Addressing Smoking in Persons With Multiple Sclerosis: State of the Science and Need for a Targeted Intervention

Motivators and barriers for smoking cessation in people with multiple sclerosis: a qualitative study to inform the design of a tailored intervention

BACKGROUND

Tobacco smoking is a relevant determinant of multiple sclerosis (MS) onset, and smokers have increased risk for faster progression of MS compared to non-smokers. While the smoking prevalence is high in Germany, no smoking cessation programs have been developed specifically in MS populations to date, and only little is known about the motivators and barriers influencing smoking cessation in people with MS (pwMS) in Germany. This study aims to identify these factors to inform the design of a tailored smoking cessation intervention.

METHODS

As part of a larger program of work, we conducted semi-structured interviews in people with MS (pwMS) to explore their needs, motivators and barriers regarding smoking cessation. We recruited via MS-websites and the email-newsletter of our institution at the University Medical Centre Hamburg-Eppendorf. Participants were eligible if they had a self-reported MS-diagnosis and currently smoked or quit smoking within the last two years but after their MS-diagnosis. Interviews were conducted online and via telephone during May and June 2023. Data were analysed using thematic analysis based on a realistic approach.

RESULTS

Eight women and seven men participated in our interviews. Eleven were current, four were former smokers. Median time since diagnosis was 4 years (range: 1-26). Interviews identified MS-diagnosis, concerns about general health, and social factors as relevant motivators to stop smoking. Furthermore, worries about negative consequences when quitting (e.g. fear of missing out on social interactions or weight gain) were identified as a great barrier to smoking cessation. Knowledge about the connection between MS and smoking, and satisfaction with communication with MS clinicians were low. PwMS expressed a need for better conversations with neurologists and expert-led smoking cessation interventions. Additionally, we found that the wish for peer-exchange and the willingness to participate in smoking cessation programs was high.

CONCLUSION

Our results confirm findings of previous studies from other countries, identifying lack of knowledge, unsatisfactory communication with MS clinicians, and worries about negative consequences when quitting as barriers, and the MS-diagnosis as a motivator for smoking cessation. In a next step, we will use our findings for the development of an MS-specific online smoking cessation program.

Resilience, Mental Health, Sleep, and Smoking Mediate Pathways Between Lifetime Stressors and Multiple Sclerosis Severity

Introduction

Lifetime stressors (e.g., poverty, violence, discrimination) have been linked to features of multiple sclerosis (MS); yet mechanistic pathways and relationships with cumulative disease severity remain nebulous. Further, protective factors like resilience, that may attenuate the effects of stressors on outcomes, are seldom evaluated.

Aim

To deconstruct pathways between lifetime stressors and cumulative severity on MS outcomes, accounting for resilience.

Methods

Adults with MS (N = 924) participated in an online survey through the National MS Society listserv. Structural equation modeling was used to examine the direct and indirect effects of lifetime stressors (count/severity) on MS severity (self-reported disability, relapse burden, fatigue, pain intensity, and interference) via resilience, mental health (anxiety and depression), sleep disturbance, and smoking.

Results

The final analytic model had an excellent fit (GFI = 0.998). Lifetime stressors had a direct relationship with MS severity (β = 0.27, p < 0.001). Resilience, mental health, sleep disturbance, and smoking significantly mediated the relationship between lifetime stressors and MS severity. The total effect of the mediation was significant (β = 0.45).

Conclusions

This work provides foundational evidence to inform the conceptualization of pathways by which stress could influence MS disease burden. Resilience may attenuate the effects of stressors, while poor mental health, smoking, and sleep disturbances may exacerbate their impact. Parallel with usual care, these mediators could be targets for early multimodal therapies to improve the disease course.

Investigating disparities in smoking cessation treatment for veterans with multiple sclerosis: A national analysis

BACKGROUND AND AIMS

Smoking is a risk factor for multiple sclerosis (MS) development, symptom burden, decreased medication efficacy, and increased disease-related mortality. Veterans with MS (VwMS) smoke at critically high rates; however, treatment rates and possible disparities are unknown. To promote equitable treatment, we aim to investigate smoking cessation prescription practices for VwMS across social determinant factors.

METHODS

We extracted data from the national Veterans Health Administration electronic health records between October 1, 2017, and September 30, 2018. To derive marginal estimates of the association of MS with receipt of smoking-cessation pharmacotherapy, we used propensity score matching through the extreme gradient boosting machine learning model. VwMS who smoke were matched with veterans without MS who smoke on factors including age, race, depression, and healthcare visits. To assess the marginal association of MS with different cessation treatments, we used logistic regression and conducted stratified analyses by sex, race, and ethnicity.

RESULTS

The matched sample achieved a good balance across most covariates, compared to the pre-match sample. VwMS (n = 3320) had decreased odds of receiving prescriptions for nicotine patches ([Odds Ratio]OR = 0.86, p < .01), non-patch nicotine replacement therapy (NRT; OR = 0.81, p < .001), and standard practice dual NRT (OR = 0.77, p < .01), compared to matches without MS (n = 13,280). Men with MS had lower odds of receiving prescriptions for nicotine patches (OR = 0.88, p = .05), non-patch NRT (OR = 0.77, p < .001), and dual NRT (OR = 0.72, p < .001). Similarly, Black VwMS had lower odds of receiving prescriptions for patches (OR = 0.62, p < .001), non-patch NRT (OR = 0.75, p < .05), and dual NRT (OR = 0.52, p < .01). The odds of receiving prescriptions for bupropion or varenicline did not differ between VwMS and matches without MS.

CONCLUSION

VwMS received significantly less smoking cessation treatment, compared to matched controls without MS, showing a critical gap in health services as VwMS are not receiving dual NRT as the standard of care. Prescription rates were especially lower for male and Black VwMS, suggesting that under-represented demographic groups outside of the white female category, most often considered as the "traditional MS" group, could be under-treated regarding smoking cessation support. This foundational work will help inform future work to promote equitable treatment and implementation of cessation interventions for people living with MS.

Resilience, mental health, sleep, and smoking mediate pathways between lifetime stressors and Multiple Sclerosis severity

Intro

Lifetime stressors (e.g., poverty, violence, discrimination) have been linked to Multiple Sclerosis (MS) features; yet mechanistic pathways and relationships with cumulative disease severity remain nebulous. Further, protective factors like resilience, that may attenuate the effects of stressors on outcomes, are seldom evaluated.

Aim

To deconstruct pathways between lifetime stressors and cumulative severity on MS outcomes, accounting for resilience.

Methods

Adults with MS (N=924) participated in an online survey through the National MS Society listserv. Structural Equation Modeling was used to examine the direct and indirect effect of lifetime stressors (count/severity) on MS severity (self-reported disability, relapse burden, fatigue, pain intensity and interference), via resilience, mental health (anxiety and depression), sleep disturbance, and smoking.

Results

The final analytic model had excellent fit (GFI=0.998). Lifetime stressors had a direct relationship with MS severity (β=0.27, p<.001). Resilience, mental health, sleep disturbance, and smoking significantly mediated the relationship between lifetime stressors and MS severity. The total effect of mediation was significant (β=0.45).

Conclusions

This work provides foundational evidence to inform conceptualization of pathways by which stress could influence MS disease burden. Resilience may attenuate effects of stressors, while poor mental health, smoking, and sleep disturbances may exacerbate their impact. Parallel with usual care, these mediators could be targets for early multimodal therapies to improve disease course.