were conducted from July to October 2021 among youths (18-35years old) who reported continued tobacco use and those who quit. Data were analyzed using a team-based thematic content approach with the help of NVivo.

RESULTS

Data was collected from a total of twenty three participants, fourteen were tobacco quitters and nine were current tobacco smokers. Recurrent habit, desire to complement the use of other drugs, peer pressure, using smoking as a replacement for alcohol consumption, low tobacco prices, smoking as a tradition were reported as motivators for continued tobacco smoking. However, reported reasons for quitting smoking by youths included; packaging health warnings, school based prevention programs, fear of associated health risks due to tobacco use, embarrassment from family members.

CONCLUSION

Targeted, and tailored tobacco prevention counselling through family support programs, intensified health education on the risks of smoking, and implementing stronger health warnings on tobacco packaging can be employed to reduce or stop tobacco use among urban youth.

Smoking cessation and relapse-prevention interventions tailored for expectant and new fathers: protocol of a systematic review and network meta-analysis

INTRODUCTION

Exposure of pregnant women and newborns to secondhand smoke (SHS) can lead to adverse maternal and neonatal health outcomes. Among expectant and new fathers, who are the main source of SHS exposure for pregnant women, new mothers and babies, smoking rates remain high. A partner's pregnancy potentially constitutes a critical period where expectant and new fathers are motivated to quit smoking. However, there is no consensus on the optimal form and delivery of smoking cessation and relapse-prevention interventions. We present a systematic review and network meta-analysis protocol that aims to synthesise and evaluate the effectiveness of smoking cessation and relapse-prevention interventions tailored for this population.

METHODS AND ANALYSIS

To identify relevant studies, we will conduct a comprehensive search, in English and Chinese, of 10 electronic databases. The review will include randomised and quasi-randomised controlled trials that compare behavioural interventions (tailored and non-tailored) with/without the addition of pharmacotherapy with usual care, a minimal or placebo control for assisting expectant and new fathers to quit smoking and prevent smoking relapse. The primary outcome of interest is the self-reported and/or biochemically verified smoking abstinence at ≥1-month follow-up. Two reviewers will independently screen, select and extract relevant studies, and perform a quality assessment. Disagreements will be resolved by a consensus or third-party adjudication. The Cochrane Risk of Bias tool V.2 will be used to assess the risk of bias in the included studies. We will obtain the results of the systematic review through pooled quantitative analyses using a network meta-analysis. Sensitivity and subgroup analyses will be performed.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review of published data. The findings will be disseminated via peer-reviewed publication.

PROSPERO REGISTRATION NUMBER

CRD42022340617.

Mobile Phone-Based Interventions for Smoking Cessation Among Young People: Systematic Review and Meta-Analysis

Background

Mobile phone-based cessation interventions have emerged as a promising alternative for smoking cessation, while evidence of the efficacy of mobile phone-based smoking cessation programs among young people is mixed.

Objective

This study aimed to determine the efficacy of mobile phone-based interventions compared to usual practice or assessment-only controls on smoking cessation in young people.

Methods

In this systematic review and meta-analysis, we searched Cochrane Library, Embase, PubMed, and Web of Science on March 8, 2023. We included randomized controlled trials that examined the efficacy of mobile phone-based interventions on smoking cessation in young people (age ≤30 years). The risk of bias was assessed with Cochrane Risk of Bias 2.

Results

A total of 13 eligible studies, comprising 27,240 participants, were included in this analysis. The age range of the participants was between 16 and 30 years. Nine studies were SMS text messaging interventions, and 4 studies were app-based interventions. The duration of the smoking cessation intervention varied from 5 days to 6 months. The included studies were conducted in the following countries: the United States, China, Sweden, Canada, Switzerland, and Thailand. The meta-analysis revealed that SMS text messaging interventions significantly improved continuous abstinence rates compared to inactive control conditions (risk ratio [RR] 1.51, 95% CI 1.24-1.84). The subgroup analysis showed pooled RRs of 1.90 (95% CI 1.29-2.81), 1.64 (95% CI 1.23-2.18), and 1.35 (95% CI 1.04-1.76) for continuous abstinence at the 1-, 3-, and 6- month follow-up, respectively. Pooling across 7 studies, SMS text messaging interventions showed efficacy in promoting 7-day point prevalence abstinence (PPA), with an RR of 1.83 (95% CI 1.34-2.48). The subgroup analysis demonstrated a significant impact at the 1- and 3-month follow-ups, with pooled RRs of 1.72 (95% CI 1.13-2.63) and 2.54 (95% CI 2.05-3.14), respectively, compared to inactive control conditions. However, at the 6-month follow-up, the efficacy of SMS text messaging interventions in promoting 7-day PPA was not statistically significant (RR 1.45, 95% CI 0.92-2.28). In contrast, app-based interventions did not show significant efficacy in promoting continuous abstinence or 7-day PPA. However, it is important to note that the evidence for app-based interventions was limited.

Conclusions

SMS text messaging-based smoking cessation interventions compared to inactive controls were associated with abstinence among young people and could be considered a viable option for smoking cessation in this population. More research is needed on smoking cessation apps, especially apps that target young people. Future research should focus on identifying the most effective mobile phone-based cessation approaches and on developing strategies to increase their uptake and intention.

Reasons to decrease or stop nicotine and tobacco use among adults and association with MPOWER scores in twenty-one middle- and high-income countries, 2019-2020

INTRODUCTION

This study examined reasons why people planned to reduce or stop tobacco consumption and their relationship with MPOWER scores, adjusting for sociodemographic, cultural, and economic factors.

METHODS

Data used were Euromonitor International's Voice of the Consumer: Nicotine Survey 2019-2020, World Bank's country income and WHO's MPOWER policy scores. Analytical sample included 21913 adults of legal smoking age in 21 middle- and high-income countries who used nicotine and tobacco products and planned to reduce or stop their consumption in the next 12 months. Poisson regression models with robust error variance, adjusted for sociodemographic and tobacco use covariables, generated adjusted risk ratios (ARRs) of selecting a certain reason to reduce tobacco consumption dependent on continuous MPOWER scores.

RESULTS

Main reasons to reduce or stop tobacco consumption were improving health (85%), saving money (65%), pressure from family (19%), and using another substance instead (4%). Country variation was observed by MPOWER scores. Positive associations were found between some MPOWER scores and reasons to reduce or stop tobacco consumption: enforcing bans on tobacco advertising and using another substance (ARR=1.28; 95% CI: 1.11-1.47); warning about dangers of tobacco and saving money (ARR=1.25; 95% CI: 1.19-1.32); offering help to quit tobacco and using another substance (ARR=1.26; 95% CI: 1.10-1.45) or family pressure (ARR=1.11; 95% CI: 1.04-1.17); anti-tobacco campaigns and using another substance (ARR=1.15; 95% CI: 1.08-1.23); and raising taxes and saving money (ARR=1.11; 95% CI: 1.09-1.13).

CONCLUSIONS

MPOWER scores are associated with reported reasons to quit tobacco including to improve health, save money, respond to family pressure or use another substance instead.

"I'm both smoking and vaping": a longitudinal qualitative study of US young adults who tried to quit smoking cigarettes by using electronic cigarettes

OBJECTIVE

To describe how young adults use electronic cigarettes (electronic nicotine delivery systems (ENDS)) for smoking cessation and reasons why they may or may not successfully quit smoking.

METHODS

Longitudinal qualitative data were collected annually from 2017 to 2019 for 25 young adult tobacco users (aged 18-29 years) in California (USA) who used ENDS to quit/reduce smoking. Thematic and trajectory analyses were used to identify key within-person and between-person changes in tobacco/nicotine use over time.

RESULTS

Five types of tobacco use transition were identified among baseline dual users of cigarettes and ENDS: sustained dual use without reduced smoking (n=8), transition to exclusive daily ENDS use (n=6), sustained dual use with reduced smoking (n=5), transition back to exclusive smoking (n=4) and transition to neither smoking nor vaping (n=2). Participants' ENDS use behaviour varied over time in terms of vaping quantity and device characteristics (eg, changing nicotine concentrations/flavours, switching between multiple devices). Three themes that related to successfully replacing cigarettes with ENDS were perceived positive physical effects, perceived satisfaction and enjoyment and context changes. Four themes for unsuccessful replacement were perceived negative physical discomforts, perceived addictiveness and harm, unsatisfactory substitution for cigarettes and device malfunction.

CONCLUSIONS

Young adults' experiences with using ENDS as a smoking cessation aid were highly variable. Adequate nicotine delivery and perceived safety and benefits contributed to successfully reducing or quitting cigarettes. Providing behavioural counselling and standardising ENDS products may enhance cessation for young adults.

A novel stress-based intervention reduces cigarette use in non-treatment seeking smokers

Tobacco use is the leading cause of preventable mortality worldwide. Since current smoking cessation aids show only modest efficacy, new interventions are needed. Given the evidence that stress is a potent trigger for smoking, the present randomized clinical trial tested whether stress could augment the effects of a memory updating (retrieval-extinction) intervention. Non-treatment seeking smokers (n = 76) were assigned to one of four conditions composed of either a stressful or non-stressful psychosocial challenge followed by either smoking or neutral cues. Ten minutes after this manipulation, all underwent a 60-minute extinction procedure during which they viewed smoking-related videos and images and manipulated smoking paraphernalia. Compared to participants who were not exposed to the laboratory stressor, the stressor-exposed groups exhibited greater psychophysiological responses during their intervention and greater decreases in cigarette use at two- and six-weeks follow-up independent of smoking cue exposure. Together, these findings suggest that the ability of stress to activate cigarette seeking processes can be exploited to decrease cigarette use. With replication, the stress-based intervention could become a novel strategy for decreasing cigarette use in non-treatment seeking smokers.Clinicaltrials.gov identifier: NCT04843969.

Black Pepper (Piper nigrum) for Tobacco Withdrawal: A Case Report

Tobacco use continues to be one of humanity’s most significant public health concerns, causing more than 8-million deaths annually. Existing treatments for tobacco use disorder are limited in efficacy and there is a strong need for identifying effective novel treatments. Small clinical trials indicate that black pepper (Piper nigrum) essential oil may be helpful for treating nicotine withdrawal and craving. However, we are unaware of any cases reporting the use of black pepper for these purposes in nonresearch settings. Here we present the case of a patient who inhaled combusted black pepper to self-medicate nicotine withdrawal when lacking access to tobacco cigarettes while incarcerated. Based on our patient’s report, inhalation of combusted black pepper may have alleviated his tobacco withdrawal and cravings by reducing his automatic motor urge to smoke, quelling withdrawal-associated anxiety, and mimicking the sensorimotor experience of smoking tobacco cigarettes. Notably, our patient reported that inhalation of combusted black pepper for treatment of nicotine craving and withdrawal was common in his correctional facility. Though combusted black pepper is highly unlikely to be an appealing treatment outside of a correctional setting, this case suggests that further investigation of vaporized black pepper essential oil for tobacco cessation may be warranted.

Tailored text message and web intervention for smoking cessation in U.S. socioeconomically-disadvantaged young adults: A randomized controlled trial

The prevalence of cigarette smoking in young adults is higher among those with socioeconomic disadvantage than those without. Low treatment-seeking among young adult smokers is compounded by few efficacious smoking cessation interventions for this group, particularly socioeconomically-disadvantaged young adults (SDYA) who smoke cigarettes. The goal of this study was to test a tailored smoking-cessation intervention for SDYA. 343 SDYA aged 18-30 living in the U.S. (85% female) who smoke cigarettes with access to a smartphone and interest in quitting smoking in the next six months were recruited online in Spring 2020 and randomized to referral to online quit resources (usual care control; n = 171) or a 12-week tailored text message smoking-cessation program with a companion web-based intervention (n = 172). Intent to treat analyses examined associations between study condition, self-reported 30-day point prevalence abstinence (PPA), and confidence to quit smoking at 12 weeks, controlling for potential confounders. Intervention group participants had greater self-reported 30-day PPA at 12-weeks than controls (adjusted relative risk 3.93, 95% CI 2.14-7.24). Among those who continued smoking, the intervention increased confidence to quit (0.81 points, 95% confidence interval 0.08-1.53). Weekly engagement in the intervention predicted greater cessation. A tailored text message intervention for SDYA increased smoking abstinence and confidence to quit at the end-of-treatment. Findings may have been influenced by recruitment at the start of the COVID pandemic but suggest that text messaging is an acceptable and efficacious cessation strategy for SDYA smokers. Future studies should examine the impact on longer-term smoking-cessation and importance of intervention tailoring for SDYA.

Use of a Rapid Qualitative Method to Inform the Development of a Text Messaging Intervention for People With Serious Mental Illness Who Smoke: Formative Research Study

Background

People with serious mental illness are disproportionately affected by smoking and face barriers to accessing smoking cessation treatments in mental health treatment settings. Text-based interventions are cost-effective and represent a widely accessible approach to providing smoking cessation support.

Objective

We aimed to identify key factors for adapting text-based cessation interventions for people with serious mental illness who smoke.

Methods

We recruited 24 adults from mental health programs who had a serious mental illness and currently smoked cigarettes or had quit smoking within the past 5 years. We then conducted virtual qualitative interviews between November 2020 and August 2021. Data were analyzed using the rapid thematic analytic approach.

Results

We identified the following 3 major themes: (1) interplay between smoking and having a serious mental illness, (2) social contextual factors of smoking in adults with serious mental illness, and (3) smoking and quitting behaviors similar to the general population. Participants reported barriers and facilitators to quitting across the 3 themes. Within the “interplay between smoking and having a serious mental illness” theme, barriers included smoking to manage stress and mental health symptoms, and facilitators to quitting included the awareness of the harm of smoking on mental health and patient-provider discussions on smoking and mental health. In the “social contextual factors of smoking in adults with serious mental illness” theme, barriers included high social acceptability of smoking among peers. Positive support and the combined social stigma of smoking and having a mental health condition outside of peer groups motivated individuals to quit. Some participants indicated that low exposure to other smokers during the COVID-19 pandemic helped them to engage in cessation efforts. In the “smoking and quitting behaviors similar to the general population” theme, barriers included smoking after eating, having coffee, drinking alcohol, and experiencing negative social support, and facilitators included health concerns, improvement in the general quality of life, and use of evidence-based tobacco treatments when available.

Conclusions

People with serious mental illness often smoke to cope with intense emotional states, manage mental health symptoms, or maintain social bonds. Text message content emphasizing equally effective and less harmful ways for stress reduction and mental health symptom management may improve quit rates in individuals with serious mental illness.

Barriers Against and Motivations for Quitting Smoking during the COVID-19 Health Crisis: Results of a Qualitative Study in France

The COVID-19 epidemic and its psychological, economic and social consequences could have an impact on the evolution of tobacco-smoking prevalence and attitudes towards quitting. The aim of this study is to analyse the specific characteristics of the motivations for and barriers against smoking cessation in this period. The study is based on qualitative data collected from late 2020 to early 2021 in France from 89 smokers with a low or intermediate socio-economic level. Among the motivations for quitting smoking, health concerns and the financial cost of cigarettes carried increased importance among the smokers in this period. Inversely, perceived stress, isolation, and a lack of social or healthcare support prevented some smokers from attempting to quit. These results are useful for explaining the evolution of smoking prevalence and preparing future interventions in the context of the health crisis and its aftermath. They highlight the relevance of educational messages, of the promotion of validated smoking-cessation aids and, in particular, remote support, as well as the implementation of community-based actions.

Mental health correlates of quitting cigarette smoking in youth experiencing homelessness

Smoking prevalence among youth experiencing homelessness (YEH) is three times higher than smoking prevalence among the general population. Many YEH who smoke are interested in quitting smoking, but also report smoking to cope with mental health symptoms. Research on factors that facilitate or impede successful smoking cessation among YEH is limited. This study examined mental health correlates (i.e., anxiety and depression symptoms) of quitting-related factors (i.e., quit attempts, perceived barriers to quitting) and whether smoking to cope moderates these relationships among this vulnerable population. The sample consisted of 77 YEH cigarette smokers between the ages of 18-25 who were interested in quitting. Participants completed a survey assessing various behavioral and cognitive factors related to tobacco use. Analyzing two separate models, hierarchical negative binomial and hierarchical linear regression were used to examine hypothesized correlates of the number of past year quit attempts and perceived barriers to quitting. Smoking to cope moderated the relationships of depression with past year quit attempts and perceived barriers to quitting. Those high in depression and smoking to cope had the fewest number of quit attempts and reported the greatest perceived barriers. Anxiety symptoms were not significantly associated with quit attempts or perceived barriers. Smoking cessation interventions that address using smoking to cope with mental health symptoms may be important for YEH with depression.

Can chatbots help to motivate smoking cessation? A study on the effectiveness of motivational interviewing on engagement and therapeutic alliance

Background

Cigarette smoking poses a major threat to public health. While cessation support provided by healthcare professionals is effective, its use remains low. Chatbots have the potential to serve as a useful addition. The objective of this study is to explore the possibility of using a motivational interviewing style chatbot to enhance engagement, therapeutic alliance, and perceived empathy in the context of smoking cessation.

Methods

A preregistered web-based experiment was conducted in which smokers (n = 153) were randomly assigned to either the motivational interviewing (MI)-style chatbot condition (n = 78) or the neutral chatbot condition (n = 75) and interacted with the chatbot in two sessions. In the assessment session, typical intake questions in smoking cessation interventions were administered by the chatbot, such as smoking history, nicotine dependence level, and intention to quit. In the feedback session, the chatbot provided personalized normative feedback and discussed with participants potential reasons to quit. Engagement with the chatbot, therapeutic alliance, and perceived empathy were the primary outcomes and were assessed after both sessions. Secondary outcomes were motivation to quit and perceived communication competence and were assessed after the two sessions.

Results

No significant effects of the experimental manipulation (MI-style or neutral chatbot) were found on engagement, therapeutic alliance, or perceived empathy. A significant increase in therapeutic alliance over two sessions emerged in both conditions, with participants reporting significantly increased motivation to quit. The chatbot was perceived as highly competent, and communication competence was positively associated with engagement, therapeutic alliance, and perceived empathy.

Conclusion

The results of this preregistered study suggest that talking with a chatbot about smoking cessation can help to motivate smokers to quit and that the effect of conversation has the potential to build up over time. We did not find support for an extra motivating effect of the MI-style chatbot, for which we discuss possible reasons. These findings highlight the promise of using chatbots to motivate smoking cessation. Implications for future research are discussed.

A cluster randomized controlled trial for a multi-level, clinic-based smoking cessation program with women in Appalachian communities: study protocol for the "Break Free" program

BACKGROUND

The cervical cancer burden is high among women living in Appalachia. Cigarette smoking, a cervical cancer risk factor, is also highly prevalent in this population. This project aims to increase smoking cessation among women living in Appalachia by embedding a smoking cessation program within a larger, integrated cervical cancer prevention program.

METHODS

The broader program, the Take CARE study, is a multi-site research collaborative designed to address three risk factors for cervical cancer incidence and mortality: tobacco use, human papillomavirus (HPV) infection, and cervical cancer screening. Break Free is a primary care clinic-based implementation program that aims to promote smoking cessation among female smokers in Appalachia by standardizing clinical practice protocols. Break Free includes: (1) implementation of a tobacco user identification system in the Electronic Health Record, (2) clinic staff and provider training on the Ask, Advise and Refer (AAR) model, (3) provider implementation of AAR to identify and treat women who want to quit smoking within the next 6 months, (4) facilitated access to cessation phone counseling plus pharmacotherapy, and (5) the bundling of Break Free tobacco cessation with HPV vaccination and cervical cancer screening interventions in an integrated approach to cervical cancer prevention. The study spans 35 Appalachian health clinics across 10 healthcare systems. We aim to enroll 51 adult female smokers per health system (total N = 510). Baseline and follow-up data will be obtained from participant (provider and patient) surveys. The primary outcome is self-reported 12-month point prevalence abstinence among enrolled patients. All randomized patients are asked to complete follow-up surveys, regardless of whether they participated in tobacco treatment. Data analysis of the primary aims will follow intent-to-treat methodology. Secondary outcomes will assess program implementation and cost effectiveness.

DISCUSSION

Addressing high tobacco use rates is critical for reducing cervical cancer morbidity and mortality among women living in Appalachia. This study evaluates the implementation and effectiveness of a smoking cessation program in increasing smoking cessation among female smokers. If results demonstrate effectiveness and sustainability, implementation of this program into other health care clinics could reduce both rates of smoking and cervical cancer. Trial registration NCT04340531 (April 9, 2020).

Barriers and Motivators for Smoking Cessation Among Caregivers of Inpatient Pediatric Patients

OBJECTIVE

To examine perceived barriers and motivators for smoking cessation among caregivers of inpatient pediatric patients.

METHODS

From December 2014 to June 2018, trained tobacco counselors conducted motivational interviews (MI) with caregivers of inpatient pediatric patients ages 0 to 17, who participated in the intervention arm of a smoking cessation randomized controlled trial. By using NVivo 12 software, the first MI session with each caregiver was evaluated by 3 individuals to identify and categorize motivators and barriers; agreement among reviewers was reached. Barriers and motivators were examined in bivariable analysis with χ2 or Fisher's exact tests for categorical factors and with t-tests for continuous factors by using SAS 9.4 software.

RESULTS

Of the 124 caregivers randomized to intervention, 99 subjects (80%) completed ≥1 MI sessions. The most prevalent barriers to cessation were stress (57%) and social influence (37%).The most prevalent motivators were desire to lead a healthy life (54%) and desire to improve the child and family's well-being (47%). Older parent age was associated with wanting to lead a healthy life, and younger child age was associated with wanting to improve the child and family's well-being.

CONCLUSIONS

Understanding barriers and motivators to cessation among caregivers is crucial in reducing pediatric secondhand smoke (SHS). When developing caregiver cessation programs in an inpatient clinic encounter, caregiver barriers and motivators may help in targeting education and strategies to help counselors and clinicians better identify and support caregivers who wish to quit smoking.

Readiness to Quit Smoking among Smokers in Substance Use Treatment: Associations with Stress, Substance Use Severity, Relapse Concerns and Gender

Smoking prevalence among individuals in substance use treatment remains higher than in the general population. Given that many smokers in substance use treatment are reluctant to quit smoking, it is important to understand the factors that impede smokers' readiness to quit. The current study used baseline data from a randomized controlled trial involving 60 adult smokers receiving substance use treatment to investigate relations between the severity of substance use problems (SSUP), perceived stress (PS), concerns about relapse (i.e., concerns that quitting smoking would hurt one's recovery process (CR)), and readiness to quit smoking. This study also investigated moderating roles of concerns about relapse and gender. Regression analyses showed a significant main effect of concerns about relapse on readiness to quit in the next 30 days, but no effect for either severity of substance use problems, perceived stress, or the SSUPxCR interaction. There were significant interaction effects between PS and both gender and CR. Among men and those with lower concerns about relapse, higher perceived stress was significantly associated with lower readiness to quit. Findings suggest that psychoeducation to alleviate concerns that quitting smoking could limit substance use recovery could be beneficial. Stress management interventions may be especially beneficial to men.

Motivational Factors for Smoking Behaviors in Individuals with Metabolic Syndrome

PURPOSE

Smoking, which is one of the major risk factors for metabolic syndrome that causes cardiovascular disease or diabetes, is a crucial risk factor, which is modifiable. This study aimed to determine the factors that promote smoking behaviors according to smoking status among adults with metabolic syndrome.

PATIENTS AND METHODS

A survey of structured self-reported questionnaires was conducted on 152 adults with metabolic syndrome. Outcome variables included cognitive motivations (self-efficacy, and perceived benefits and barriers), emotional motivation (emotional salience), and autonomous and controlled motivation based on self-determination theory. The participants were categorized by their smoking status (never smoking, quit smoking, or current smoking). Their sociodemographic and motivational factors were examined using one-way analysis of variance, analysis of covariance, and multinomial logistic regression analysis.

RESULTS

Data on 152 individuals with metabolic syndrome with a mean age of 57.5 years were included. The findings indicated that the motivational factors for the never-smoking and quit-smoking groups significantly differed from those for the current-smoking group in terms of self-efficacy, perceived benefits, perceived barriers, and autonomous motivation. Based on multinomial logistic regression with current smoking as the reference group, sex (being female, OR=57.69) and perceived barriers (OR=0.39) were the significant predictors for the never-smoking group, while autonomous motivation (OR=1.96) was the significant predictor for the quit-smoking group.

CONCLUSION

The motivational factors for smoking behaviors varied according to the smoking status of adults with metabolic syndrome. Autonomous motivation was the significant predictor of smoking cessation for individuals who successfully quit, whereas cognitive motivation was influential in the prevention of smoking by individuals who have never smoked. Further studies are warranted to develop smoking cessation strategies, which should focus on specific motivational factors to lead effective smoking prevention programs in this population.

Perceptions of Mobile Apps for Smoking Cessation Among Young People in Community Mental Health Care: Qualitative Study

BACKGROUND

Young adults with serious mental illness are over twice as likely to have tobacco use disorder than those in the general population and are less likely to utilize proven treatment methods during quit attempts. However, little research has evaluated the efficacy of interventions for this group. Smartphone apps may be an underutilized tool for tobacco use disorder among young adults with serious mental illness.

OBJECTIVE

The aim of this study was to explore attitudes toward smoking cessation apps and preferences regarding app design in young adult smokers with serious mental illness.

METHODS

Five focus groups involving 25- to 35-year-old adults with serious mental illness receiving treatment at a community mental health center were conducted between May 2019 and August 2019. Three researchers independently coded transcripts and identified themes using thematic analysis.

RESULTS

Participants (n=22) were individuals who smoke daily: 10 (46%) self-identified as female, 18 (82%) self-identified as White, and 9 (41%) had psychotic disorders. Key themes that emerged included a general interest in using health apps; a desire for apps to provide ongoing motivation during a quit attempt via social support, progress tracking, and rewards; a desire for apps to provide distraction from smoking; concerns about app effectiveness due to a lack of external accountability; and concerns that apps could trigger cravings or smoking behavior by mentioning cigarettes or the act of smoking.

CONCLUSIONS

Apps have the potential to support smoking cessation or reduction efforts among young adults with serious mental illness. However, they may require tailoring, optimization, and clinical support to effectively promote cessation in this population.

Age and pre quit-day attrition during smoking cessation treatment

The present study aimed to replicate the finding that younger age predicts higher pre quit-day attrition. Our second aim was to explain this relation by examining empirically and theoretically informed age-related risk factors for low smoking cessation treatment engagement. 136 participants (Mage = 44.2 years, SD = 11.3 years; age = 22-64 years) were randomized to 15-weeks of either 1) an exercise intervention (n = 72) or 2) a wellness education control condition (n = 64). First, a logistic regression analysis was employed to test whether younger adults were more likely than older adults to drop prior to quit date. Next, we assessed whether smoking related health concerns, social expectancies, and/or perceived severity of craving affected the strength of the relation between age and attrition, by adding these three variables to the logistic regression along with age. The logistic regression model indicated that younger age and treatment condition were significantly related to the odds of dropping from treatment prior to the scheduled quit date. Further, health concerns, social expectancies, and/or perceived severity of cravings did not account for the effect of age on pre quit-day attrition. These findings highlight the importance of identifying empirically and theoretically informed variables associated with the pre quit-day attrition problem of young smokers.

Changes in Black-White Difference in Lung Cancer Incidence among Young Adults

Background

We previously reported that lung cancer incidence between Blacks and Whites younger than 40 years of age converged in women and approached convergence in men. Whether this pattern has continued in contemporary young birth cohorts is unclear.

Methods

We examined 5-year age-specific lung cancer incidence in Blacks and Whites younger than 55 years of age by sex and calculated the Black-to-White incidence rate ratios (IRRs) and smoking prevalence ratios by birth cohort using nationwide incidence data from 1997 to 2016 and smoking data from 1970 to 2016 from the National Health Interview Survey.

Results

Five-year age-specific incidence decreased in successive Black and White men born since circa 1947 and women born since circa 1957, with the declines steeper in Blacks than Whites. Consequently, the Black-to-White IRRs became unity in men born 1967-1972 and reversed in women born since circa 1967. For example, the Black-to-White IRRs in ages 40-44 years born between 1957 and 1972 declined from 1.92 (95% confidence interval [CI] = 1.82 to 2.03) to 1.03 (95% CI = 0.93 to 1.13) in men and from 1.32 (95% CI = 1.24 to 1.40) to 0.71 (95% CI = 0.64 to 0.78) in women. Similarly, the historically higher sex-specific smoking prevalence in Blacks than Whites disappeared in men and reversed in women born since circa 1965. The exception to these patterns is that the incidence became higher in Black men than White men born circa 1977-1982.

Conclusions

The historically higher lung cancer incidence in young Blacks than young Whites in the United States has disappeared in men and reversed in women, coinciding with smoking patterns, though incidence again became higher in Black men than White men born circa 1977-1982.

Smoking Prevalence, Patterns, and Cessation Among Adults in Hebei Province, Central China: Implications From China National Health Survey (CNHS)

As part of the China National Health Survey, the objective of this study was to explore the prevalence, patterns, and influencing factors of smoking, and understand reasons for smoking cessation among adults in Hebei Province, central China. Using a multi-stage stratified cluster sampling method, 6,552 adults (2,594 males) aged 20–80 were selected in 2017. Demographic, socioeconomic, and tobacco use information were collected by questionnaire interview. The prevalence of ever-smoking, current smoking, and ex-smoking was 28.94, 21.08, and 7.86%, respectively. Male participants had a much higher prevalence of ever-smoking and current smoking (67.39 and 48.77%) than females (3.74 and 2.93%). In male participants, the daily cigarette consumption was 16.61, and the mean age of smoking initiation was 20.95, decreasing with birth year (27.50 in people born before 1946 vs. 17.9 for those born after 1985, p for trend < 0.001). Over 40% of male ever-smokers initiated regular smoking before 20. Compared with never drinking, the ORs (95% CI) of ever-smoking for low, moderate, and high alcohol consumption in male participants were 1.44 (1.11–1.86), 2.80 (1.91–4.11), and 2.40 (1.72–3.33), respectively. Among 479 male ex-smokers, 50.94% stopped smoking because of illness and 49.06% by choice. Among male ex-smokers, hypertensive men were more likely to quit smoking than the normotensive individuals (OR: 1.48, 95% CI: 1.13–1.96). For CVD patients, this effect was estimated as 2.27 (95% CI: 1.56–3.30). This study revealed a high prevalence of ever-smoking, especially in men, in a representative population in central China. Health education focus on tobacco control could be integrated with alcohol consumption reduction to achieve additional benefit.

Islam and Motivation to Quit Smoking: Public Health Policy Implications

In the WHO Eastern Mediterranean Regional Office some 14 years ago, a 'religiously inspired approach' was proposed to combat tobacco use. This promoted a useful debate in the region. The purpose of this paper is to argue the need to identify the role which Islamic beliefs and teachings play (1) in influencing individual motivation to quit smoking and (2) in gaining support for public policies to reduce smoking. Ramadan and Hajj are taken as key points. These, it is argued, are times when Muslim religious motivation to abstain from smoking is strongest. This paper concludes that there is an insufficient evidence base on which to adopt a religiously inspired approach. All of civil society, including religious Muslim authorities, should rather supplement the efforts of health professionals to encourage smoking cessation.

Motivation to quit cigarettes and alternative tobacco products: prevalence and correlates among youth experiencing homelessness

Use of alternative tobacco products, as well as regular cigarettes, is widespread among unaccompanied youth experiencing homelessness. However, little is known about their level of motivation for quitting use of these products, factors associated with motivation to quit, or how these might vary by type of tobacco product. Unaccompanied homeless youth were sampled from 25 street and service sites in Los Angeles County (N = 469). All participants were past month tobacco users who completed a survey on their tobacco-related behaviors and cognitions, including motivation to quit, as well as background characteristics. Among self-reported users of each product, motivation to quit in the next 30 days was highest for regular cigarettes (33%), followed by e-cigarettes/vaporizers (30%), little cigars/cigarillos (25%), cigars (20%), and natural cigarettes (20%). Between 33 and 49% of youth, depending on product, were not thinking about quitting at all. Correlates of lower motivation to quit differed somewhat by product type, with the most consistent being race, more frequent use, lower perceived riskiness of the product, and using the product because of its good taste or smell. Results from this study identify a set of psychosocial and behavioral factors, some that are common across tobacco products and others that are product-specific, that may be particularly important to address in efforts to reduce tobacco use among youth experiencing homelessness. Future regulations on the sale of flavored tobacco products may also serve to increase motivation to quit in this population.

Motivations to quit smoking and challenges faced during cessation among individuals with first episode psychosis in Singapore

AIMS

The prevalence of smoking has been noted to be higher among individuals with mental illness, particularly among those with schizophrenia and related psychosis than in the general population. The present paper sought to examine the motivations and challenges to quit smoking among first episode psychosis patients (N = 281) enrolled in the Early Psychosis Intervention Programme (EPIP) in Singapore.

METHODS

Questionnaires were used to collect details on an individual's smoking status, cessation attempts, motivations to quit, and challenges to stop smoking. Using baseline data, multiple linear regressions were conducted to examine the socio-demographic correlates of motivations and challenges of smoking cessation behaviour.

RESULTS

Of the study sample, 59.4% reported to have never smoked while 39.9% were currently smoking or had attempted smoking. Health reasons and cost were the most highly endorsed motivations to stop smoking; whereas cravings, stress, and boredom were highly endorsed as challenges to stop smoking. Socio-demographic factors such as age, educational level, and marital status were also found to be associated with the motivations to stop smoking and challenges faced during smoking cessation.

CONCLUSIONS

The present study highlights the most highly endorsed motivations and challenges reported among individuals with first episode psychosis (FEP) in an Asian population. Given that the literature examining motivations and challenges to quit smoking has predominantly focused on the general population, results from the current study have implications for the formulation of smoking cessation programmes targeted at individuals with mental illness, particularly those with FEP.

Financial Hardship, Motivation to Quit and Post-Quit Spending Plans among Low-Income Smokers Enrolled in a Smoking Cessation Trial

Background:

Tobacco spending may exacerbate financial hardship in low-income populations by using funds that could go toward essentials. This study examined post-quit spending plans among low-income smokers and whether financial hardship was positively associated with motivation to quit in the sample.

Methods:

We analyzed data from the baseline survey of a randomized controlled trial testing novel a smoking cessation intervention for low-income smokers in New York City (N = 410). Linear regression was used to examine the relationship between financial distress, food insecurity, smoking-induced deprivation (SID) and motivation to quit (measured on a 0-10 scale). We performed summative content analyses of open-ended survey questions to identify the most common plans among participants with and without SID for how to use their tobacco money after quitting.

Results:

Participants had an average level of motivation to quit of 7.7 (SD = 2.5). Motivation to quit was not significantly related to having high financial distress or food insecurity (P > .05), but participants reporting SID had significantly lower levels of motivation to quit than those without SID (M = 7.4 versus 7.9, P = .04). Overall, participants expressed an interest in three main types of spending for after they quit: Purchases, Activities, and Savings/Investing, which could be further conceptualized as spending on Oneself or Family, and on Needs or Rewards. The top three spending plans among participants with and without SID were travel, clothing and savings. There were three needs-based spending plans unique to a small number of participants with SID: housing, health care and education.

Conclusions:

Financial distress and food insecurity did not enhance overall motivation to quit, while smokers with SID were less motivated to quit. Most low-income smokers, including those with SID, did not plan to use their tobacco money on household essentials after quitting.

Perceived barriers to quitting cigarettes among hospitalized smokers with substance use disorders: A mixed methods study

AIMS

Smoking cessation may promote long-term recovery in patients with substance use disorders (SUD). Yet smoking rates remain alarmingly high in this population. Using a sequential explanatory mixed methods approach, we examined smoking rates among hospitalized patients with SUD at a large safety-net hospital, and then characterized factors associated with smoking behaviors both quantitatively and qualitatively.

METHOD

We abstracted data from all hospital admissions (7/2016-6/2017) and determined demographics, substance use type, and other characteristics associated with cigarette use among those with SUD. We then conducted semi-structured qualitative interviews with 20 hospitalized SUD smokers. We analyzed transcripts to characterize factors that affect patients' smoking habits, focusing on the constructs of the Health Belief Model.

RESULTS

The prevalence of cigarette smoking among hospitalized smokers with SUD was three times higher than those without SUD. Qualitative analyses showed that patients perceived that smoking cigarettes was a less serious concern than other substances. Some patients feared that quitting cigarettes could negatively impact their recovery and perceived that clinicians do not prioritize treating tobacco dependence. Almost all patients with heroin use disorder described how cigarette use potentiated their heroin high. Many SUD patients are turning to vaping and e-cigarettes to quit smoking.

CONCLUSION

Hospitalized patients with SUD have disproportionately high smoking rates and perceive multiple barriers to quitting cigarettes. When designing and implementing smoking cessation interventions for hospitalized patients with SUD, policymakers should understand and take into account how patients with SUD perceive smoking-related health risks and how that influences their decision to quit smoking.

Predictors of Retention in an Adult Text Messaging Smoking Cessation Intervention Program: Cohort Study

Background

Mobile health tools such as text messaging programs can support smoking cessation. However, high rates of disengagement from these tools decrease their effectiveness.

Objective

The purpose of this study was to identify user characteristics associated with retention in an adult text messaging smoking cessation intervention.

Methods

Adults initiating a quit attempt using the publicly available program SmokefreeTXT between March 6 and June 21, 2016 (n=6215), were included. Data were collected to assess nicotine dependence, frequency of being around other smokers, time of the day for cigarette cravings, extrinsic and intrinsic motivation to quit smoking, confidence in quitting, and long-term intention to be smoke free. Multivariable survival analysis modeling for time to opt out was conducted to identify characteristics associated with opting out over the course of the intervention, adjusting for age, sex, and smoking frequency, reset of the quit date by the user, and the number of days enrolled before initiating the quit attempt. Among those who opted out, multivariable multinomial logistic regression analysis was used to identify predictors of opting out early (within 3 days and between 4 and 7 days into the quit attempt) compared to opting out late (more than 7 days into the quit attempt), adjusting for the same confounders.

Results

Survival analyses indicated that younger age, female sex, higher levels of nicotine dependence, lower intention to be smoke free, and enrolling in SmokefreeTXT ≤1 week before initiating the quit attempt were associated with an increased risk of opting out. For example, users who smoked within 5 minutes of waking up were 1.17 times more likely to opt out than those who smoked more than 5 minutes after waking up (95% CI 1.01-1.35). Among users who opted out from SmokefreeTXT, logistic regression modeling indicated that compared to users who were never or rarely around other smokers, those who were sometimes around other smokers had 1.96 times more likely to opt out within the first 3 days of the quit attempt (95% CI 1.18-3.25). In addition, compared to users with high levels of long-term quit intention, users with lower levels of intention had 1.80 times the odds of opting out between 4 and 7 days into the quit attempt (95% CI 1.02-3.18). Users who reset their quit date after initiating a quit attempt were less likely to opt out at either time point compared with those who did not reset their quit date.

Conclusions

Several user characteristics are associated with retention in an adult text messaging smoking cessation program. These results provide guidance on potential characteristics that should be addressed in future text messaging smoking cessation programs. Providing additional support to users with these characteristics may increase retention in text messaging programs and ultimately lead to smoking cessation.

Combining Education With Auricular Acupressure to Facilitate Smoking Cessation in Young Adults

Young adults rarely use pharmacotherapy to cease smoking. This prospective experimental study was performed using a nonpharmacotherapy design. Smoking cessation education combined with auricular acupressure may be more attractive. The key factor for superior smoking cessation was the decrease of nicotine dependence in the early stage of smoking cessation.

Ecological momentary assessment of various tobacco product use among young adults

INTRODUCTION

Young adults are at high risk for using traditional and novel tobacco products. However, little is known about daily/weekly use patterns or psychosocial triggers for using various tobacco products.

METHODS

This ecological momentary assessment (EMA) study examined timing, tobacco cravings, affect, social context, and other substance use (alcohol, marijuana) in relation to use of cigarettes, electronic nicotine delivery systems (ENDS), and any tobacco product (i.e., cigarettes, ENDS, cigars, hookah), respectively. We also examined interactions between these predictors, sex, and race/ethnicity. From a longitudinal study of 3418 18-25 year-olds from seven Georgia colleges/universities, we recruited 72 reporting current tobacco use to participate in the 21-day EMA study; 43 participated, of which 31 completed ≥66% assessments and were analyzed. Cravings, affect, social context, and substance use were assessed daily across four four-hour windows.

RESULTS

Of the 31 participants, average age was 21.10 years (SD = 1.95), 45.2% were female, and 71.0% non-Hispanic White; 71.0% used cigarettes, 58.1% ENDS, 38.7% cigars, and 25.8% hookah (25.6% used one product, 46.5% two, 27.9% ≥ three). Predictors of cigarette use included higher anxiety, greater odds of marijuana and alcohol use, and higher boredom levels among women. Predictors of ENDS use included being non-White and greater odds of marijuana use, as well as higher tobacco cravings among women and higher boredom among men. Predictors of any tobacco product use included being non-White, higher boredom levels, and greater odds of marijuana and alcohol use.

CONCLUSIONS

Distinct interventions may be needed to address use of differing tobacco products among young adults.

Smoker perceptions of health warnings on cigarette packaging and cigarette sticks: A four-country study

INTRODUCTION

Innovations in tobacco control interventions are required to ensure continued reductions in global tobacco use, and to minimise attributable morbidity and mortality. We therefore aimed to investigate the perceived effectiveness of current cigarette packaging warnings and the potential effectiveness of cigarette-stick warnings across four countries.

METHODS

An online survey was distributed to adult smokers in Australia, Canada, the United Kingdom, and the United States. Participants rated (using a 5-point Likert scale) and commented on the effectiveness of current cigarette packaging warnings and text warnings on eight cigarette sticks that prompted smokers to quit. Ratings were analysed using proportional odds logistic regression, and comments were analysed using content analysis.

RESULTS

Participants (N=678, mean age=44.3 years) from all four countries perceived cigarette packaging warnings as being minimally effective in prompting smokers to quit, citing desensitisation and irrelevance of the warnings, with US participants particularly critical of the text-only warnings. Compared to packaging warnings, the cigarette-stick warnings describing the financial costs of smoking and the effect of smoking on others, were the highest rated in all four countries (OR=3.42, 95% CI: 2.75–4.25, p<0.001 and OR=2.85, 95% CI: 2.29–3.55, p<0.001, respectively) and cited as strong messages to reduce smoking. Half of the participants either ‘agreed’ or ‘strongly agreed’ to the use of cigarette-stick warnings.

CONCLUSIONS

The findings of this study suggest that cigarette packaging warnings may experience a loss of effectiveness over time, eventually resulting in minimal impact on smoker behaviour. Health and non-health focused warnings and messages on individual cigarette sticks represent a novel and potentially effective method for reducing tobacco use. This would complement tobacco control interventions currently employed, resulting in public health benefits.

Differential Associations Between Anti-Tobacco Industry Attitudes and Intention to Quit Smoking Across Young Adult Peer Crowds

PURPOSE

To compare the relationship between anti-tobacco industry attitudes and intention and attempts to quit smoking across 6 young adult peer crowds.

DESIGN

A cross-sectional bar survey in 2015.

SETTING

Seven US cities (Albuquerque, Los Angeles, Nashville, Oklahoma City, San Diego, San Francisco, and Tucson).

PARTICIPANTS

Two thousand eight hundred seventeen young adult bar patrons who were currently smoking.

MEASURES

Intention to quit in the next 6 months and having made a quit attempt in the last 12 months were binary outcomes. Anti-industry attitudes were measured by 3 items indicating support for action against the tobacco industry. Peer crowd affiliation was measured using the I-Base Survey.

ANALYSIS

Adjusted multivariable logistic regression models examined the association between anti-industry attitudes and the outcomes for the total sample and for each peer crowd.

RESULTS

Overall, anti-industry attitudes were positively associated with both intention to quit (odds ratio [OR] = 1.37, 95% confidence interval [CI] = 1.24-1.52) and attempt to quit (OR = 1.14, 95% CI = 1.03-1.27). Intriguingly, the relationship between anti-industry attitudes and intention to quit differed by peer crowd affiliation, with significant associations for Homebody, Partier, Hipster, and Hip Hop, but not for Young Professional and Country.

CONCLUSIONS

Developing health communication messages that resonate with unique peer crowd values can enhance the relevance of public health campaigns. Tobacco control practitioners should tailor anti-industry messages to promote intention to quit smoking among the highest risk young adults.

A randomised controlled trial examining the efficacy of smoking-related response inhibition training in smokers: a study protocol

BACKGROUND

Smoking is one of the leading preventable causes of illness and premature death worldwide. Despite a variety of effective treatments, relapse rates remain high, and novel, innovative interventions are needed in order to reduce the global prevalence of smoking. Research has indicated that deficits in the ability to inhibit a response (referred to as response inhibition) is a predictor of relapse and subsequently, targeting this potentially modifiable risk factor may lead to improvements in smoking outcomes. Indeed, in recent years, stimulus-specific response inhibition training has emerged as a potentially efficacious intervention to reduce unwanted/unhealthy behaviours such as alcohol and unhealthy food consumption. As such, the present trial is the first to evaluate the real-world efficacy of response inhibition smoking training (INST) in a sample of adult heavy smokers.

METHODS/DESIGN

This randomised controlled trial will recruit nicotine dependent smokers aged between 18 and 60 using social media and advertisements in Victoria, Australia. The sample target was 150 to account for drop out and non-adherence. Once informed consent has been obtained, participants complete a range of baseline measures during a face to face interview. Participants are randomly allocated to one of two online training conditions: an intervention training group (INST), which requires participants to exercise response inhibition towards smoking-related stimuli; or an active control group, which requires participants to exercise response inhibition towards household items and does not include any smoking-related stimuli. They complete the first training session during the interview to ensure the training protocol is clear. Both groups are instructed to complete a further 13 training sessions (1 per day) at home on their computer and follow-up phone calls will be conducted at three time points: post-intervention, one-month and three months. The primary outcomes are: a) rates of smoking cessation and; b) reduction in the quantity of average daily smoking at post-intervention, one and three months follow-up.

DISCUSSION

There is a pressing need to develop novel and innovative smoking interventions. If proven to be effective, INST could make a highly cost-effective contribution to improvements in smoking intervention outcomes.

TRIAL REGISTRATION

The trial was prospectively registered with the Australian New Zealand Clinical Trials Registry 17th February 2017. Trial ID: ACTRN12617000252314 .

Prevalence and characteristics of young adult smokers in the U.S. in the precontemplation stage of smoking cessation

INTRODUCTION

The precontemplation stage of smoking cessation refers to having no intention to quit smoking in the next six months. We aimed to estimate the prevalence of and characteristics associated with the precontemplation stage of smoking cessation among U.S. young adult smokers to inform the development of targeted interventions.

METHODS

We analyzed data in 2017 from the 2013-2014 National Adult Tobacco Survey. Young adult (18-29 years old) daily and non-daily smokers were included (n = 1809). We applied weighted multiple logistic regression models to examine the associations between demographics, tobacco use behaviors, exposure to pro- and anti-tobacco messages, and the precontemplation stage of smoking cessation.

RESULTS

59.0% of U.S. young adult smokers are in the precontemplation stage of smoking cessation. Unemployment was positively associated with being in the precontemplation stage of smoking cessation (AOR = 1.42 95% CI = 1.05, 1.91). Smoking every day (vs. some days), more cigarettes smoked per day, using roll-your-own cigarettes (vs. manufactured cigarettes only), currently smoking cigars, and signing up for promotional offers were positively associated with being in the precontemplation stage of smoking cessation (p < 0.05). Non-Hispanic Black was negatively associated with precontemplation stage (AOR = 0.40, 95% CI = 0.27, 0.59). Not smoking after viewing a health warning on a cigarette pack was negatively associated with the precontemplation stage of smoking cessation (AOR = 0.36, 95% CI = 0.25, 0.51).

CONCLUSIONS

Many U.S. young adult smokers classify as being in the precontemplation stage of smoking cessation. Interventions to motivate these smokers to quit smoking with considerations of their specific characteristics (e.g., being unemployed) are warranted.

Planning a Change Easily (PACE): A randomized controlled trial for smokers who are not ready to quit

Smoking cessation programs are efficacious and have been validated to assist the 10% to 30% of smokers who are ready to quit in the next 30 days. While the majority of smokers want to quit smoking in the future, only 69% are planning to quit within the next year. Planning a Change Easily (PACE) is a nation-wide, telephone-based comparative effectiveness, randomized controlled trial for smokers not ready to quit (SNRTQ). This project, as well as its intervention components, outcomes, and hypotheses are discussed. This study will compare the effectiveness of four intervention conditions that could potentially help SNRTQ to quit smoking: Brief Advice, Motivational Interviewing, Rate Reduction, and Motivational Interviewing plus Rate Reduction combined. Rate Reduction conditions will include the provision of nicotine replacement therapy in the form of gum. Approximately 840 participants will be recruited and randomized to the four intervention conditions. The main outcomes for this study include self-report prolonged and point prevalence abstinence with biochemical verification of cessation. Secondary outcomes include quit attempts, cost-per-quit, and cost-effectiveness analyses. Informed by evidenced-based interventions, strong clinical guidelines, and economic analysis, PACE has the potential for significant public health impact. Results could readily be disseminated and translated to tobacco quitlines, which are present in all 50 states and are offered free to the public.

Smoking Cessation Is Associated With Lower Indirect Costs

Objective:

This study quantified differences in indirect costs due to decreased work productivity between current and former smokers. Former smokers were further categorized by number of years since quitting to assess corresponding differences.

Methods:

Data on employed individuals were obtained from the 2013 US National Health and Wellness Survey (NHWS; N = 75,000). Indirect costs were calculated for current smokers and former smokers from weekly wages based on age and sex.

Results:

The annual total indirect costs for current smokers were $1327.53, $1560.18, and $1839.87 higher than for those who quit 0 to 4 years, 5 to 10 years, and more than or equal to 11 years prior, respectively. There were no significant differences in mean total indirect costs between the former smoker groups.

Conclusions:

Current smokers showed significantly higher total annual indirect costs compared with former smokers, independently of the number of years since quitting smoking.

Reasons for quitting smoking in young adult cigarette smokers

BACKGROUND

Although most young adult smokers want to quit smoking, few can do so successfully. Increased understanding of reasons to quit in this age group could help tailor interventions, but few studies document reasons to quit in young adults or examine reasons to quit by smoker characteristics.

METHODS

In 2011-12, 311 current smokers (age 22-28, M=24.1; 48.9% male, 51.1% female; 50.4% daily smokers) from the Nicotine Dependence in Teens Study completed the Adolescent Reasons for Quitting scale. We assessed differences in the importance of 15 reasons to quit by sex, education, smoking frequency, quit attempt in the past year, perceived difficulty in quitting, and motivation to quit. We also examined differences between participants who discounted the importance of long-term health risks and those who acknowledged such risks.

RESULTS

Concerns about getting sick or still smoking when older were considered very important by >70% of participants. Median scores were higher among daily smokers, those who had tried to quit or who expressed difficulty quitting, and those with strong motivation to quit. Discounters (14.5% of participants) were primarily nondaily, low-consumption smokers. Their Fagerström Test for Nicotine Dependence scores did not differ from non-discounters', and 11% (vs. 35.7% of non-discounters) were ICD-10 tobacco dependent.

CONCLUSIONS

Novel smoking cessation interventions are needed to help young adult smokers quit by capitalizing on their health concerns. Discounters may need educational intervention to better understand the impact of even "light" smoking on their health before or in conjunction with quit interventions.

Young Australian women's accounts of smoking and quitting: a qualitative study using visual methods

Background

Although the overall rate of smoking in Australia continues to decline, the rate of decline has begun to slow. Rates of smoking among young women in Australia have been a particular concern, which has led to the development of targeted public health campaigns. Poststructuralist theory has successfully been used in research to explore the way in which young women experience smoking. However, there is an absence of poststructuralist analysis of young women’s experiences of quitting. This study aims to address this gap.

Methods

We carried out 27 interviews with young Australian women smokers and ex-smokers. Eighteen of those women then participated in a photography activity and follow-up interviews. A Foucauldian discourse analysis of the data was conducted.

Results

Through our analysis, we identified three discourses: ‘The irresponsibility of smoking: Quitting as responsible’, ‘The difficulties of quitting: Smoking as addictive’, and ‘Making a decision to quit: Smoking as a choice’. In relation to these discourses, participants took up contradictory positions of responsibility and resistance, addiction and agency. Taking up these positions had implications for young women’s subjectivity, and the way they engaged with tobacco controls and cessation support.

Conclusions

The analysis highlights the complex and contradictory nature of young women’s experiences with smoking and quitting. The study’s findings are considered in relation to the improvement of tobacco control policies and cessation support programmes targeted at young women.

Self-guided Change: The most common form of long-term, maintained health behavior change

Millions of people change risky, health-related behaviors and maintain those changes. However, they often take years to change, and their unhealthy behaviors may harm themselves and others and constitute a significant cost to society. A review-similar in nature to a scoping review-was done of the literature related to long-term health behavior change in six areas: alcohol, cocaine and heroin misuse, gambling, smoking, and overeating. Based on the limited research available, reasons for change and strategies for changing and for maintaining change were also reviewed. Fifty years of research clearly indicate that as people age, in the case of alcohol, heroin and cocaine misuse, smoking, and gambling, 80-90 percent moderate or stop their unhealthy behaviors. The one exception is overeating; only 20 percent maintain their weight loss. Most of these changes, when they occur, appear to be the result of self-guided change. More ways to accelerate self-guided, health-related behavior change need to be developed and disseminated.

Implementation of a Quit Smoking Programme in Community Adult Mental Health Services-A Qualitative Study

Little is known about the experiences of people with severe mental health difficulties in smoking cessation interventions. This study aimed to review the implementation of a smoking cessation programme across 16 community mental health day services. The aim was to establish the experience from both service user and facilitator perspectives and refine implementation for future groups. In-depth interviews were conducted with 20 service users and four focus groups held with 17 facilitators. Thematic analysis was used to analyse the data for emergent themes in relation to key enablers and barriers to implementation. Data from service users and facilitators revealed that implementation was enabled by an open and engaged recruitment approach; the resourcefulness of facilitators; programme materials and group-based format; combining the cessation programme with other and broader health initiatives; and participants' motivations, including health and money. Barriers included the structure of the service; the lack of a joined-up approach across the health services; literacy issues and the serial/logical process assumed by the programme. Barriers perceived as more specific to those with mental health difficulties included the use of smoking as a coping mechanism, lack of alternative activities/structure and lack of consistent determination. The tobacco free policy, implemented shortly before the programme, interestingly emerged as both a barrier and an enabler. In conclusion, although this group-based cessation programme in community mental health settings was well-received overall, a number of key barriers persist. A joined-up approach which addresses the culture of smoking in mental health settings, inconsistencies in smoking policies, and provides consistent cessation support, is needed. Care needs to be taken with the timing as overall it may not be helpful to introduce a new smoking cessation programme at the same time as a tobacco free policy.

Beyond education and income: Identifying novel socioeconomic correlates of cigarette use in U.S. young adults

Young adulthood is defined by transitions in family life, living situations, educational settings, and employment. As a result, education and income may not be appropriate measures of socioeconomic status (SES) in young people. Using a national sample of young adults aged 18-34 (n=3364; collected February 2016), we explored novel socioeconomic correlates of ever cigarette use, past 30-day cigarette use, and daily cigarette use, weighted to account for non-response. Measures of SES assessed current education, household income, employment status, and subjective financial situation (SFS) and childhood SES (maternal and paternal education, SFS during childhood, parental divorce before age 18). Parental smoking during childhood was examined in sensitivity analyses. The highest prevalence of ever cigarette use was in young adults whose parents divorced before age 18 (57% vs. 47% overall). In general, current education, subjective financial status, and parental education were inversely correlated with past 30-day and daily cigarette use in bivariate analyses. In multivariable Poisson regression models controlling for age, gender, race/ethnicity, and other SES measures, lower education and poorer SFS were most strongly correlated with ever and past 30-day cigarette use. Lower maternal education emerged as the strongest correlate of daily smoking, conferring a twofold higher prevalence of daily smoking compared to maternal education of a Bachelor's degree or greater. Current household income was not a strong predictor of any cigarette use outcome. Novel measures like SFS may improve estimates of socioeconomic disadvantage during this developmental stage.

Barriers to Smoking Cessation Among Drug-Resistant Tuberculosis Patients in South Africa

BACKGROUND

Drug-resistant tuberculosis (DR-TB) remains a significant cause of morbidity and mortality. The long-term health effects of smoking and the risk of adverse TB outcomes, including increased periods of infectiousness, have been reported among DR-TB patients in South Africa.

OBJECTIVES

This study aimed to identify the barriers to smoking cessation among DR-TB inpatients at a hospital in Durban, South Africa.

METHODS

A qualitative design using in-depth interviews with a purposive sample of 20 DR-TB inpatients was employed. The sample included 15 men and 5 women aged 18-70 years who self-identified as smokers. Open-ended questions were used to explore barriers militating against smoking cessation among this sample. Data were analyzed with the aid of the software QSR NVivo10.

FINDINGS

Personal and structural-level barriers (factors) to smoking cessation were identified. Personal factors included addiction and non-addiction-related barriers. Addiction-related barriers included smoking history, cravings for a cigarette, smoking as part of a daily routine, and failed quit attempts. Non-addiction-related barriers included lack of knowledge about quit strategies, psychosocial stress, lack of the willpower to quit smoking, and the influence of peers. Structural barriers included ineffective health education programs, lack of extramural activities when on admission in hospital leading to a lot of spare time, lack of smoking cessation interventions, and access to cigarettes within and around the hospital environment. Patients expressed interest in smoking cessation and conveyed their frustration at the lack of appropriate support to do so.

CONCLUSIONS

The findings reiterate the need for smoking cessation intervention to be incorporated as an integral component of DR-TB management in South Africa. Many patients expressed an interest in pharmacological aids and psychological support to help them to quit smoking. Additionally, offering extramural activities and enforcing smoke-free policies in hospital facilities will help to reduce patients' access to cigarettes while at the hospital.

Integrating tobacco treatment into cancer care: Study protocol for a randomized controlled comparative effectiveness trial

BACKGROUND

Despite the well-established risks of persistent smoking, 10-30% of cancer patients continue to smoke after diagnosis. Evidence-based tobacco treatment has yet to be integrated into routine oncology care. This paper describes the protocol, manualized treatment, evaluation plan, and overall study design of comparing the effectiveness and cost of two treatments across two major cancer centers.

METHODS/DESIGN

A two-arm, two-site randomized controlled comparative effectiveness trial is testing the hypothesis that an Intensive Treatment (IT) intervention is more effective than a Standard Treatment (ST) intervention in helping recently diagnosed cancer patients quit smoking. Both interventions include 4 weekly counseling sessions and FDA-approved smoking cessation medication advice. The IT includes an additional 4 biweekly and 3 monthly booster sessions as well as dispensal of the recommended FDA-approved smoking cessation medication at no cost. The trial is enrolling patients with suspected or newly diagnosed cancer who have smoked a cigarette in the past 30days. Participants are randomly assigned to receive the ST or IT condition. Tobacco cessation outcomes are assessed at 3 and 6months. The primary study outcome is 7-day point prevalence biochemically-validated tobacco abstinence. Secondary study outcomes include the incremental cost-effectiveness of the IT vs. ST.

DISCUSSION

This trial will answer key questions about delivering tobacco treatment interventions to newly diagnosed cancer patients. If found to be efficacious and cost-effective, this treatment will serve as a model to be integrated into oncology care settings nation-wide, as we strive to improve treatment outcomes and quality of life for cancer patients.