Medicinal nicotine nonuse: smokers' rationales for past behavior and intentions to try medicinal nicotine in a future quit attempt

Associations between electronic cigarette use and quitting behaviours among South African adult smokers

BACKGROUND

The South African Medicines Control Council classifies e-cigarettes as Schedule 3 substances and requires them to be dispensed only within pharmacies. e-Cigarettes are however ubiquitous and are marketed as cessation aids. We investigated the relationship between e-cigarette use and smoking cessation among South African adult smokers.

METHODS

Data came from a 2018 web survey of South African adults aged ≥18 years (n=18 208). Cessation-related attitudes and behaviours were assessed. Using multivariable logistic regression, we measured the association between e-cigarette use and cessation behaviours among ever-established combustible tobacco smokers who tried to quit.

FINDINGS

Among current combustible smokers, more e-cigarette ever versus never users believed e-cigarettes could assist smokers to completely quit (35.5% vs 20.4%) or cut down (51.7% vs 26.5%) (all p<0.05). Among ever-established smokers, the odds of sustained quitting at the 12-month mark were lower among those who used e-cigarettes once off/rarely (adjusted OR (AOR)=0.20, 95% CI=0.16-0.24), former e-cigarette users (AOR=0.30, 95% CI=0.24-0.38) and current e-cigarette users (AOR=0.23, 95% CI=0.18-0.29), compared with never e-cigarette users. Among ever-established smokers who had ever tried to quit, 53.6% relapsed into smoking after quitting for any length of time. The odds of relapsing among ever-established smokers who had made a quit attempt and had a quit intention were higher among those who used e-cigarettes once off/rarely (AOR=2.66; 95% CI=2.31-3.08), former e-cigarette users (AOR=1.41; 95% CI=1.18-1.69) and current e-cigarette users (AOR=1.85; 95% CI=1.55-2.22) than never e-cigarette users.

CONCLUSION

e-Cigarette use depressed long-term cessation. These findings can inform restrictions on unsubstantiated claims of e-cigarettes as cessation aids within South Africa.

Non-pharmacological Considerations in Human Research of Nicotine and Tobacco Effects: A Review

Human research of nicotine and tobacco effects demonstrates that non-pharmacological factors may systematically affect responses to administered substances and inert placebos. Failure to measure or manipulate these factors may compromise study reliability and validity. This is especially relevant for double-blind placebo-controlled research of nicotine, tobacco, and related substances. In this article, we review laboratory-based human research of the impact of non-pharmacological factors on responses to tobacco and nicotine administration. Results suggest that varying beliefs about drug content and effects, perceptions about drug use opportunities, and intentions to cease drug use systematically alter subjective, behavioral, and physiological responses to nicotine, tobacco, and placebo administration. These non-pharmacological factors should be considered when designing and interpreting the findings of human research of nicotine and tobacco effects, particularly when a double-blind placebo-controlled design is used. The clinical implications of these findings are discussed, and we propose methodological strategies to enhance the reliability and validity of future research.

IMPLICATIONS

Growing research demonstrates that non-pharmacological factors systematically alter responses to acute nicotine, tobacco, and placebo administration. Indeed, varying beliefs about nicotine and/or tobacco administration and effects, differing perceptions about nicotine and/or tobacco use opportunities, and inconsistent motivation to quit smoking have been found to exert important influences on subjective, physiological, and behavioral responses. These variables are infrequently measured or manipulated in nicotine and tobacco research, which compromises the validity of study findings. Incorporating methodological strategies to better account for these non-pharmacological factors has the potential to improve the quality of addiction research and treatment.

'Very brief advice' (VBA) on smoking in family practice: a qualitative evaluation of the tobacco user's perspective

BACKGROUND

Very Brief Advice on smoking (VBA) is an evidence-based intervention designed to increase quit attempts among patients who smoke. VBA has been widely disseminated in general practice settings in the United Kingdom, however its transferability to Southern European settings is not well established. This study sought to document the perspectives of Greek general practice patients in terms of the acceptability and satisfaction with receiving VBA from their general practitioner (GP) and its influence on patients' motivation to make a quit attempt. We also examine patient identified barriers and facilitators to acting on VBA.

METHODS

Semi-structured interviews were conducted with 50 patients who reported current tobacco use recruited from five general practices in Crete, Greece. All patients received VBA from their GP and interviews were conducted immediately after the GP appointment. Thematic analysis was used to analyze data.

RESULTS

The majority of patients were satisfied with the VBA intervention. Approximately one quarter of patients reported they were motivated to make an attempt to quit smoking after receiving VBA from their GP. Patients identified a clear preference for VBA to be delivered in a supportive manner, which communicated genuine concern versus fear-based approaches. Patients with an existing smoking-related illness were more likely to report plans to act on their GP's VBA. Patients not ready to quit smoking indicated they would be likely to seek the support of their GP for future quit attempts as a result of VBA. Many patients reported low self-efficacy with quitting and apprehension about available quit smoking supports.

CONCLUSIONS

VBA was positively received by the majority of smokers interviewed. Participating patients confirmed the motivational role of advice when delivered in a supportive and caring manner. Personal health status, beliefs about quit smoking supports, and low self-efficacy appear to influence patient's motivation to make an aided quit attempt.

Factors Associated with Recent Use of Nicotine Replacement Therapy Among Multiethnic Smokers Residing in Public Housing

Introduction

Understanding factors associated with increased use of nicotine replacement therapy (NRT) is critical to implementing cessation interventions for low-income individuals yet the factors associated with NRT use among low-income smokers are poorly understood.

Aims

Assess factors associated with NRT use among low-income public housing residents.

Methods

'Kick it for Good' was a randomised smoking cessation intervention study conducted among residents of public housing sites in Boston, MA. Secondary, cross-sectional analyses were conducted on smokers from a community-based intervention cessation intervention who reported making a quit attempt and use of NRT in the past 12 months (n = 234).

Results

Among smokers who made a quit attempt in the past year, 29% reported using NRT. Black (prevalence ratio,PR = 0.52, 95% CI: 0.38-0.71) and Hispanic (PR = 0.52, 95% CI: 0.31-0.88) participants were less likely to report use of NRT compared with Whites. The prevalence of recent NRT use was greatest among those both asking for and receiving provider advice (PR = 1.90, 95% CI: 0.96-3.78).

Conclusions

Minority race and ethnicity and low provider engagement on NRT use were associated with lower NRT use. Providing barrier-free access to NRT and facilitating provider engagement with smokers regarding NRT use can increase NRT use among low-income populations.

Utilization of smoking cessation medication benefits among medicaid fee-for-service enrollees 1999-2008

Objective

To assess state coverage and utilization of Medicaid smoking cessation medication benefits among fee-for-service enrollees who smoked cigarettes.

Methods

We used the linked National Health Interview Survey (survey years 1995, 1997–2005) and the Medicaid Analytic eXtract files (1999–2008) to assess utilization of smoking cessation medication benefits among 5,982 cigarette smokers aged 18–64 years enrolled in Medicaid fee-for-service whose state Medicaid insurance covered at least one cessation medication. We excluded visits during pregnancy, and those covered by managed care or under dual enrollment (Medicaid and Medicare). Multivariate logistic regression was used to determine correlates of cessation medication benefit utilization among Medicaid fee-for-service enrollees, including measures of drug coverage (comprehensive cessation medication coverage, number of medications in state benefit, varenicline coverage), individual-level demographics at NHIS interview, age at Medicaid enrollment, and state-level cigarette excise taxes, statewide smoke-free laws, and per-capita tobacco control funding.

Results

In 1999, the percent of smokers with ≥1 medication claims was 5.7% in the 30 states that covered at least one Food and Drug Administration (FDA)-approved cessation medication; this increased to 9.9% in 2008 in the 44 states that covered at least one FDA-approved medication (p<0.01). Cessation medication utilization was greater among older individuals (≥ 25 years), females, non-Hispanic whites, and those with higher educational attainment. Comprehensive coverage, the number of smoking cessation medications covered and varenicline coverage were all positively associated with utilization; cigarette excise tax and per-capita tobacco control funding were also positively associated with utilization.

Conclusions

Utilization of medication benefits among fee-for-service Medicaid enrollees increased from 1999–2008 and varied by individual and state-level characteristics. Given that the Affordable Care Act bars state Medicaid programs from excluding any FDA-approved cessation medications from coverage as of January 2014, monitoring Medicaid cessation medication claims may be beneficial for informing efforts to increase utilization and maximize smoking cessation.

Perceived role of motivation and self-efficacy in smoking cessation: A secondary data analysis

BACKGROUND

This secondary analysis tested whether smokers' perceived importance of willpower, ability to quit (i.e., self-efficacy), and use of treatment would prospectively predict occurrence of a quit attempt, duration of abstinence, or use of cessation aids.

METHODS

Smokers (n=143) who planned to quit sometime in the next 3months were asked whether, for most smokers, a) willpower is necessary for quitting, b) willpower is sufficient for quitting, c) they could quit anytime, d) they were too addicted to quit, and e) they thought use of aids indicated weakness of character. Smokers then reported quit attempts and abstinence daily for 3months. No treatment was provided.

RESULTS

The two willpower beliefs were often endorsed (78% and 60% each); the can quit any time and being too addicted beliefs were endorsed less consistently (12% and 35% each); and the belief that use of aids indicates a weakness was rarely endorsed (8%). The beliefs were only modestly correlated. Those who more strongly endorsed the two willpower beliefs or use of aids as a weakness were less likely to make a quit attempt. None of the constructs predicted duration of quit attempt. Seeing treatment as a weakness predicted less use of treatment.

CONCLUSIONS

The large majority of smokers believe willpower is necessary and sufficient for quitting and this belief appears to impede quit attempts. Given this is a post-hoc finding, replication tests are needed. If replicated, clinical and media interventions to combat willpower beliefs may increase quit attempts.

An Argument for Change in Tobacco Treatment Options Guided by the ASAM Criteria for Patient Placement

Tobacco use is a major threat to public health in the United States, and the number one cause of preventable death. Although most smokers try to quit unaided, robust data indicate that pairing behavioral support to US Food Drug Administration-approved cessation medications significantly increase cessation rates. Those who do receive assistance in quitting usually receive very low intensity treatment, regardless of the severity of their dependence or their medical and environmental circumstances. This is in stark contrast to how other substance use disorders are treated, where there are varying levels of care depending on addiction severity and biopsychosocial circumstances. The American Society of Addiction Medicine (ASAM) developed a formal algorithm for assessing substance use disorders and determining the optimal level of care. The ASAM Patient Placement Criteria are regularly used to determine the appropriate level of care for all substance use disorders except tobacco. This paper will review key aspects of the ASAM dimensions of care and placement levels, with emphasis on how they apply to tobacco use and present case examples of typical smokers who would benefit from a higher intensity of tobacco dependence treatment. We also present current barriers to reimbursing healthcare providers for these services. We conclude with a commentary and discussion regarding recommendations for improvements in tobacco dependence treatment care.

Why do smokers try to quit without medication or counselling? A qualitative study with ex-smokers

OBJECTIVE

When tobacco smokers quit, between half and two-thirds quit unassisted: that is, they do not consult their general practitioner (GP), use pharmacotherapy (nicotine-replacement therapy, bupropion or varenicline), or phone a quitline. We sought to understand why smokers quit unassisted.

DESIGN

Qualitative grounded theory study (in-depth interviews, theoretical sampling, concurrent data collection and data analysis).

PARTICIPANTS

21 Australian adult ex-smokers (aged 28-68 years; 9 males and 12 females) who quit unassisted within the past 6 months to 2 years. 12 participants had previous experience of using assistance to quit; 9 had never previously used assistance.

SETTING

Community, Australia.

RESULTS

Along with previously identified barriers to use of cessation assistance (cost, access, lack of awareness or knowledge of assistance, including misperceptions about effectiveness or safety), our study produced new explanations of why smokers quit unassisted: (1) they prioritise lay knowledge gained directly from personal experiences and indirectly from others over professional or theoretical knowledge; (2) their evaluation of the costs and benefits of quitting unassisted versus those of using assistance favours quitting unassisted; (3) they believe quitting is their personal responsibility; and (4) they perceive quitting unassisted to be the 'right' or 'better' choice in terms of how this relates to their own self-identity or self-image. Deep-rooted personal and societal values such as independence, strength, autonomy and self-control appear to be influencing smokers' beliefs and decisions about quitting.

CONCLUSIONS

The reasons for smokers' rejection of the conventional medical model for smoking cessation are complex and go beyond modifiable or correctable problems relating to misperceptions or treatment barriers. These findings suggest that GPs could recognise and respect smokers' reasons for rejecting assistance, validate and approve their choices, and modify brief interventions to support their preference for quitting unassisted, where preferred. Further research and translation may assist in developing such strategies for use in practice.

Is nicotine replacement therapy overvalued in smoking cessation? Analysis of smokers' and quitters' communication in social media

BACKGROUND

Internet discussion forums provide new, albeit less used data sources for exploring personal experiences of illness and treatment strategies.

OBJECTIVE

To gain an understanding of how discussion forum participants value nicotine replacement therapy (NRT) in smoking cessation (SC).

SETTING

Finnish national Internet-based discussion forum, STUMPPI, supporting SC and consisting of ten free discussion areas, each with a different focus. The analysis was based on STUMPPI forum participants' postings (n = 24 481) in five discussion areas during January 2007-January 2012.

DESIGN

Inductive content analysis of the postings concerning NRT use or comparing NRT to other SC methods.

RESULTS

Three major themes related to NRT in SC emerged from the discussions. These were as follows: (I) distrust and negative attitude towards NRT; (II) neutral acceptance of NRT as a useful SC method; and (III) trust on the crucial role of NRT and other SC medicines. The negative attitude was related to following perceptions: NRT use maintains tobacco dependence, fear of NRT dependence or experience of not gaining help from NRT use. NRT was perceived to be useful particularly in the initiation of SC attempts and in dealing with physiological dependence. The most highlighted factors of successful quitting were quitters' own psychological empowerment and peer support from the discussion community.

CONCLUSIONS

The majority of STUMPPI forum participants had low or balanced expectations towards the role of NRT in SC. More research from the smokers' and quitters' perspective is needed to assess the real value of NRT compared to other methods in SC.

One cigarette is one too many: evaluating a light smoker-targeted media campaign

BACKGROUND

Light smokers represent an increasing share of adult smokers in various parts of the world including New York City (NYC). Since 2007, the NYC Department of Health and Mental Hygiene has aired hard-hitting antitobacco media campaigns paired with time-limited nicotine replacement therapy (NRT) giveaways. We evaluated an original antitobacco media campaign, developed to increase awareness of smoking risks and encourage cessation service use among light smokers in NYC.

METHODS

We compared cessation service request volume during the campaign to historical periods without ads targeting light smokers. We used a cross-sectional online panel survey to assess the ad's perceived effectiveness and its impact on learning something new, quit intentions and concern for smoking-related health risks among non-daily, light daily and heavy daily smokers.

RESULTS

The proportion of light smokers among smokers requesting cessation services increased 50% (from 13% to 20%) relative to previous time-limited NRT giveaways. Compared to heavy daily smokers, non-daily (aOR: 1.95, p<0.05) and light daily (aOR: 2.27, p<0.05) smokers were more likely to express increased concern about smoking-related health risks after viewing the ad. Perceived effectiveness of the ad did not differ by smoker type.

CONCLUSIONS

This study provides evidence that light smokers were receptive to a targeted antitobacco message encouraging use of cessation services. The campaign appears to have been particularly effective in increasing smoking-related health concerns in this group. The lack of difference in perceived ad effectiveness by smoker type suggests the potential to develop such ads without sacrificing broad impact.