Disparities in tobacco cessation medication orders and fills among special populations

Cocreation of a conversational agent to help patients adhere to their varenicline treatment: A study protocol

Objective

Varenicline is the most efficacious approved smoking cessation medication, making it one of the most cost-effective clinical interventions for reducing tobacco-related morbidity and mortality. Adhering to varenicline is strongly associated with smoking cessation. Healthbots have the potential to help people adhere to their medications by scaling up evidence-based behavioral interventions. In this protocol, we outline how we will follow the UK's Medical Research Council's guidance to codesign a theory-informed, evidence-based, and patient-centered healthbot to help people adhere to varenicline.

Methods

The study will utilize the Discover, Design and Build, and Test framework and will include three phases: (a) a rapid review and interviews with 20 patients and 20 healthcare providers to understand barriers and facilitators to varenicline adherence (Discover phase); (b) Wizard of Oz test to design the healthbot and get a sense of the questions that chatbot has to be able to answer (Design phase); and (c) building, training, and beta-testing the healthbot (Building and Testing phases) where the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability framework will be used to develop the healthbot using the simplest sensible solution, and 20 participants will beta test the healthbot. We will use the Capability, Opportunity, Motivation-Behavior (COM-B) model of behavior change and its associated framework, the Theoretical Domains Framework, to organize the findings.

Conclusions

The present approach will enable us to systematically identify the most appropriate features for the healthbot based on a well-established behavioral theory, the latest scientific evidence, and end users' and healthcare providers' knowledge.

Barriers and Facilitators for Smoking Cessation in Chinese Smokers with Chronic Obstructive Pulmonary Disease: A Qualitative Study

Background

Smoking cessation is recommended as a key intervention for chronic obstructive pulmonary disease (COPD) smokers. However, in China, few COPD smokers quit successfully. The aim of this study was to explore in depth the barriers and facilitators for smoking cessation among smokers with COPD in China.

Methods

A purposive sample of 32 hospitalized smokers with COPD were included, 17 ex-smokers and 15 current smokers, participated in the semi-structured interviews. Interviews were analyzed thematically and using a deductive approach guided by Capability, Opportunity, Motivation-Behavior (COM-B) framework.

Results

Three inter-related themes were generated: smokers’ motivation was a prerequisite for quitting, maintaining capability to quit smoking, and opportunities that facilitated smokers to quit. Motivation to quit for most participants was activated by COPD-related symptoms, although they had a limited knowledge of COPD. Physical benefits from quitting and strong willpower were facilitators for maintaining quitting, while exposure to smoking environment and strong addiction to nicotine were frequent reasons for relapse. Most ex-smokers quit smoking by their own willpower rather than professionally delivered smoking cessation interventions. Smokers’ attitudes toward these interventions depended on their effectiveness and convenience. Very few participants had experienced pharmacotherapy or behavioral support from physicians. However, interviewees preferred auricular acupressure to pharmacotherapy.

Conclusion

Motivation to quit among smokers with COPD was usually initiated by COPD-related symptoms. Physical benefits observed by quitting and strong willpower facilitated smoking cessation, while exposure to smoking environment and strong addiction to nicotine led to relapse. COPD smokers in China preferred auricular acupressure to pharmacotherapy.

Disparities in the receipt of medical doctors' advice to quit smoking in the U.S., 1992-2019

There has been significant progress in reducing tobacco use in the last few decades. However, there is a considerable concern that the decrease in cigarette use has not been distributed equally across certain groups. The current study examines sociodemographic trends in the receipt of advice to quit from healthcare professionals. Data were drawn from the 1992-2019 Tobacco Use Supplement to the Current Population Survey (n = 192,398). Cochran-Armitage tests were used to assess changes in the prevalence over time in the population and by demographic characteristics. Multivariable logistic regression was used to examine factors associated with the receipt of advice to quit smoking. The prevalence of receiving advice to quit increased significantly from 50.1% in 1992/1993 to 63.9% in 2018/2019. Results showed differences in the receipt of quit advice from medical doctors by demographic characteristics, with a significant increase in smoking quit advice for all races (p < 0.0001). Current Hispanic smokers consistently had lower rates of receiving advice to quit than non-Hispanics throughout the study period. Multivariable analysis showed that in 2018/19, male (aOR 0.89; 95% CI 0.81-0.98) and Hispanic (aOR 0.73; 95% CI 0.61-0.88) current smokers were less likely to receive advice to quit. Those older and living in metropolitan areas had higher odds of receiving advice to quit. Findings that Hispanics appear to be significantly less likely to receive advice to quit from health care professionals indicate that these populations might need additional targeted efforts.

Tobacco Cessation Counseling and Medications Provided by Physicians to Tobacco Users During Primary Care Visits

INTRODUCTION

The established guidelines for treating tobacco use and dependency is brief provider intervention to assist those willing to quit by providing access to medication and/or behavioral counseling. The purpose of the study is to determine the extent of cessation treatment offered by providers during primary care visits by patients who are current tobacco users, and to examine associations between patient factors and treatment received.

METHODS

Using data from the 2015 to 2018 National Ambulatory Medical Care Survey (NAMCS), we examined tobacco cessation counseling and medications from 4590 visits by patients with current tobacco use. Separate multivariate logistic regressions were used to assess whether the odds of receiving tobacco cessation treatment varied by age, gender, race/ethnicity, and payment source.

RESULTS

Of visits by current tobacco users, 18.4% included cessation counseling, 5.5% included cessation medication, and 22.1% included at least 1 type of treatment. Visits by patients with Medicare had 44% greater odds of including counseling (CI = 1%-205%) and treatment (OR = 1.44; 95% CI = 1.01-2.06). Visits classified as "other payment type" had 73% greater odds of including counseling (OR = 1.73; 95% CI = 1.05-2.84). Visits by women had 86% greater odds of including medication (CI = 17%-294%).

CONCLUSIONS

Tobacco cessation treatment is underutilized by providers during primary care visits. Further research is necessary to understand and address barriers to providing routine cessation assistance.

A qualitative analysis of nicotine replacement therapy uptake, consistent use, and persistence among primary care patients who smoke

•Adherence can be broken into three processes: uptake, consistent use, and persistence.•Barriers and facilitators to NRT use vary over the three adherence processes.•Information gaps and negative stories about NRT are common barriers to adherence.•NRT adherence may be improved by addressing patient knowledge and concerns.

Nicotine Patch Prescription Fulfillment Rates for Emergency Department Patients

Introduction

Smoking cessation has significant health benefits, and the emergency department (ED) can be an important venue for smoking cessation counseling. Nicotine replacement therapy with transdermal patches has been shown to be associated with smoking cessation in a variety of studies. This study evaluated fulfillment rates for prescriptions for nicotine replacement transdermal patches (NRT-P) from the ED.

Methods

We conducted a retrospective review of all patients receiving a prescription for a NRT-P product from January 2018–October 2019. Charts were reviewed to gather data including age, gender, presence of chronic heart or lung problems, and health insurance. We assessed the fulfillment rate of prescriptions using the Surescripts system, which is a functionality within our electronic health record system that queries participating pharmacies. Statistical analysis was conducted to determine associations between fill rates and the other variables collected from charts.

Results

We had follow-up on 500 patients prescribed nicotine patches. Of those patients, 44% filled their prescriptions. Those who filled their prescriptions were more likely to be female and have a history of chronic lung disease. Self-pay patients were least likely to fill their prescriptions. Overall, we had evidence of smoking cessation in 13% of patients.

Conclusion

This study found that a substantial proportion of patients fail to fill their NRT-P prescriptions. Further work on means of enhancing fulfillment rates is warranted.

Adherence and Efficacy of Smoking Cessation Treatment Among Patients with COPD in China

Background

Smoking cessation is a key intervention for all smokers with chronic obstructive pulmonary disease (COPD). Poor treatment adherence is a challenge in clinical practice that might contribute to the lower efficacy of medication (eg, oral drug). However, it is unclear what factors will influence adherence among smokers with COPD.

Methods

This study was based on an open-label randomized controlled trial (RCT) of varenicline and bupropion for smoking cessation among patients with COPD in China. The medication was given for 12 weeks, and visits and assessments were conducted at weeks 0, 1, 2, 4, 6, 9, 12, and 24. We assessed whether the adherence to smoking cessation treatment affects the smoking cessation efficacy and evaluated predictors of adherence.

Results

A total of 136 participants were recruited from February 2019 to June 2020, and analyzed using the intention-to-treat (ITT) method. In this study, 48.5% (66/136) of the total participants had good adherence to smoking cessation, and good adherence significantly improved the efficacy of smoking cessation (OR=9.60, 95% CI 4.02–22.96, P < 0.001). After adjusting for age, gender, nationality, education, and marital status, we found older age, higher education level, having more previous quitting attempts, stronger self-efficacy and preparation in quitting smoking, recognizing hazards of smoking, longer duration of COPD, and higher St. George’s Respiratory Questionnaire (SGRQ) scores were relevant to good adherence (P < 0.05).

Conclusion

To our best knowledge, this is the first study to evaluate adherence to smoking cessation treatment among patients with COPD in China. Our study found that good adherence to smoking cessation treatment significantly improved the smoking cessation efficacy, and predictors of adherence were evaluated. We call on the medical community to pay attention to the adherence to smoking cessation among patients with COPD.

Barriers and Facilitators of Adherence to Nicotine Replacement Therapy: A Systematic Review and Analysis Using the Capability, Opportunity, Motivation, and Behaviour (COM-B) Model

BACKGROUND

Poor adherence to nicotine replacement therapy (NRT) is associated with low rates of smoking cessation. Hence, this study aims to identify and map patient-related factors associated with adherence to NRT using the capability, opportunity, motivation, and behaviour (COM-B) model.

METHODS

A systematic review was conducted by searching five databases (MEDLINE, Scopus, EMBASE, CINAHL, and PsycINFO) and grey literature on 30 August 2020. Data were extracted, thematically analysed, and mapped to the COM-B model. The Joanna Briggs Institute (JBI) critical appraisal tool was utilised to assess the quality of studies.

RESULTS

A total of 2929 citations were screened, and 26 articles with a total of 13,429 participants included. Thirty-one factors were identified and mapped to COM-B model: psychological capability (forgetfulness, education), physical capability (level of nicotine dependence, withdrawal symptoms), reflective motivation (perception about NRT and quitting), automatic motivation (alcohol use, stress, depression), physical opportunity (cost), and social opportunity (social support). The most prominent element associated with adherence was reflective motivation followed by physical capability and automatic motivation.

CONCLUSIONS

Multiple personal, social, and environmental factors affect NRT adherence. Hence, it is recommended to implement a multifaceted behavioural intervention incorporating factors categorised under the COM-B model, which is the hub of the behaviour change wheel (BCW) to improve adherence and quitting.

Evaluating level of adherence to nicotine replacement therapy and its impact on smoking cessation: a protocol for systematic review and meta-analysis

INTRODUCTION

Nicotine replacement therapy (NRT) has proven effective for smoking cessation in clinical trials, however it was found less effective in population-based studies, potentially due to inconsistent or incorrect use of NRT. The aim of this paper is to describe a systematic review protocol to evaluate level of adherence to NRT; the discrepancy of adherence to NRT in clinical and population-based studies and degree of association between level of adherence and success of smoking cessation.

METHODS AND ANALYSIS

Literature search will use five databases (Medline, Scopus, Embase, CINAHL and PsycINFO). Studies will be appraised for methodological quality using National Institutes of Health Quality Assessment Tool. To reduce heterogeneity, we will analyse clinical trials and population-based studies separately; pooled analyses will be done among studies that used similar measurements. Heterogeneity of studies will be assessed by Higgins' I² statistical test. When studies are adequately homogeneous, results will be pooled using random-effects model with proportion and ORs with 95% CIs and p values for each outcome. We will explain sources of heterogeneity by subgroup analysis or sensitivity analysis. Funnel plots and Egger's regression asymmetry test with p<0.05 will be used as a cut-off point to affirm presence of statistically significant publication bias. Statistical analyses will be carried out using Stata V.16 software. Only studies reporting a valid strategy to control for reverse causality will be included.

DISCUSSION

This review will provide evidence to support the importance of adherence on rate of smoking cessation and level of adherence to NRT. The findings will be used to inform smoking cessation interventions, researchers and policymakers.

ETHICS AND DISSEMINATION

As a systematic literature review, this protocol does not require ethics approval. Research outcomes will be presented at relevant conferences and findings will be published in a relevant peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020176749.

Cold Turkey and Hot Vapes? A National Study of Young Adult Cigarette Cessation Strategies

INTRODUCTION

Young adults have high smoking rates and low utilization of evidence-based smoking cessation strategies. We investigated smoking cessation intentions, strategy use, and socioeconomic predictors of strategy use among young adult smokers (age 18-24) and compared patterns with those of older adults (age 25-64).

METHODS

We used a population-based sample from the Population Assessment of Tobacco and Health (PATH) study of young adult (n = 1,881) and older adult (n = 6,366) established smokers of conventional cigarettes at Wave 1 (2013-2014), who were surveyed at Wave 2 (2014-2015). Simple regression analysis compared intentions to quit between age groups. Among Wave 1 smokers who reported a Wave 2 quit attempt (young adults [YA] n = 748; older adults [OA] n = 2,068), bivariate and multinomial logistic regression estimated differences in use of behavioral support, pharmacotherapy, product substitution, and unassisted quit attempts. Interaction terms estimated age-group differences in relationships between predictors and cessation strategy use.

RESULTS

Young adults planned to quit on a longer time frame, expressed lower interest in quitting, and were more confident they would be successful, compared with older adults. Young adults were significantly less likely to use pharmacotherapy (adjusted odds ratio: 0.15; confidence interval: 0.09, 0.24; reference: quitting unassisted). Both groups reported using product substitution (YA: 31.6%; OA: 28.5%), primarily with e-cigarettes, more than any evidence-based cessation strategy. Socioeconomic predictors of cessation strategy use did not differ between age groups.

CONCLUSIONS

More research on why young adult smokers underutilize evidence-based cessation support is needed, as are innovative efforts to increase intentions to quit and utilization of cessation assistance.

IMPLICATIONS

Young adulthood is a key transition time for tobacco use, and early cessation substantially reduces the risk of morbidity and mortality from smoking. In the context of high e-cigarette and polytobacco use, this study finds young adults have significantly less intention to quit than older adults and are less likely to use evidence-based cessation strategies to help quit. Innovative methods are needed to increase young adult intentions to quit and use of evidence-based cessation assistance.

What components of smoking cessation care during pregnancy are implemented by health providers? A systematic review and meta-analysis

BACKGROUND

Pregnancy is an opportunity for health providers to support women to stop smoking.

OBJECTIVES

Identify the pooled prevalence for health providers in providing components of smoking cessation care to women who smoke during pregnancy.

DESIGN

A systematic review synthesising original articles that reported on (1) prevalence of health providers' performing the 5As ('Ask', 'Advise', 'Assess', 'Assist', 'Arrange'), prescribing nicotine replacement therapy (NRT) and (2) factors associated with smoking cessation care.

DATA SOURCES

MEDLINE, EMBASE, CINAHL and PsycINFO databases searched using 'smoking', 'pregnancy' and 'health provider practices'.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies included any design except interventions (self-report, audit, observed consultations and women's reports), in English, with no date restriction, up to June 2017.

PARTICIPANTS

Health providers of any profession.

DATA EXTRACTION, APPRAISAL AND ANALYSIS

Data were extracted, then appraised with the Hawker tool. Meta-analyses pooled percentages for performing each of the 5As and prescribing NRT, using, for example, 'often/always' and 'always/all'. Meta-regressions were performed of 5As for 'often/always'.

RESULTS

Of 3933 papers, 54 were included (n=29 225 participants): 33 for meta-analysis. Health providers included general practitioners, obstetricians, midwives and others from 10 countries. Pooled percentages of studies reporting practices 'often/always' were: 'Ask' (n=9) 91.6% (95% CI 88.2% to 95%); 'Advise' (n=7) 90% (95% CI 72.5% to 99.3%), 'Assess' (n=3) 79.2% (95% CI 76.5% to 81.8%), 'Assist (cessation support)' (n=5) 59.1% (95% CI 56% to 62.2%), 'Arrange (referral)' (n=6) 33.3% (95% CI 20.4% to 46.2%) and 'prescribing NRT' (n=6) 25.4% (95% CI 12.8% to 38%). Heterogeneity (I2) was 95.9%-99.1%. Meta-regressions for 'Arrange' were significant for year (p=0.013) and country (p=0.037).

CONCLUSIONS

Health providers 'Ask', 'Advise' and 'Assess' most pregnant women about smoking. 'Assist', 'Arrange' and 'prescribing NRT' are reported at lower rates: strategies to improve these should be considered.

PROSPERO REGISTRATION NUMBER

CRD42015029989.

[COPD and smoking cessation: Patients' expectations and responses of health professionals]

The importance of smoking cessation in the management of COPD is well-established: the benefit of quitting smoking as regards morbidity and mortality outcomes in patients, is unquestioned. The smoking cessation in COPD patients is difficult: high levels of consumption, the duration of smoking, high dependence level, psychological co-morbidities such as anxiety and depression, lower socio-economic and intellectual level, constitute barriers. Studies have shown that patients often minimize the risks of smoking, that others do not believe in the benefits of quitting or doubt their ability to quit smoking. The patients' experience, and expectations with regard to smoking cessation are incompletely satisfied: are considered, the smoking characteristics of these patients, the understanding of the tobacco dependence, the beliefs and ideas of smokers, the knowledge of smoking cessation methods, the role of validated aids and alternative treatments, failure management. The answers of the health professionals can be in several directions: establishment of a better communication patient-doctor (empathy), more centered on the needs of the smoker, the role of the motivation and the place of the motivational interview, the understanding of the mechanisms of addiction, a better individualisation of therapeutics, the necessity of a extended follow-up, the contribution of modern technologies, the electronic cigarette, the smoking cessation in respiratory rehabilitation, guidelines that address smoking cessation treatment.

Adherence to Pharmacological Smoking Cessation Interventions: A Literature Review and Synthesis of Correlates and Barriers

Introduction

Efficacious pharmacological interventions for smoking cessation are available, but poor adherence to these treatments may limit these interventions overall impact. To improve adherence to smoking cessation interventions, it is first necessary to identify and understand smoker-level characteristics that drive nonadherence (ie, nonconformance with a provider's recommendation of timing, dosage, or frequency of medication-taking during the prescribed length of time).

Methods

We present a literature review of studies examining correlates of, or self-reported reasons for, nonadherence to smoking cessation pharmacotherapies. Studies were identified through PubMed-using MeSH terms, Embase-using Emtree terms, and ISI Web of Science.

Results and Conclusions

This literature review included 50 studies that examined nonpreventable (eg, sociodemographics) and preventable (eg, forgetfulness) factors associated with adherence to smoking cessation medication and suggestions for overcoming some of the identified barriers. Systematic study of this topic would be facilitated by consistent reporting of adherence and correlates thereof in the literature, development of consistent definitions of medication adherence across studies, utilization of more objective measures of adherence (eg, blood plasma levels vs. self-report) in addition to reliance on self-reported adherence.

Implications

This article provides the most comprehensive review to date on correlates of adherence to pharmacological smoking cessation interventions. Challenges and specific gaps in the literature that should be a priority for future research are discussed. Future priorities include additional research, particularly among vulnerable populations of smokers, developing standardized definitions of adherence and methods for measuring adherence, regular assessment of cessation pharmacotherapy adherence in the context of research and clinical practice, and development of novel treatments aimed at preventable barriers to medication adherence.

Predicting smoking abstinence with biological and self-report measures of adherence to varenicline: Impact on pharmacogenetic trial outcomes

INTRODUCTION

Adherence to pharmacotherapies for tobacco dependence, such as varenicline, is necessary for effective treatment. The relationship between varenicline adherence, determined by commonly used indirect (i.e., self-reported pill counts) and infrequently used direct (i.e., varenicline levels) methods, and abstinence outcomes have not been previously examined, nor has their impact on the outcomes of a genetically randomized clinical trial been assessed.

METHODS

At Week 1 following target quit date, self-reported pill count and salivary varenicline levels were obtained from participants (N = 376) in a smoking cessation clinical trial (NCT01314001). Point-prevalence abstinence was biochemically-verified by salivary cotinine at Week 1 and by exhaled carbon monoxide at Week 1, end-of-treatment, 6 and 12 months following treatment. Blood nicotine metabolite ratio (NMR) was obtained at baseline.

RESULTS

Adherent individuals based on varenicline levels were significantly more likely to be abstinent than non-adherent individuals at Week 1 (odds ratios [ORs] 1.92-3.16, p's≤0.006), end-of-treatment (OR = 2.53, p = .004), and six months following treatment (OR = 2.30, p = .03). In contrast, pill counts did not consistently predict abstinence. Including direct measures of adherence enhanced the association between rate of nicotine metabolism (NMR) and end-of-treatment abstinence; normal metabolizers (NMR ≥ 0.31) were significantly more likely than slow metabolizers (NMR < 0.31) to be abstinent at end-of-treatment (OR = 2.00, p = .005).

CONCLUSION

Adherence based on salivary varenicline, rather than on pill counts, is predictive of Week 1 abstinence, irrespective of the biomarker of abstinence assessed, and of long-term abstinence. Direct measures of adherence enhance the ability to assess the impact of a biomarker or genetic marker on abstinence outcomes.

[Characteristics of non-pharmacological interventions in the elderly with COPD. Smoking cessation, pulmonary rehabilitation, nutritional management and patient education]

Chronic obstructive pulmonary disease (COPD) is a respiratory disorder responsible for a high mortality and disability. People older than 65 years are more commonly affected than younger people and tend to present with more symptoms and a greater level of disability. Non-pharmacological interventions play an important role in the management of all patients with COPD and this is particularly true in the elderly. Given the improvement in quality of life and risk of hospitalization, smoking cessation should be promoted to patients of all ages. Increased physical activity is associated with reduced respiratory symptoms. Tests such as the "Short Physical Performance Battery" can be useful in frailer older people with COPD, while walking tests such as the 6-minute walk test are used as an assessment before pulmonary rehabilitation. Increased physical activity should be combined with nutritional management. Screening for undernutrition by questionnaire, body mass index and albumin quantification is recommended in the elderly. In case of undernutrition, oral supplementation seems to reduce the risk of re-admission. All these measures must be included in an education program adapted to the elderly comorbidities (hearing loss, isolation…).

Disparities in Smoking Cessation Assistance in US Primary Care Clinics

OBJECTIVES

To examine associations between patient factors and smoking cessation assistance in US safety-net clinics.

METHODS

Using electronic health record data from the OCHIN network, we identified adults with at least 1 primary care visit to a study clinic (n = 143 clinics in 12 states) with at least 1 documented "current smoker" status during 2014 to 2016 (n = 136 314; 29.8%). We estimated odds ratios (ORs) of smoking cessation assistance receipt (none [reference], counseling, medication, or both) by patient covariates.

RESULTS

For all cessation assistance categories, odds of assistance were higher among women, those with more visits, those assessed and ready to quit, and patients with asthma or chronic obstructive pulmonary disease and hyperlipidemia. Odds of receiving both counseling and medication were lower among uninsured patients (OR = 0.56; 95% confidence interval [CI] = 0.48, 0.64), those of a race/ethnicity other than non-Hispanic White (OR range = 0.65-0.82), and those with diabetes (OR = 0.85; 95% CI = 0.79, 0.92), and higher among older patients and those with a comorbidity, with few exceptions.

CONCLUSIONS

Disparities in smoking cessation assistance receipt exist in safety-net settings, in particular by health insurance coverage and across race/ethnicity, even after control for other socioeconomic and demographic factors.

Association between race and receipt of counselling or medication for smoking cessation in primary care

BACKGROUND

Previous evidence of race disparities in smoking cessation treatment has been limited to mostly survey studies which increase the potential for recall bias. We examined if African American versus white patients in primary care are less likely to receive any treatment or if race disparities are specific to the type of treatment offered using data pulled from a large electronic health record system.

METHODS

Medical record data from 3510 white and 2707 African American patients were available from primary care encounters between 2008 and 2015 and was used to define smoking status, cessation treatments (counselling and medication), and covariates. The association between race and type of smoking cessation treatment offered was measured by logistic regression models before and after adjusting for covariates.

RESULTS

Smoking cessation counselling was offered to 9.3% of African American and 7.8% of white patients, and a prescription for smoking cessation medication was offered to 12.3% of African American and 16.4% of white patients. After adjusting for covariates in logistic regression models, whites were significantly less likely than African American patients to receive smoking cessation counselling [odds ratio (OR) = 0.81; 95% confidence interval (CI) = 0.65-0.99] and were significantly more likely to receive a prescription for a smoking cessation medication (OR = 1.23; 95% CI = 1.03-1.47).

CONCLUSIONS

Less than 20% of smokers received any type of therapy to assist in smoking cessation. We observed a race disparity in type of smoking cessation therapy provided to white and African American primary care patients. Further research is needed to increase treatment rates and eliminate disparities.

Pharmacological Smoking Cessation Therapies in Older Adults: A Review of the Evidence

Nearly 12% of adults 65 years and over in Europe and 9% in the USA are current cigarette smokers. Numerous studies have demonstrated tangible benefits of smoking cessation, regardless of advanced age. However, it is unclear which pharmacotherapy strategies are most effective in the elderly population. To that end, the literature on smoking cessation in older adults was reviewed with the aim of identifying the safest and most effective cessation pharmacotherapies. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for all articles pertaining to elderly smoking cessation strategies. Randomized controlled trials and cohort studies were included. Studies were included without regard to population or intervention, as long as results were analyzed with a group of smokers aged 60 years and above and at least one arm of the study involved a pharmacotherapy. Only 12 studies were identified that met our inclusion criteria. The limited existing literature does not allow for a definitive answer to the most effective pharmacotherapy for smoking cessation in older adult smokers. Nicotine replacement therapy (NRT) is the pharmacotherapy most studied in older adults, and the limited evidence that exists suggests that NRT is effective for smoking cessation among this population. Higher-quality studies that directly compare cessation strategies, including bupropion and varenicline, are needed in the older population in order to guide treatment decision making.

Community-based navigators for tobacco cessation treatment: a proof-of-concept pilot study among low-income smokers

BACKGROUND

A majority of continuing smokers in the United States are socioeconomically disadvantaged (SED) adults, who are less likely than others to achieve and maintain abstinence despite comparable quit-attempt rates. A national research initiative seeks effective new strategies for increasing successful smoking cessation outcomes among SED populations. There is evidence that chronic and acute stressors may interfere with SED smokers who try to quit on their own. Patient navigators have been effectively used to improve adherence to chronic disease treatment. We designed and have pilot-tested an innovative, non-clinical community-based intervention--smoking cessation treatment navigators--to determine feasibility (acceptance, adherence, and uncontrolled results) for evaluation by randomized controlled trial (RCT).

METHODS

The intervention was developed for smokers among parents and other household members of inner city pre-school for low-income children. Smoking cessation treatment navigators were trained and deployed to help participants choose and adhere to evidence-based cessation treatment (EBCT). Navigators provided empathy, resource-linking, problem-solving, and motivational reinforcement. Measures included rates of study follow-up completion, EBCT utilization, navigation participation, perceived intervention quality, 7-day point abstinence and longest abstinence at three months. Both complete-case and intent-to-treat analyses were performed.

RESULTS

Eighty-five percent of study participants (n = 40) completed final data collection. More than half (53%) enrolled in a telephone quitline and nearly three-fourths (71%) initiated nicotine replacement therapy. Participants completed a mean 3.4 navigation sessions (mean 30 min duration) and gave the intervention very high quality and satisfaction ratings. Self-reported abstinence was comparable to rates for evidence-based cessation strategies (21% among study completers, 18% using intent-to-treat analysis; median 21 days abstinent among relapsers).

CONCLUSIONS

The pilot results suggest that smoking cessation treatment navigators are feasible to study in community settings and are well-accepted for increasing use of EBCT among low-income smokers. Randomized controlled trial for efficacy is warranted.

Effect of nicotine replacement therapy on quitting by young adults in a trial comparing cessation services

CONTEXT

Young adult smokers have the highest smoking prevalence among all US age groups but are least likely to use evidence-based cessation counseling or medication to quit.

OBJECTIVE

Use and effectiveness of nicotine patch were explored in a randomized trial evaluating smoking cessation interventions with this population.

PARTICIPANTS

Smokers aged 18 to 30 (n = 3094) were recruited through online and off-line methods and from telephone quit lines and analyzed.

DESIGN

Smokers were enrolled in a pretest-posttest trial, and randomized to 1 of 3 cessation services.

SETTING

Trial delivering counseling services by self-help booklet, telephone quit lines, or online expert system in the 48 continental United States.

INTERVENTION

Smokers could request a free 2-week course of nicotine replacement therapy (NRT) patches from the project.

MAIN OUTCOME MEASURE

Follow-up surveys at 12 and 26 weeks assessed smoking abstinence, use of NRT, counseling, and other cessation medications, and smoking-related variables.

RESULTS

Overall, 69.0% of smokers reported using NRT (M = 3.2 weeks) at 12 weeks and 74.8% (M = 3.3 weeks) at 26 weeks. More smokers who were sent the free nicotine patches (n = 1695; 54.8%) reported using NRT than those who did not receive them (12 weeks: 84.3% vs 41.9%, P < .001; 26 weeks: 87.6% vs 51.1%, P < .001). The use of NRT was associated with greater smoking abstinence at 12 weeks (P < .001) and 26 weeks (P < .05), especially if used for more than 2 weeks (P < .001). Smokers assigned to a self-help booklet or cessation Web site and heavier smokers were most likely to use NRT (P < .05), whereas those reporting marijuana use and binge drinking used NRT less (P < .05).

CONCLUSIONS

Many young adults were willing to try NRT, and it appeared to help them quit in the context of community-based cessation services. Strategies should be developed to make NRT available to this age group and support them in using it to prevent lifelong smoking.

Comparative Effectiveness of Post-Discharge Strategies for Hospitalized Smokers: study protocol for the Helping HAND 2 randomized controlled trial

Background

Smoking cessation interventions for hospitalized smokers are effective in promoting smoking cessation, but only if the tobacco dependence treatment continues after the patient leaves the hospital. Sustaining tobacco dependence treatment after hospital discharge is a challenge for health care systems. Our previous single-site randomized controlled trial demonstrated the effectiveness of an intervention that facilitated the delivery of comprehensive tobacco cessation treatment, including both medication and counseling, after hospital discharge. We subsequently streamlined the intervention model to increase its potential for dissemination. This new model is being tested in a larger multi-site trial with broader eligibility criteria in order to enroll a more representative sample of hospitalized smokers. This paper describes the trial design and contrasts it with the earlier study.

Methods/Design

A 2-arm, 3-site randomized controlled trial is testing the hypothesis that a multi-component Sustained Care intervention is more effective than Standard Care in helping hospitalized cigarette smokers stop smoking after hospital discharge. The trial enrolls adult daily cigarette smokers who are admitted to 1 of 3 participating hospitals in Massachusetts or Pennsylvania. Participants receive the same smoking cessation intervention in the hospital. They are randomly assigned to receive either Standard Care or Sustained Care after hospital discharge. Participants in the Sustained Care arm receive a free 3-month supply of FDA-approved smoking cessation medication and 5 interactive voice response calls that provide tailored motivational messages, medication refills, and access to a live tobacco treatment counselor. Participants in the Standard Care arm receive a smoking cessation medication recommendation and information about community resources. Outcomes are assessed at 1, 3, and 6 months after discharge. The primary outcome is biochemically-validated tobacco abstinence for the past 7 days at 6-month follow-up. Other outcome measures include self-reported tobacco abstinence measures, use of medication and counseling after discharge, hospital readmissions, and program cost-effectiveness.

Discussion

We adapted a proven intervention for hospitalized smokers to enhance its potential for dissemination and are testing it in a multi-site trial. Study enrollment data suggests that the trial achieved the goal of recruiting a broader sample of hospitalized smokers.

Trial registration

Comparative Effectiveness of Post-Discharge Strategies for Hospitalized Smokers (Helping HAND2) NCT01714323. Registered October 22, 2012.

Predictors of smoking cessation medication use among nonobese and obese smokers

The objective of this study was to identify and compare the predictors of smoking cessation medication use among obese and nonobese adult smokers. A retrospective cross-sectional study was conducted using the Medical Expenditure Panel Survey (MEPS) data (2008-2009). The study participants included smokers aged 18 years and older who self-reported their smoking status as smoker. The outcome variable was utilization of any Food and Drug Administration approved smoking cessation medication (varenicline, bupropion, and nicotine replacement therapy). Multivariable logistic regression analyses were conducted. A total of 82.20 million (weighted sample size for two years) adult smokers were included; of which nearly 30% were obese-smokers. The use of smoking cessation medication was 2.66% and 5.17% among nonobese and obese smokers, respectively. Multivariable logistic regression results showed that race/ethnicity, health insurance coverage, prescription insurance coverage, usual source of health care, urban residence, region, Charlson comorbidity index, and instrumental activities of daily living (IADL), were significant predictors of using smoking cessation medications. The overall smoking cessation medication use rate was low implying limited compliance to guideline. Predictors identified in this study should be taken into consideration in health promotion programs that are designed to optimize the utilization of these smoking cessation medications.

Health disparities in cost of care in patients with Alzheimer's disease: an analysis across 4 state Medicaid populations

OBJECTIVES

To investigate health disparities with respect to cost of care across 4 state Medicaid populations.

METHODS

Data were obtained from Centers for Medicare and Medicaid Services (CMS) for this retrospective study. Patients were enrolled in a California, Florida, New Jersey, or New York Medicaid programs during 2004, with a diagnosis of Alzheimer's disease (International Classification of Diseases, Ninth Revision 331.0). Outcome of interest was cost of care. Decomposition of cost to calculate disparities was estimated using the Oaxaca-Blinder model. An a priori α level of .01 was used.

RESULTS

Approximately 158 974 individuals qualified for this study. Disparities were found to exist between blacks and whites (with blacks having higher costs; P < .0001), whites and others (with whites having higher costs; P < .0001), blacks and Hispanics (with blacks having higher costs; P < .0001), blacks and others (with blacks having higher costs; P < .0001), and Hispanics and others (with Hispanics having higher costs; P < .0001).

CONCLUSIONS

Disparities in cost among minority-to-minority populations were just as prevalent, if not higher, than minority-white disparities.

Comparative effectiveness of post-discharge interventions for hospitalized smokers: study protocol for a randomized controlled trial

Background

A hospital admission offers smokers an opportunity to quit. Smoking cessation counseling provided in the hospital is effective, but only if it continues for more than one month after discharge. Providing smoking cessation medication at discharge may add benefit to counseling. A major barrier to translating this research into clinical practice is sustaining treatment during the transition to outpatient care. An evidence-based, practical, cost-effective model that facilitates the continuation of tobacco treatment after discharge is needed. This paper describes the design of a comparative effectiveness trial testing a hospital-initiated intervention against standard care.

Methods/design

A two-arm randomized controlled trial compares the effectiveness of standard post-discharge care with a multi-component smoking cessation intervention provided for three months after discharge. Current smokers admitted to Massachusetts General Hospital who receive bedside smoking cessation counseling, intend to quit after discharge and are willing to consider smoking cessation medication are eligible. Study participants are recruited following the hospital counseling visit and randomly assigned to receive Standard Care or Extended Care after hospital discharge. Standard Care includes a recommendation for a smoking cessation medication and information about community resources. Extended Care includes up to three months of free FDA-approved smoking cessation medication and five proactive computerized telephone calls that use interactive voice response technology to provide tailored motivational messages, offer additional live telephone counseling calls from a smoking cessation counselor, and facilitate medication refills. Outcomes are assessed at one, three, and six months after hospital discharge. The primary outcomes are self-reported and validated seven-day point prevalence tobacco abstinence at six months. Other outcomes include short-term and sustained smoking cessation, post-discharge utilization of smoking cessation treatment, hospital readmissions and emergency room visits, and program cost per quit.

Discussion

This study tests a disseminable smoking intervention model for hospitalized smokers. If effective and widely adopted, it could help to reduce population smoking rates and thereby reduce tobacco-related mortality, morbidity, and health care costs.

Trial registration

United States Clinical Trials Registry NCT01177176.

Pharmacotherapy for smoking cessation: current advances and research topics

Promoting smoking cessation is among the key medical interventions aimed at reducing worldwide morbidity and mortality in this century. Both behavioural counselling and pharmacotherapy have been shown to significantly increase long-term abstinence rates, and combining the two treatment modalities is recommended. This article provides an update on pharmacotherapy for smoking cessation in the general population. Current first-line agents used to support quit attempts are nicotine replacement therapy (NRT), bupropion and varenicline. Research suggests that abstinence rates can be increased by combining different forms of NRT or simultaneously administering NRT and non-nicotine medications. New treatments targeting the nicotinic acetylcholine receptor as well as other pathophysiological pathways involved in nicotine addiction are being developed, with nicotine vaccines now being tested in phase III clinical trials. Among the numerous research topics currently addressed, pharmacogenetics and tailoring therapy to specific groups of smokers look most promising. However, substantial progress is unlikely to be made unless social gradients impeding effective treatment of all smokers are overcome. In addition, public smoking bans and reimbursement of medication costs are crucial in reducing the future burden of disease caused by smoking on a global level.

Varenicline for smoking cessation: efficacy, safety, and treatment recommendations

Smoking is the leading preventable cause of morbidity and mortality in the US, and decreasing smoking prevalence is a public health priority. Patients achieve the greatest success when quit attempts involve behavioral therapy combined with pharmacotherapy. Varenicline is the most recent addition to the pharmacotherapeutic armamentarium for the treatment of tobacco dependence. Varenicline is efficacious and cost-effective. Smoking relapse and adverse treatment-related side effects may decrease medication adherence and patient satisfaction with varenicline. In the clinical setting, varenicline treatment can be optimized by reducing doses in patients who experience intolerable side effects, increasing the dose in partial responders, and providing long-term maintenance therapy for relapse prevention.