Self-help educational booklets for the prevention of smoking relapse following smoking cessation treatment: a randomized controlled trial

Preventing smoking relapse in patients with cancer: A randomized controlled trial

BACKGROUND

Abstaining from smoking after a cancer diagnosis is critical to mitigating the risk of multiple adverse health outcomes. Although many patients with cancer attempt to quit smoking, the majority relapse. The current randomized controlled trial evaluated the efficacy of adapting an evidence-based smoking relapse prevention (SRP) intervention for patients with cancer.

METHODS

The trial enrolled 412 patients newly diagnosed with cancer who had recently quit smoking. Participants were randomized to usual care (UC) or SRP. Participants in the UC group received the institution's standard of care for treating tobacco use. Participants in the SRP group in addition received a targeted educational DVD plus a validated self-help intervention for preventing smoking relapse. The primary outcome was smoking abstinence at 2 months, 6 months, and 12 months.

RESULTS

Abstinence rates for participants in the SRP and UC groups were 75% versus 71% at 2 months and 69% versus 64% at 6 months (Ps > .20). At 12 months, abstinence rates among survivors were 68% for those in the SRP group and 63% for those in the UC group (P = .38). Post hoc analyses revealed that across 2 months and 6 months, patients who were married/partnered were more likely to be abstinent after SRP than UC (P = .03).

CONCLUSIONS

A smoking relapse prevention intervention did not reduce relapse rates overall, but did appear to have benefited those participants who had the social support of a partner. Future work is needed to extend this effect to the larger population of patients.

Impact of specialist and primary care stop smoking support on socio-economic inequalities in cessation in the United Kingdom: a systematic review and national equity initial review completed 22 January 2019; final version accepted 19 July 2019 analysis

AIM

To assess the impact of UK specialist and primary care-based stop smoking support on socio-economic inequalities in cessation.

METHODS

Systematic review and narrative synthesis, with a national equity analysis of stop smoking services (SSS). Ten bibliographic databases were searched for studies of any design, published since 2012, which evaluated specialist or primary care-based stop smoking support by socio-economic status (SES) or within a disadvantaged group. Studies could report on any cessation-related outcome. National Statistics were combined to estimate population-level SSS reach and impact among all smokers by SES. Overall, we included 27 published studies and three collated, national SSS reports for England, Scotland and Northern Ireland (equivalent data for Wales were unavailable).

RESULTS

Primary care providers and SSS in the United Kingdom were particularly effective at engaging and supporting disadvantaged smokers. Low SES groups were more likely to have their smoking status assessed, to receive general practitioner brief cessation advice/SSS referral and to attempt a quit with SSS support. Although disadvantaged SSS clients were less successful in quitting, increased service reach offset these lower quit rates, resulting in higher service impact among smokers from low SES groups. Interventions that offer tailored and targeted support have the potential to improve quit outcomes among disadvantaged smokers.

CONCLUSIONS

Equity-orientated stop smoking support can compensate for lower quit rates among disadvantaged smokers through the use of equity-based performance targets, provision of targeted services and the development of tailored interventions.

Relapse prevention interventions for smoking cessation

BACKGROUND

A number of treatments can help smokers make a successful quit attempt, but many initially successful quitters relapse over time. Several interventions have been proposed to help prevent relapse.

OBJECTIVES

To assess whether specific interventions for relapse prevention reduce the proportion of recent quitters who return to smoking.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register, clinicaltrials.gov, and the ICTRP in May 2019 for studies mentioning relapse prevention or maintenance in their title, abstracts, or keywords.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of relapse prevention interventions with a minimum follow-up of six months. We included smokers who quit on their own, were undergoing enforced abstinence, or were participating in treatment programmes. We included studies that compared relapse prevention interventions with a no intervention control, or that compared a cessation programme with additional relapse prevention components with a cessation programme alone.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 81 studies (69,094 participants), five of which are new to this update. We judged 22 studies to be at high risk of bias, 53 to be at unclear risk of bias, and six studies to be at low risk of bias. Fifty studies included abstainers, and 30 studies helped people to quit and then tested treatments to prevent relapse. Twenty-eight studies focused on special populations who were abstinent because of pregnancy (19 studies), hospital admission (six studies), or military service (three studies). Most studies used behavioural interventions that tried to teach people skills to cope with the urge to smoke, or followed up with additional support. Some studies tested extended pharmacotherapy. We focused on results from those studies that randomised abstainers, as these are the best test of relapse prevention interventions. Of the 12 analyses we conducted in abstainers, three pharmacotherapy analyses showed benefits of the intervention: extended varenicline in assisted abstainers (2 studies, n = 1297, risk ratio (RR) 1.23, 95% confidence interval (CI) 1.08 to 1.41, I2 = 82%; moderate-certainty evidence), rimonabant in assisted abstainers (1 study, RR 1.29, 95% CI 1.08 to 1.55), and nicotine replacement therapy (NRT) in unaided abstainers (2 studies, n = 2261, RR 1.24, 95% Cl 1.04 to 1.47, I2 = 56%). The remainder of analyses of pharmacotherapies in abstainers had wide confidence intervals consistent with both no effect and a statistically significant effect in favour of the intervention. These included NRT in hospital inpatients (2 studies, n = 1078, RR 1.23, 95% CI 0.94 to 1.60, I2 = 0%), NRT in assisted abstainers (2 studies, n = 553, RR 1.04, 95% CI 0.77 to 1.40, I2 = 0%; low-certainty evidence), extended bupropion in assisted abstainers (6 studies, n = 1697, RR 1.15, 95% CI 0.98 to 1.35, I2 = 0%; moderate-certainty evidence), and bupropion plus NRT (2 studies, n = 243, RR 1.18, 95% CI 0.75 to 1.87, I2 = 66%; low-certainty evidence). Analyses of behavioural interventions in abstainers did not detect an effect. These included studies in abstinent pregnant and postpartum women at the end of pregnancy (8 studies, n = 1523, RR 1.05, 95% CI 0.99 to 1.11, I2 = 0%) and at postpartum follow-up (15 studies, n = 4606, RR 1.02, 95% CI 0.94 to 1.09, I2 = 3%), studies in hospital inpatients (5 studies, n = 1385, RR 1.10, 95% CI 0.82 to 1.47, I2 = 58%), and studies in assisted abstainers (11 studies, n = 5523, RR 0.98, 95% CI 0.87 to 1.11, I2 = 52%; moderate-certainty evidence) and unaided abstainers (5 studies, n = 3561, RR 1.06, 95% CI 0.96 to 1.16, I2 = 1%) from the general population.

AUTHORS' CONCLUSIONS

Behavioural interventions that teach people to recognise situations that are high risk for relapse along with strategies to cope with them provided no worthwhile benefit in preventing relapse in assisted abstainers, although unexplained statistical heterogeneity means we are only moderately certain of this. In people who have successfully quit smoking using pharmacotherapy, there were mixed results regarding extending pharmacotherapy for longer than is standard. Extended treatment with varenicline helped to prevent relapse; evidence for the effect estimate was of moderate certainty, limited by unexplained statistical heterogeneity. Moderate-certainty evidence, limited by imprecision, did not detect a benefit from extended treatment with bupropion, though confidence intervals mean we could not rule out a clinically important benefit at this stage. Low-certainty evidence, limited by imprecision, did not show a benefit of extended treatment with nicotine replacement therapy in preventing relapse in assisted abstainers. More research is needed in this area, especially as the evidence for extended nicotine replacement therapy in unassisted abstainers did suggest a benefit.

Which Types of Tobacco Treatment Interventions Work for People with Schizophrenia? Provider and Mental Health Consumer Perspectives

People with schizophrenia and other psychotic disorders (PWS) consume tobacco at high rates, resulting in disproportionate tobacco-related morbidity and mortality. Conventional tobacco treatment (TT) approaches may not adequately address unique affective, cognitive, and social challenges of PWS during cessation. This study sought to obtain provider and mental health consumer perspectives on effective, desirable, applicable, and acceptable components of TT for PWS. This convergent mixed-method study used structured interviews and a cross-sectional survey to obtain data. Eighteen mental health consumers and six mental health providers were engaged in face-to-face or telephone interviews. The qualitative data were analyzed using content analysis and theme identification and descriptive statistics were used for the analysis of quantitative data. In the qualitative analysis, consumers endorsed education, counseling, social support, and pharmacotherapy as key TT components. Consumers further stressed the need for flexible interventions that are available at any point in a quit attempt. Both providers and consumers endorsed targeting TT interventions to consider learning needs, potential cognitive issues, and motivation for behavioral change. Providers encouraged a recovery-driven TT framework with peer support and health promotion activities. Quantitative findings mirrored the qualitative findings with support sessions, relapse prevention, and skills training having the highest desirability, applicability, and acceptability TT component scores. Providers and consumers agreed on components of an effective TT program targeted to PWS. Given these findings, it is crucial to further investigate successful TT approaches for PWS and to test whether targeted or tailored programs are more effective than conventional approaches.

Re-Configuring Identity Postpartum and Sustained Abstinence or Relapse to Tobacco Smoking

Relapse to smoking postpartum is a common and important public health problem. Difficulty in adjusting to a non-smoking identity is a key factor prompting relapse. However, postpartum relapse prevention interventions rarely focus upon offering support for identity change. We conducted an exploratory inductive analysis of a dataset from the Prevention of Return to Smoking Postpartum (PReS) study to understand identity constructs and experiences of pre- and postpartum women (smokers and ex-smokers), partners and health professionals. Data were obtained from 77 unique participants via focus groups, interviews, email or online questionnaires, and were analyzed by two researchers independently, using NVivo 12. Four main themes emerged reflecting identity transition from the pre- to the postpartum period: (i) Pregnancy and the categorization of smoking status; (ii) the disruption of motherhood and loss of self; (iii) adapting to a maternal non-smoking identity; and (iv) factors influencing sustained abstinence versus relapse to smoking. Postpartum relapse prevention interventions need to consider support for women, and the whole family unit, in adjusting to a new identity as a non-smoking mother. Smoking status should be revisited throughout pregnancy and into the postpartum period to aid the long-term integration of smoke-free behavior.

Barriers to smoking cessation: a qualitative study from the perspective of primary care in Malaysia

OBJECTIVES

This qualitative study aims to construct a model of the barriers to smoking cessation in the primary care setting.

DESIGN

Individual in-depth, semistructured interviews were audio-taped, then verbatim transcribed and translated when necessary. The data were first independently coded and then collectively discussed for emergent themes using the Straussian grounded theory method.

PARTICIPANTS AND SETTING

Fifty-seven current smokers were recruited from a previous smoking related study carried out in a primary care setting in Malaysia. Current smokers with at least one failed quit attempts were included.

RESULTS

A five-theme model emerged from this grounded theory method. (1) Personal and lifestyle factors: participants were unable to resist the temptation to smoke; (2) Nicotine addiction: withdrawal symptoms could not be overcome; (3) Social cultural norms: participants identified accepting cigarettes from friends as a token of friendship to be problematic; (4) Misconception: perception among smokers that ability to quit was solely based on one's ability to achieve mind control, and perception that stopping smoking will harm the body and (5) Failed assisted smoking cessation: smoking cessation services were not felt to be user-friendly and were poorly understood. The themes were organised into five concentric circles based on time frame: those actionable in the short term (themes 1 and 2) and the long term (themes 3, 4, 5).

CONCLUSIONS

Five themes of specific beliefs and practices prevented smokers from quitting. Clinicians need to work on these barriers, which can be guided by the recommended time frames to help patients to succeed in smoking cessation.

Relapse prevention interventions for smoking cessation

BACKGROUND

A number of treatments can help smokers make a successful quit attempt, but many initially successful quitters relapse over time. Several interventions have been proposed to help prevent relapse.

OBJECTIVES

To assess whether specific interventions for relapse prevention reduce the proportion of recent quitters who return to smoking.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register, clinicaltrials.gov, and the ICTRP in February 2018 for studies mentioning relapse prevention or maintenance in their title, abstracts, or keywords.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials of relapse prevention interventions with a minimum follow-up of six months. We included smokers who quit on their own, were undergoing enforced abstinence, or were participating in treatment programmes. We included studies that compared relapse prevention interventions with a no intervention control, or that compared a cessation programme with additional relapse prevention components with a cessation programme alone.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 77 studies (67,285 participants), 15 of which are new to this update. We judged 21 studies to be at high risk of bias, 51 to be at unclear risk of bias, and five studies to be at low risk of bias. Forty-eight studies included abstainers, and 29 studies helped people to quit and then tested treatments to prevent relapse. Twenty-six studies focused on special populations who were abstinent because of pregnancy (18 studies), hospital admission (five studies), or military service (three studies). Most studies used behavioural interventions that tried to teach people skills to cope with the urge to smoke, or followed up with additional support. Some studies tested extended pharmacotherapy.We focused on results from those studies that randomised abstainers, as these are the best test of relapse prevention interventions. Of the 12 analyses we conducted in abstainers, three pharmacotherapy analyses showed benefits of the intervention: extended varenicline in assisted abstainers (2 studies, n = 1297, risk ratio (RR) 1.23, 95% confidence interval (CI) 1.08 to 1.41, I² = 82%; moderate certainty evidence), rimonabant in assisted abstainers (1 study, RR 1.29, 95% CI 1.08 to 1.55), and nicotine replacement therapy (NRT) in unaided abstainers (2 studies, n = 2261, RR 1.24, 95% Cl 1.04 to 1.47, I² = 56%). The remainder of analyses of pharmacotherapies in abstainers had wide confidence intervals consistent with both no effect and a statistically significant effect in favour of the intervention. These included NRT in hospital inpatients (2 studies, n = 1078, RR 1.23, 95% CI 0.94 to 1.60, I² = 0%), NRT in assisted abstainers (2 studies, n = 553, RR 1.04, 95% CI 0.77 to 1.40, I² = 0%; low certainty evidence), extended bupropion in assisted abstainers (6 studies, n = 1697, RR 1.15, 95% CI 0.98 to 1.35, I² = 0%; moderate certainty evidence), and bupropion plus NRT (2 studies, n = 243, RR 1.18, 95% CI 0.75 to 1.87, I² = 66%; low certainty evidence). Analyses of behavioural interventions in abstainers did not detect an effect. These included studies in abstinent pregnant and postpartum women at end of pregnancy (8 studies, n = 1523, RR 1.05, 95% CI 0.99 to 1.11, I² = 0%) and at postpartum follow-up (15 studies, n = 4606, RR 1.02, 95% CI 0.94 to 1.09, I² = 3%), studies in hospital inpatients (4 studies, n = 1300, RR 0.95, 95% CI 0.81 to 1.11, I² = 0%), and studies in assisted abstainers (10 studies, n = 5408, RR 0.99, 95% CI 0.87 to 1.13, I² = 56%; moderate certainty evidence) and unaided abstainers (5 studies, n = 3561, RR 1.06, 95% CI 0.96 to 1.16, I² = 1%) from the general population.

AUTHORS' CONCLUSIONS

Behavioural interventions that teach people to recognise situations that are high risk for relapse along with strategies to cope with them provided no worthwhile benefit in preventing relapse in assisted abstainers, although unexplained statistical heterogeneity means we are only moderately certain of this. In people who have successfully quit smoking using pharmacotherapy, there were mixed results regarding extending pharmacotherapy for longer than is standard. Extended treatment with varenicline helped to prevent relapse; evidence for the effect estimate was of moderate certainty, limited by unexplained statistical heterogeneity. Moderate-certainty evidence, limited by imprecision, did not detect a benefit from extended treatment with bupropion, though confidence intervals mean we could not rule out a clinically important benefit at this stage. Low-certainty evidence, limited by imprecision, did not show a benefit of extended treatment with nicotine replacement therapy in preventing relapse in assisted abstainers. More research is needed in this area, especially as the evidence for extended nicotine replacement therapy in unassisted abstainers did suggest a benefit.

Relapse to smoking and health-related quality of life: Secondary analysis of data from a study of smoking relapse prevention

Background

Previous studies have shown that smoking and smoking cessation may be associated with health-related quality of life (HRQoL). In this study, we compared changes in HRQoL in people who maintained abstinence with people who had relapsed to smoking.

Methods

This was a secondary analysis of data from a trial of a relapse prevention intervention in 1,407 short-term quitters. The European Quality of Life -5 Dimensions (EQ-5D) measured HRQoL at baseline, 3 and 12 months. Smoking outcome was continuous abstinence from 2 to 12 months, and 7-day smoking at 3 and 12 months. We used nonparametric test for differences in EQ-5D utility scores, and chi-square test for dichotomised response to each of the five EQ-5D dimensions. Multivariable regression analyses were conducted to evaluate associations between smoking relapse and HRQoL or anxiety/depression problems.

Results

The mean EQ-5D tariff score was 0.8252 at baseline. People who maintained abstinence experienced a statistically non-significant increase in the EQ-5D score (mean change 0.0015, P = 0.88), while returning to smoking was associated with a statistically significant decrease in the EQ-5D score (mean change -0.0270, P = 0.004). After adjusting for multiple baseline characteristics, the utility change during baseline and 12 months was statistically significantly associated with continuous abstinence, with a difference of 0.0288 (95% CI: 0.0006 to 0.0571, P = 0.045) between relapsers and continuous quitters. The only difference in quality of life dimensions between those who relapsed and those who maintained abstinence was in the proportion of participants with anxiety/depression problems at 12 months (30% vs. 22%, P = 0.001). Smoking relapse was associated with a simultaneous increase in anxiety/depression problems.

Conclusions

People who achieve short-term smoking abstinence but subsequently relapse to smoking have a reduced quality of life, which appears mostly due to worsening of symptoms of anxiety and depression. Further research is required to more fully understand the relationship between smoking and health-related quality of life, and to develop cessation interventions by taking into account the impact of anxiety or depression on smoking.

Self-help materials for smoking relapse prevention: a process evaluation of the SHARPISH randomized controlled trial

Background

UK Stop Smoking Services are effective at assisting smokers to quit. However, smoking relapse rates are high, representing a significant public health problem. No effective interventions are currently available. This embedded qualitative process evaluation, within a randomized controlled trial of a self-help smoking relapse prevention intervention, aimed to understand patient perspectives in explaining the null trial finding, and to make recommendations for intervention development.

Methods

The intervention was a British version of the 'Forever Free' self-help booklets (SHARPISH-ISRCTN 36980856). The qualitative evaluation purposefully sampled 43 interview participants, triangulated with the views of 10 participants and 12 health professionals in focus groups. Data were thematically analysed.

Results

Analysis revealed important variation in individual engagement with the self-help booklets. Variation was interpreted by the meta-themes of 'motivation for cessation', and 'positioning on information provision', interacting with the theme of 'mechanisms for information provision'.

Conclusions

Targeting self-help information towards those most motivated to engage may be beneficial, considering the social and cultural realities of individual's lives. Individual preferences for the mechanisms of information delivery should be appraised when designing future interventions. Long-term personalized follow-up may be a simple step in improving smoking relapse rates.

The Use of Self-Directed Relapse Prevention Booklets to Assist in Maintaining Abstinence After a 6-Week Group Smoking Cessation Treatment Program: A Randomized Controlled Trial

Background. Identifying effective relapse prevention interventions is a vital step to help smokers maintain abstinence for the long term. Aims. The purpose of this study is to determine if providing recently quit smokers with self-directed relapse prevention booklets is effective at maintaining abstinence after intensive group smoking cessation treatment. Method. Two hundred and twenty-five participants were randomized to receive Forever Free (FF) relapse prevention booklets or a control booklet (Surgeon General’s report, SG) at the end of a 6-week group treatment program. Participants were then contacted by phone to assess whether they had read the materials. Smoking status was assessed 6 months after their target quit date. Primary analyses focused on the 115 participants who quit at the end of treatment. Results. There was no difference in the 6-month quit rate between groups (40.7% quit FF vs. 44.6% quit SG, p = .67). The FF group read a significantly smaller proportion of the materials versus the control booklet (20.0% read most or all of FF vs. 72.0% of SG, p < .001). Conclusion. Forever Free self-directed relapse prevention booklets did not reduce relapse or enhance cessation over general tobacco and health information when added to intensive group smoking cessation treatment. However, this study lacked power to detect a small but clinically meaningful positive effect.

Withdrawal exposure with withdrawal regulation training for smoking cessation: a randomized controlled pilot trial

INTRODUCTION

Although withdrawal processes form a key motivational basis for cigarette use, smoking cessation treatments appear to exert only modest effects on withdrawal. One treatment option for further reducing withdrawal severity would be to provide smokers with withdrawal regulation training. The objective of this study was to pilot a smoking cessation intervention comprising withdrawal exposure with withdrawal regulation training.

METHODS

Adult smokers (N=80) were randomized to one of two conditions: 1) Withdrawal Exposure with Withdrawal Regulation Training (WT), which included the development and application of individualized withdrawal regulation strategies over four separate sessions that spanned the first four hours of abstinence; 2) or Relaxation Control (RC) training, which controlled for the therapeutic contact of WT. All sessions occurred before the quit date, after which differential treatment was discontinued and all participants received brief counseling, nicotine replacement therapy, and self-help literature. Biochemically-confirmed (CO≤3) seven-day point-prevalence abstinence was assessed at Months 2 and 3 after end-of-treatment.

RESULTS

Treatment completion and ratings of credibility and efficacy were high and equivalent across conditions. 22.2% of participants in the WT condition were abstinent at both time points, whereas 0% and 4.2% of participants in the RC condition were abstinent at Months 2 and 3 (Month 3 OR=6.5 [0.73, 59.19]). In-session withdrawal ratings suggested WT improved regulation of withdrawal symptoms, which were in turn associated with abstinence.

CONCLUSIONS

This small pilot study suggests that WT promotes abstinence by enhancing withdrawal regulation. Results warrant further investigation of this innovative treatment approach.

Self-help educational booklets for the prevention of smoking relapse following smoking cessation treatment: a randomized controlled trial

AIMS

Most people who quit smoking for a short term will return to smoking again in 12 months. We tested whether self-help booklets can reduce relapse in short-term quitters after receiving behavioural and pharmacological cessation treatment.

DESIGN

A parallel-arm, pragmatic individually randomized controlled trial.

SETTING

Smoking cessation clinics in England. Participants People who stopped smoking for 4 weeks after receiving cessation treatment in stop smoking clinics.

INTERVENTION

Participants in the experimental group (n=703) were mailed eight booklets, each of which taught readers how to resist urges to smoke. Participants in the control group (n=704) received a leaflet currently used in practice.

MEASUREMENTS

The primary outcome was prolonged, carbon monoxide-verified abstinence from months 4 to 12. The secondary outcomes included 7-day self-reported abstinence at 3 and 12 months. Mixed-effects logistic regression was used to estimate treatment effects and to investigate possible effect modifying variables.

FINDINGS

There were no statistically significant differences between the groups in prolonged abstinence from months 4 to 12 (36.9% versus 38.6%; odds ratio 0.93, 95% confidence interval 0.75-1.16; P=0.524). In addition, there were no significant differences between the groups in any secondary outcomes. However, people who reported knowing risky situations for relapse and using strategies to handle urges to smoke were less likely to relapse.

CONCLUSIONS

In people who stop smoking successfully with behavioural support, a comprehensive self-help educational programme to teach people skills to identify and respond to high-risk situations for return to smoking did not reduce relapse.