Do predictors of smoking relapse change as a function of duration of abstinence? Findings from the United States, Canada, United Kingdom and Australia

Hypothalamic Pituitary Adrenal and Autonomic Nervous System Biomarkers of Stress and Tobacco Relapse: Review of the Research

Tobacco smoking is a risk factor for countless diseases, and smoking relapse remains a major public health concern. Subjective reports of stress by smokers are a common theme for relapse, however, the role of objective stress-related biomarkers in predicting tobacco relapse risk has been less studied. The aim of this manuscript was to review existing literature on the connection between biomarkers of stress and smoking relapse. Overall, trends indicate that blunted hypothalamic-pituitary-adrenal (HPA) responses to acute stress, larger reductions in HPA biomarkers during the initial days of abstinence during cessation (compared to pre-cessation levels), and exaggerated autonomic responses to stress predict increased risk of relapse. In addition, successful cessation is followed by changes in stress biomarkers (e.g., reductions in cortisol and heart rate, HR). This review also identifies potential modifiers, such as methodological differences, biological sex, and chronic stress, to account for heterogeneity of findings within and across studies. In addition, we identify gaps in the literature and suggest future research directions focusing on the roles of genetics and gene expression as well as the influence of neurobiological mechanisms on stress and relapse risk. Future clinical implications of this research include identifying reliable indicators of relapse risk and the potential of pharmacotherapeutic treatments to target stress response systems to correct dysregulation and potentially reduce stress-related risk of relapse.

Does alcohol consumption elevate smoking relapse risk of people who used to smoke? Differences by duration of smoking abstinence

BACKGROUND

Past research indicates dual users of tobacco and alcohol find it harder to quit smoking and may be more likely to relapse. This study investigated whether post-quit alcohol use predicted smoking relapse among ex-smokers, and whether this relationship varied by length of smoking abstinence.

METHOD

The study included 1064 ex-smokers (18+ years) from Canada (n = 340), US (n = 314), England (n = 261), and Australia (n = 149) who participated in the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping Survey, and we conducted analyses using multivariable logistic regression. We assessed alcohol consumption in 2018 using AUDIT-C and coded as never/low, moderate or heavy level and used alcohol consumption to predict smoking status in 2020.

RESULTS

Overall 26 % and 21 % of ex-smokers consumed alcohol at a moderate and heavy level, respectively. Compared to never/low alcohol consumption, risk of smoking relapse among those who consumed alcohol at a moderate level was significantly lower within the first year of abstinence (OR = 0.34, 95 % CI = 0.14-0.81, p = 0.015) but higher thereafter (OR = 2.44, 95 % CI = 1.13-5.23, p = 0.023). The pattern of results was similar for those who consumed alcohol at a heavy level.

CONCLUSIONS

Overall, baseline alcohol consumption of ex-smokers did not predict their smoking relapse risk. As expected, risk differed by smoking abstinence duration. However, the pattern was unexpected among the short-term quitters as the subgroup who drank moderately/heavily had lower relapse risk than their counterparts who never drink or at low level, underscoring the need to replicate this unexpected finding.

Comparison of smoking prevalence in Canada before and after nicotine vaping product access using the SimSmoke model

OBJECTIVES

The public health impact of nicotine vaping products (NVPs) is subject to complex transitions between NVP and cigarette use. To circumvent the data limitations and parameter instability challenges in modeling transitions, we indirectly estimate NVPs' impact on smoking prevalence and resulting smoking-attributable deaths using the SimSmoke simulation model.

METHODS

Canada SimSmoke uses age- and sex-specific data on Canadian population, smoking prevalence and tobacco control policies. The model incorporates the impact of cigarette-oriented policies on smoking prevalence but not the explicit contribution of NVPs. The model was calibrated from 1999 to 2012, thereby projecting smoking prevalence before NVPs were widely used in Canada. The NVP impact on smoking prevalence is inferred by comparing projected 2012-2020 smoking trends absent NVPs to corresponding trends from two Canadian national surveys. We further distinguish impacts before and after NVPs became regulated in 2018 and more available.

RESULTS

Comparing 2012-2020 survey data of post-NVP to SimSmoke projected smoking prevalence trends, one survey indicated an NVP-related relative reduction of 15% (15%) for males (females) age 15+, but 32% (52%) for those ages 15-24. The other survey indicated a 14% (19%) NVP-related smoking reduction for ages 18+, but 42% (53%) for persons ages 18-24. Much of the gain occurred since Canada relaxed NVP restrictions. NVP-related 2012-2020 smoking reductions yielded 100,000 smoking-attributable deaths averted from 2012 to 2060.

CONCLUSION

Smoking prevalence in Canada, especially among younger adults, declined more rapidly once NVPs became readily available. The emergence of NVPs into the Canadian marketplace has not slowed the decline in smoking.

"Boy, what are we all doing? We are crazy, really crazy": a qualitative study of psychosocial processes around an atypical one-time smoking cessation course

BACKGROUND

Smoking prevalence is still high, which requires effective interventions that help many people who smoke at once in addition to time-consuming individual interventions. 'I Quit' is a large-scale smoking cessation course in The Netherlands. This qualitative study explored I Quit participants' experiences during and after the course, and perceptions of whether and how the course may have altered their smoking behavior.

METHODS

We performed individual semi-structured interviews with course participants (N = 21) who had either quit successfully, attempted to quit but relapsed, or had continued to smoke after 'I Quit'. Shortly after qualitative data collection was completed, Foundation I Quit was accused in the media of a number of misbehaviors. Although unplanned, this provided a unique opportunity to explore participants' views on alleged fraud in a second round of interviews (N = 16). Data were collected from 2016 to 2018.

RESULTS

Qualitative findings showed two psychosocial processes that may explain smoking cessation after course attendance. First, the confrontation with a large group of people who smoke, of whom some had already developed smoking-related complaints, triggered identity processes both towards and away from quitting smoking. Unorthodox methods used in the course appeared to trigger identity processes. Second, social support after the course from participants' own social network facilitated maintenance of successful quitting. The study also found that interview participants' opinions on I Quit did not change much after allegations of fraud in the media.

CONCLUSIONS

Findings suggest that a one-time course might initiate psychosocial processes that could help certain smokers to gain motivation to quit, requiring a minimum of resources. Identity processes triggered by the course seem tricky as people have different ways of dealing with identity threat, some of which can be counterproductive and even result in more difficulty quitting. More research is needed to examine who can benefit from a one-time course, and who needs more support in order to quit successfully.

Cigarette Coupon Receipt and Smoking Relapse by Duration of Smoking Abstinence

INTRODUCTION

It is unknown whether and to what extent the duration of smoking abstinence may modify the association between receiving cigarette coupons and smoking relapse in the U.S. This study aims to fill this gap.

METHODS

Data were from the Population Assessment of Tobacco and Health study Wave 4 (December 2016-January 2018, baseline) and Wave 5 (December 2018-November 2019, follow-up) surveys. Analysis was conducted in May 2022. The study sample was participants who formerly smoked cigarettes at baseline (N=5,186). The exposure was past 12-month receipt of cigarette coupons (yes/no) at baseline, and the outcome was cigarette smoking relapse (yes/no) at follow-up. A potential modifier was the duration of smoking abstinence (within/>1 year) at baseline. Baseline single-wave weights were applied, and a multivariable logistic regression model was used to estimate the adjusted association. Interaction between cigarette coupon receipt and duration of smoking abstinence was examined to explore potential modification effects.

RESULTS

Participants who received cigarette coupons at baseline were more likely to relapse at follow-up (AOR=1.63, 95% CI=1.15, 2.32). This association was significantly stronger among participants who quit within 1 year than among participants who quit >1 year at baseline (AOR for the interaction term=2.77, 95% CI=1.22, 6.25). Subgroup analysis shows that receipt of cigarette coupons was significantly associated with smoking relapse among participants who quit within 1 year (AOR=2.10, 95% CI=1.39, 3.17), and this association was not statistically significant among participants who quit >1 year (AOR=0.76, 95% CI=0.36, 1.63).

CONCLUSIONS

Policies restricting cigarette coupons may help adults who recently quit sustain abstinence.

Smoking relapse reasons among current smokers with previous cessation experience in Shanghai: A cross-sectional study

INTRODUCTION

Quitting smoking can lead to substantial health gains, even later in life. Many smokers who attempt to quit experience several relapses before achieving sustainable cessation. This study aims to ascertain the differences between quitters with short and long abstinence time and to explore relapse reasons among smokers with cessation experience in Shanghai.

METHODS

From January to December 2022, 1745 current smokers were recruited in Minhang, Jiading, Qingpu and Songjiang districts of Shanghai. We used an electronic questionnaire to collect data. We implemented logistic regression for odds ratio (OR) and 95% confidence interval (CI) calculation to explore factors associated with long cessation time among smokers with cessation experience of ≥3 months, ≥6 months, and ≥12 months.

RESULTS

Of the 1745 smokers included, 1452 (83.2%) were males, with an average age of 44.2 years, and 48.0% (838/1745) had cessation experience but relapsed. Logistic regression indicated that smokers aged ≥45 years had a longer cessation duration (adjusted odds ratio, AOR=3.10; 95% CI: 1.97-4.88). Moreover, longer cessation duration among smokers was positively associated with low education level of junior high or lower (AOR=2.30; 95% CI: 1.42-3.72) and senior high (AOR=2.19; 95% CI: 1.53-3.15), older age at first tobacco smoking (AOR=1.62; 95% CI: 1.1.16-2.25), but was negatively associated with longer smoking duration (AOR=0.67; 95% CI: 0.43-0.00) and higher smoking burden (AOR=0.44; 95% CI: 0.28-0.72). The main reasons for cessation relapse were social interaction needs (34.5%) and discomfort due to abstinence (29.1%).

CONCLUSIONS

The relapse rate was high among smokers even after 12 months of abstinence. Smokers with older age, lower education level, shorter smoking duration and lower tobacco burden had longer cessation duration. Social interaction needs and withdrawal symptoms were the main relapse reasons. It is highly recommended that health bureaux consistently conduct tobacco control initiatives to spread awareness about the detrimental effects of tobacco smoke and the advantages of quitting smoking, even after achieving cessation.

Psychiatric symptoms and intentions to quit smoking: How regularity and volume of cigarette consumption moderate the relationship

INTRODUCTION

Smoking prevalence is disproportionately higher in those with psychiatric symptoms. Smokers with psychiatric symptoms are less likely to have an intention to quit smoking and attain eventual smoking abstinence. This study presents the relationship between depressive/anxiety symptoms and the intention to quit smoking and related influencing factors.

METHODS

A cross-sectional study recruited 931 current smoking individuals covering two provinces in China in July 2022. The online survey comprised questions concerning sociodemographic characteristics, smoking conditions and psychiatric symptoms. Chi-squared analyses and moderation analyses were applied.

RESULTS

The proportion of smokers who had the intention to quit smoking within six months was 46.1%. In comparison with subjects without depressive/anxiety symptoms, individuals who had both psychiatric symptoms were less likely to have the intention to quit smoking (39.3% vs 49.8%, χ²=9.130, p=0.028). As for the moderating model of depression, the interaction term of depressive symptoms and smoking regularly was significant (β=0.554, t=3.260, p=0.001). For those who were occasional smokers, depressive symptoms significantly lowered their quitting intentions. The regularity of smoking similarly moderated the effect of anxiety symptoms on quitting intentions. When the number of cigarettes used weekly served as the moderator, the interaction of this number and depressive symptoms was significant, as well as for anxiety (p<0.001), indicating that the volume of cigarette consumption moderated the relationship between depressive/anxiety symptoms and intention to quit smoking.

CONCLUSIONS

Psychiatric symptoms were significant factors in reducing the willingness of smokers to quit smoking, and the effects were moderated by smokers' cigarette consumption conditions. Interventions are urged to enhance quitting intentions of these vulnerable smokers.

Persistent impacts of smoking on resting-state EEG in male chronic smokers and past-smokers with 20 years of abstinence

Smoking is a severe addictive health risk behavior and notorious for the high likelihood of relapse after attempted cessation. Such an addictive pattern in smoking has been associated with neurobiological changes in the brain. However, little is known whether the neural changes associated with chronic smoking persist after a long period of successful abstinence. To address this question, we examined resting state EEG (rsEEG) in chronic smokers who have been smoking for 20 years or more, past-smokers who have been successfully abstaining for 20 years or more, and never-smokers. Both current-smokers and past-smokers showed significantly decreased relative theta power than never-smokers, showcasing persistent effect of smoking on the brain. Other rsEEG features in alpha frequency band demonstrated distinctive patterns associated with active smoking, such that compared to never-smokers, only current-smokers, but not past-smokers, showed significantly higher relative power, EEG reactivity-power changes between eyes-closed and eyes-open conditions-, and coherence between channels. Furthermore, individual variabilities across these rsEEG biomarkers were accounted for by individuals' self-reported smoking history and nicotine dependence in current- and past- smokers. These data suggest the persistent effect of smoking on the brain even after sustained remission for 20 years.

Workplace Supported Recovery from Substance Use Disorders: Defining the Construct, Developing a Model, and Proposing an Agenda for Future Research

Substance use disorders (SUDs) represent a critical public and occupational health issue. Therefore, understanding the process of SUD recovery has become an issue of growing importance among substance use and recovery professionals. Nonetheless, despite the acknowledged importance of employment for SUD recovery, little conceptual or empirical work exists on how the workplace might support or undermine SUD recovery. In this article, we address this limitation in several ways. First, to promote a better understanding of SUD recovery for occupational health researchers, we provide a brief overview of the nature of a SUD, prior definitions of SUD recovery, and general themes associated with the recovery process. Second, we develop a working definition of workplace supported recovery. Third, we present a heuristic conceptual model showing how the workplace might impact the SUD recovery process. Fourth, using this model and research from the substance use and occupational health literatures, we develop a series of general research propositions. These propositions highlight broad directions requiring more detailed conceptualization and empirical research to understand better how work conditions may support or undermine the process of employee SUD recovery. Our overarching goal is to motivate innovative conceptualization and research on workplace supported recovery from SUDs. Such research may inform the development and evaluation of workplace interventions and policies supporting SUD recovery and highlight the benefits of workplace supported SUD recovery for employees, employers, and communities. Research on this issue may allow occupational health researchers to impact a significant societal and occupational health issue.

Association between successful smoking cessation and preferred smoking time

INTRODUCTION

We examined the relationship between preferred daily smoking times and typical situations in which smoking occurs and aimed to determine the association between successful smoking cessation and preferred smoking time.

METHODS

We conducted an internet survey and categorized participants based on their selected smoking status: 'successful smoking cessation', 'failed smoking cessation', or 'currently smoking'. Ultimately, 3637 people (1854 men, 1789 women) aged 30-59 years were included in the study. Participants also described the time points at which smoking seemed to be the most appealing and those at which smoking seemed the most difficult to resist.

RESULTS

Regarding times of tobacco cravings, the number of non-smokers for more than 1 year who chose 'after dinner' was significantly higher than the number who chose 'after breakfast' or 'after waking up'. Regarding the time when smoking was the most difficult to resist, the proportion of people who chose 'after dinner' that had quit smoking for less than 3 months was significantly low.

CONCLUSIONS

Those who prefer smoking 'after dinner' are less likely to start smoking cessation, but when they do, the rate of continuation for more than 1 year is high. We suggest that smoking cessation support based on preferred smoking times may lead to a decrease in the smoking rate.

Use of a microsimulation method for assessing dynamics of smoking status and gains in life expectancy after quitting in a longitudinal cohort of US older adults

OBJECTIVES

Previous studies were unable to estimate the dynamics of smoking status in the US elderly general population, and no study has assessed the benefit of quitting in terms of resultant gains in life expectancy. We proposed a novel method to estimate the per cent of quitting in remaining lifetime, successful quitting and relapse, as well as life expectancy by participants' baseline smoking status.

DESIGN

Longitudinal cohort.

SETTING

US community-dwelling population.

PARTICIPANTS

Respondents from the Medicare Health Outcome Survey Cohort 15 (baseline 2012, follow-up 2014). We included respondents who were aged ≥65 years and alive at the baseline and participated in the baseline survey (n=164 597).Primary and secondary outcome measuresAttempt quitting, successful quitting, relapse rates and life expectancy by smoking status at age 65-95 years.

RESULTS

Among daily smokers aged 65 years, 61% would attempt to quit during their remaining lifetime, and 31% would quit successfully. Among some days smokers aged 65 years, 69% would attempt to quit during their remaining lifetime, and 37% would quit successfully. Among recent ex-smokers aged 65 years, 53% would relapse. Life expectancy at age 65 years was 20.0 (SE=0.27), 17.2 (SE=0.30), 16.2 (SE=0.29) and 15.9 (SE=0.29) years for long time non-smokers, recent ex-smokers, some days smokers and daily smokers, respectively. Although recent ex-smokers had a higher 2-year mortality than current smokers, those who quit up to 77 years (77 years for men and 87 years for women) had a significantly longer (p<0.05) life expectancy. Sensitivity analysis demonstrated that the model assumptions had a relatively small impact on estimates with a maximum relative bias within ±7%.

CONCLUSIONS

This study provides detailed information regarding the dynamics of smoking status in an understudied and growing population and demonstrates the benefit of smoking cessation on life expectancy. Future research should focus on understanding specific predictors of smoking cessation.

Experienced Effects on Well-Being following Smoking Cessation: Findings from the 2020 ITC Four Country Smoking and Vaping Survey

BACKGROUND AND AIMS

There has been limited research addressing changes in subjective well-being as a result of quitting smoking. This paper examines recent ex-smokers' well-being related experiences overall and as a function of (1) duration of cessation and (2) continued nicotine use from vaping.

METHODS

A sample of 1379 ever-daily smoking ex-smokers (quit for up to 5 years) from the 2020 ITC Four Country Smoking and Vaping Survey (Australia, Canada, the UK, and the US), of which 27.1% currently vaped daily. Well-being measures were perceived changes post-quitting in emotion coping (stress and negative emotions), enjoyment of life, and day-to-day functioning. We also assessed the level of persisting worry about past smoking leading to future health problems.

RESULTS

Overall, among those answering all four well-being measures, 51.8% of the ex-smokers reported positive effects and no negatives, but 27.3% reported at least one negative effect, with the remainder reporting no change in any measure. Positive effects were greater among those who had quit more than 1 year prior. The largest improvement (56.3%) was for daily functioning, which showed improvement over time since having quit. Current daily vapers reported similar well-being as those not vaping; however, fewer daily vapers reported worsening ability to cope with stress (10.2% vs. 20.7%). Overall, 84% reported being worried about future negative health effects of smoking, with no clear differences by quitting duration or vaping status.

CONCLUSIONS

Most ex-smokers reported changes in their well-being since quitting, with more reporting improvements than declines. Well-being improved with duration of time since quitting, but did not appear to be influenced by daily vaping use, but stress coping may be better among vapers. Persisting worries about possible future health effects from smoking may be reducing the experienced benefits of quitting smoking for some.

Factors associated with long-term smoking relapse in those who succeeded in smoking cessation using regional smoking cessation programs

It is known that approximately 10% of successful quitters relapse annually. This study aimed to investigate the factors related to long-term smoking relapse in individuals who succeeded in maintaining smoking cessation for 6 months after attending a regional smoking cessation program. This study enrolled 943 individuals registered for the regional smoking cessation program at the Busan Smoking Cessation Center in 2018-2019 who maintained smoking cessation for 6 months. A survey was conducted using a smartphone link or through phone calls, and the data for 305 participants who finally completed the survey were analyzed. The questionnaire addressed individual, inter-individual, organizational, and community-level factors related to smoking relapse. Multivariate logistic regression analysis was performed to evaluate the factors associated with smoking relapse by period. The Cox proportional hazard regression model was used for the factors associated with smoking relapse for the entire period. The smoking relapse rate at the time of the survey was 25.4%. In the analysis of smoking relapse by period, relapse was associated with the belief that smoking relieves stress, the number of single-person households, and poor subjective health status. In the analysis of smoking relapse during the entire period, we observed a significant association with the belief that smoking relieves stress (hazard ratio [HR]: 2.65, 95% confidence interval [CI]: 1.52-4.61), single-person households (HR: 1.95, 95% CI: 1.16-3.26), and high levels of emotional stress (HR: 1.72, 95% CI: 1.04-2.85). Long-term follow-up is necessary to prevent smoking relapse in single-person households, individuals who believe that smoking relieves stress, and those experiencing high levels of subjective emotional stress. Interventional therapies for stress relief and awareness improvement in smokers need to be developed.

Risk Factors of Relapse After Smoking Cessation: Results in China Family Panel Studies From 2010 to 2018

Background

Tobacco use is still highly prevalent globally in spite of the tobacco control efforts made by the governments. In view of the harm of smoking and relapse after smoking cessation, the purpose of this study is to establish a competitive risk model to determine potential risk factors for smoking relapse.

Methods

The population-based cohort of ex-smokers over the age of 18 years was obtained from the China Family Panel Studies (CFPS) database from 2010 to 2018. Competing risk models were conducted to identify the risk factors for relapse.

Results

A total of 1,019 subjects were included in this study, of which 311 (30.52%) subjects relapsed during the follow-up period. A multivariate analysis indicated that age < 40 years [hazard ratio (HR) 19.142; 95% CI: 10.641–34.434, p < 0.01], cohabitation (HR: 1.422; 95% CI: 1.081–1.87, p = 0.01), and often depression [HR 1.422; 95% CI, (1.081–1.87), p = 0.01] were associated with a great risk of relapse while the age of quitting smoking < 60 years (HR: 0. 436; 95% CI: 0.229–0.831, p < 0.01) and joining the Chinese Communist Party (CCP) (HR 0.611; 95% CI: 0.397–0.939, p = 0.03) were reduced risk factors for relapse.

Conclusions

Approximately 3 in 10 ex-smokers were observed to relapse. There are various risk factors for relapse as well. In the face of such a serious situation, it is urgent to take action to control smoking.

Do post-quitting experiences predict smoking relapse among former smokers in Australia and the United Kingdom? Findings from the International Tobacco Control Surveys

INTRODUCTION

Many smokers attempt to stop smoking every year, but the vast majority of quit attempts fail. This study examined prospectively the association between post-quitting experiences and smoking relapse among ex-smokers in Australia and the United Kingdom.

METHODS

Data came from 584 adult ex-smokers from Australia and the United Kingdom who participated in Wave 9 of the International Tobacco Control Four Country Survey and successfully followed up a year later (Wave 10). Binary logistic regression was used to examine whether baseline post-quitting experiences predicted relapse back to smoking at follow-up.

RESULTS

Ex-smokers who perceived their stress coping ability had gotten worse since quitting were more likely to relapse back to smoking compared to their counterparts who reported no change (odds ratio = 5.77, 95% confidence interval = 1.64, 20.31, P < 0.01). Ex-smokers who reported their homes had become fresher and cleaner post quitting were less likely to relapse compared to those who did not notice any change (odds ratio = 0.34, 95% confidence interval = 0.13, 0.93, P < 0.05). Perceived changes in life enjoyment, negative affect control, social confidence, work performance, leisure time and financial situation did not independently predict relapse. No country differences were found.

DISCUSSION AND CONCLUSIONS

The study showed that ex-smokers' relapse risk was elevated if they perceived any negative impact of quitting on their stress coping whereas relapse risk was reduced if they perceived any positive impact of quitting on the home (e.g. fresher and cleaner). Helping ex-smokers to develop alternative stress coping strategies and highlighting the positive impacts of quitting smoking on the homes may help protect against smoking relapse.

Optimising tobacco control campaigns within a changing media landscape and among priority populations

Reviews published over the past decade confirm tobacco control campaigns can be effective for influencing adult and youth tobacco use behaviours, with strengthening evidence for high cost-effectiveness. Evidence is also accumulating for positive campaign effects on interpersonal discussions, social norms and policy support that can help motivate and sustain quitting and reduce uptake. Research needs over the next decade centre on the rapidly changing media environment and the equity of campaign effects among high smoking prevalence communities. The field needs specific evidence on: how to measure total campaign reach and frequency across the diverse range of media platforms and channels; the optimum mix of traditional, digital and social media to achieve behaviour change, especially among high smoking prevalence communities; the relative reach and impact of the wide variety of integrated, digital and social media message delivery methods; the relative effectiveness of messages that aim to build capacity to quit and optimum methods for combining motivational and capacity-building messages, especially for high prevalence groups who face additional barriers to staying quit; the ongoing effectiveness of traditional versus new versions of messages highlighting tobacco industry practices; the influence of e-cigarette use on tobacco control campaign effects; and the effectiveness of different types of campaigns aiming to prevent e-cigarette uptake and motivate e-cigarette cessation. Research is also needed to investigate the potential for campaigns to influence the public's understanding and support for endgame tobacco control policies and for campaign elements that may influence the social and environmental contexts surrounding smokers that support and maintain behaviour change.

Changes in Smoking Behavior Before and After Gastric Bypass: A 7-year Study

OBJECTIVE

To evaluate smoking history and change in smoking behavior, from 1 year before through 7 years after Roux-en-Y gastric bypass (RYGB) surgery, and to identify risk factors for post-surgery smoking.

BACKGROUND

Smoking behavior in the context of bariatric surgery is poorly described.

METHODS

Adults undergoing RYGB surgery entered a prospective cohort study between 2006 and 2009 and were followed up to 7 years until ≤2015. Participants (N = 1770; 80% female, median age 45 years, median body mass index 47 kg/m2) self-reported smoking history pre-surgery, and current smoking behavior annually.

RESULTS

Almost half of participants (45.2%) reported a pre-surgery history of smoking. Modeled prevalence of current smoking decreased in the year before surgery from 13.7% [95% confidence interval (CI) = 12.1-15.4] to 2.2% (95% CI = 1.5-2.9) at surgery, then increased to 9.6% (95% CI = 8.1-11.2) 1-year post-surgery and continued to increase to 14.0% (95% CI = 11.8-16.0) 7-years post-surgery. Among smokers, mean packs/day was 0.60 (95% CI = 0.44-0.77) at surgery, 0.70 (95% CI = 0.62-0.78) 1-year post-surgery and 0.77 (95% CI = 0.68-0.88) 7-years post-surgery. At 7-years, smoking was reported by 61.7% (95% CI = 51.9-70.8) of participants who smoked 1-year pre-surgery (n = 221), 12.3% (95% CI = 8.5-15.7) of participants who formerly smoked but quit >1 year pre-surgery (n = 507), and 3.8% (95% CI = 2.1-4.9) of participants who reported no smoking history (n = 887). Along with smoking history (ie, less time since smoked), younger age, household income <$25,000, being married or living as married, and illicit drug use were independently associated with increased risk of post-surgery smoking.

CONCLUSION

Although most adults who smoked 1-year before RYGB quit pre-surgery, smoking prevalence rebounded across 7-years, primarily due to relapse.

Within-person longitudinal associations between electronic nicotine delivery systems use and smoking cessation efforts among U.S. continuing adult cigarette smokers

OBJECTIVES

Prior studies that examined the role of electronic nicotine delivery systems (ENDS) use in smoking cessation have shown divergent conclusions. This study examined the time-course of ENDS-associated smoking abstinent behaviors among continuing cigarette smokers who were willing but unable to quit smoking.

METHODS

Data were drawn from the four waves of the Population Assessment of Tobacco and Health Study. Of the 1,684 smokers who tried to quit smoking completely at Wave 1, a total of 1,094 who were continuing smokers until Wave 4 and were not lost to follow-ups comprised the sample. Using generalized linear mixed modeling, we fitted weighted negative binomial regression models to examine within-person associations of ENDS use with quit attempts and number of days abstinent from smoking.

RESULTS

Quit attempt frequency and smoking abstinent days were highest at Wave 1, dropped at Wave 2, and then either increased a little or remained stagnant in later waves. ENDS use to quit smoking was associated with more frequent quit attempts (aIRR=1.67, 95% CI=1.42-1.95) and more abstinent days (aIRR=3.28, 95% CI=2.43-4.44), and the magnitude of such associations became stronger over time. ENDS use was associated with becoming a non-daily smoker among baseline daily smokers.

CONCLUSIONS

ENDS use among continuing smokers may help increase the number of quit attempts and smoking abstinent days. Given that the study sample is continuing smokers who failed in complete smoking cessation, future research would be desirable that evaluates whether such abstinent behaviors sustain and manifest harm reduction with improved health outcomes.

IMPLICATIONS

Smokers increasingly adopt electronic nicotine delivery systems (ENDS) to quit smoking. However, the association of ENDS use with smoking cessation efforts among continuing cigarette smokers who were willing but unable to quit smoking is largely unknown. This study found that quit attempts and smoking abstinent days increased with ENDS use to quit smoking by following up with population-representative continuing smokers. Additionally, this study assessed whether cigarette smokers' abstinent behaviors vary with their use of ENDS by estimating within-person associations with frequent assessments of both exposures and outcomes in a long-term perspective.

Age as a predictor of quit attempts and quit success in smoking cessation: findings from the International Tobacco Control Four-Country survey (2002-14)

BACKGROUND AND AIMS

Past research has found that young smokers are more likely to make quit attempts; however, there are conflicting findings regarding age and quit success. This study examined the degree to which smoker age is related to making quit attempts and quit success.

DESIGN

Ten waves of the International Tobacco Control Policy Cohort survey (ITC-4C) collected between 2002 and 2014, with nine wave-to-wave transitions with predictors at the first wave predicting quit attempts and success by the next wave.

SETTING

Canada, the United States, the United Kingdom and Australia.

PARTICIPANTS

Data from 15 874 smokers categorized into four age groups at baseline (18-24, 25-39, 40-54 and 55+ years).

MEASUREMENTS

Age, quit attempts and success (defined as ≥ 30 days abstinence confirmed, if possible, on a third wave for recent attempts).

FINDINGS

Older smokers were more likely to smoke daily (χ2  = 1557.86, r = 0.136, P < 0.001) than younger smokers. Daily smokers were less likely to report quit attempts (38.1 versus 58.2%) and to achieve 30 days of abstinence (22.9 versus 34.3%) than non-daily smokers. Older daily smokers were less likely to make quit attempts [0.61, confidence interval (CI) = 0.54-0.70, P < 0.001], even after controlling for indicators of nicotine dependence, country, sex, education, income, relationship status and household composition, than younger smokers. Younger smokers (< 25) were more likely to succeed for at least 30 days of abstinence, but only when compared with those aged 40-54 (OR = 0.83, 95% CI = 0.68-0.99). However, when controlling for heaviness of smoking the age effect disappeared. Significant interactions with age were found between age and intention when predicting quit attempts, and age and heaviness of smoking when predicting quit success.

CONCLUSIONS

An international cohort study indicates that young smokers are more likely to attempt to quit and appear to have similar levels of success in abstaining from smoking compared with older smokers when controlling for dependence. Quit success in all ages is most predicted by lower levels of nicotine dependence.

Establishment of a multimodal protocol combining a motivational interview, subcutaneous injection of NicoSan® and hyper-hydration for the "stopsmoking therapy": A multicentre real-life study'

OBJECTIVES

The StopSmoking Therapy, combins a motivational interview, a subcutaneous injection of NicoSan® and a hyperhydration protocol. The objectives were to evaluate the number of patients declaring cessation and factors related to relapse.

METHODS

In the 18 months following protocol, 554 subjects who consented, responded to the study's questionnaire. Categorical variables are presented as the frequency and percentage, continuous variables are presented as the mean and standard deviation, responses of abstinent subjects and of those who had started smoking again are compared via the chi-square test for categorical variables, and the Student's t-test for continuous variables.

RESULTS

In our sample 92.8% of the subjects reported smoking for 10 years or more. A total of 475 subjects (85.7%) reported a complete cessation (31.2% for more than 6 months and 33.1% for more than a year). Among relapsing subjects, were significantly over-represented: youngest ages, lower motivation, more frequent close friends or family using tobacco, lower dependency scores. No subject reported any significant adverse effects.

CONCLUSION

The multimodal protocol explored seems to have a favorable impact on smoking cessation, which could be enhanced by additional interventions dedicated to the youngest age groups, to people having smoking close friends and family, and should possibly add interventions based on cognitive behavioral therapy. A dedicated support by specialist tobacco addiction in the first weeks after treatment and/or the use of mobile support applications could also be useful. In order to asses efficacy, a prospective randomized double blind controlled versus placebo protocol could be considered.

Predictors and reasons for quitting smoking in remote Aboriginal and Torres Strait Islander communities

ISSUE ADDRESSED

National smoking prevalence is decreasing among Aboriginal and Torres Strait Islander people. In remote areas, Aboriginal and Torres Strait Islander smoking prevalence remains higher than in nonremote areas and is not improving.

METHODS

We analysed data from 539 daily and weekly smokers from remote areas who completed baseline surveys at either Wave 1 (April 2012-October 2013) or Wave 2 (August 2013-August 2014), including 157 from Wave 1 who also completed Wave 2, from the Talking About The Smokes project. We assessed associations between baseline predictor measures and having made any quit attempt in the past year and, among those who did, having sustained the last quit attempt for one month or more.

RESULTS

More smokers had made a quit attempt if they were younger or reported being unable to buy essentials due to money spent on smokes, being more stressed, having several pro-quitting motivations and attitudes, having an effective smoke-free home, or being encouraged to quit by a health professional or by family/friends. Of these, more had sustained their last quit attempt for one month or more if they reported being more socially advantaged, no smoking-induced deprivation, being less dependent, chewing pituri or an having effective smoke-free home.

CONCLUSIONS

Health staff should consider the quite different factors associated with starting and then sustaining a quit attempt. SO WHAT?: Our findings support continued attention in remote areas on smoke-free homes and health staff providing regular encouragement to all smokers to quit and more use of smokers' friends and family for support.

What kind of smoking identity following quitting would elevate smokers relapse risk?

BACKGROUND

Research has suggested that smokers who quit smoking and continue to identify themselves as a smoker versus a non-smoker are at greater risk of relapse. This study examines the relationship between post-quit smoker identities and relapse risk of former smokers in Australia and the UK comparing those who still identified as a smoker with firm choice to no longer smoke versus those not expressing a firm choice. Cross-country differences were examined.

METHODS

Data analysed came from 544 former smokers (quit 1 month or more) who participated in the Australian and UK Waves 9 (2013) and 10 (2014) of the International Tobacco Control (ITC) surveys. Post-quit smoker identities were assessed at baseline and smoking relapse at follow-up.

RESULTS

Baseline self-reported smoker identity independently predicted smoking relapse at 12-month follow-up (p < .01). Compared with the subgroup who identified themselves as smokers trying to quit, those who identified themselves as smokers who had chosen to no longer smoke (OR = 0.01, 95% CI = 0.01-0.25, p < .001), ex-smokers (OR = 0.05, CI = 0.01-0.25, p < .001) or non-smokers (OR = 0.07, CI = 0.02-0.37, p < .001) were less likely to relapse at follow-up. No cross-country differences were found.

CONCLUSIONS

Following quitting, smokers who maintained a smoker identity with a firm choice to no longer smoke or adopted a non-smoker or ex-smoker identity were less likely to relapse than those who failed to do so, suggesting that a clear rule/commitment to not smoke and/or a shift to a non-smoking identity may be protective of relapse.

Real-World Effectiveness of Pharmaceutical Smoking Cessation Aids: Time-Varying Effects

BACKGROUND

There are a limited number of studies that have examined the real-world effectiveness of smoking cessation aids and relapse longitudinally in population-representative samples. This study examines the association between use of nicotine gum, patch, bupropion, and varenicline and time to relapse as well as any changes in the association with increased length of abstinence.

METHODS

Data of 1821 current adult smokers (18+) making their first serious quit attempt were compiled from 4504 individuals enrolled in the Ontario Tobacco Survey, a representative telephone survey of Ontario adults, which followed smokers every 6 months for up to 3 years. Use of cessation aids at the time of initial report of a quit attempt was analyzed. A flexible parametric survival model was developed to model length of abstinence, controlling for potential confounders.

RESULTS

The best fit model found knots at 3, 13, 43, and 212 days abstinent, suggesting different rates of relapse in the periods marked by those days. Use of the patch and varenicline was associated with lower rates of relapse, but no positive effect was found for bupropion or nicotine gum. The effectiveness of the patch reversed in effect after the first month of abstinence.

CONCLUSIONS

This study is one of few reports of long-term quitting in a population-representative sample and demonstrates that the effectiveness of some pharmacological cessation aids (the patch and varenicline can be seen in a population sample). Previous failures in real-world studies of the effectiveness of smoking cessation aids may reflect differences in the products individuals use and differences in the timing of self-reported cessation.

IMPLICATIONS

While a large number of randomized controlled trials have shown the efficacy of many pharmaceutical smoking cessation aids, evidence of their effectiveness in observational studies in the real world is ambiguous. This study uses a longitudinal cohort of a representative sample of smokers to show that the effectiveness of pharmaceutical cessation aids can be demonstrated in real-world use situations, but effectiveness varies by product type and has time-varying effects.

Changes in Smoking and Vaping over 18 Months among Smokers and Recent Ex-Smokers: Longitudinal Findings from the 2016 and 2018 ITC Four Country Smoking and Vaping Surveys

This descriptive study of smokers (smoked at least monthly) and recent ex-smokers (quit for ≤2 years) examined transitions over an 18 month period in their smoking and vaping behaviors. Data are from Waves 1 (W1: 2016) and 2 (W2: 2018) of the ITC Four Country Smoking and Vaping Survey, a cohort study of adult (≥18+) smokers, concurrent users (smoke and vape), and recent ex-smokers from Australia, Canada, England, and the United States (US). Respondents (N = 5016) were classified according to their smoking and vaping status, which resulted in eight subgroups: (1) exclusive daily smokers (2) exclusive non-daily smokers; (3–6) concurrent users (subdivided into four groups by each combination of daily/non-daily smoking and daily/non-daily vaping); (7) ex-smokers who vape; (8) ex-smokers not vaping. The analyses focused first on describing changes between groups from W1 to W2. Second, transition outcomes were assessed based on changes in smoking and vaping between W1 and W2. Transitions focused on smoking were: no change in smoking (continued smoking at the same frequency); decreased smoking; increased smoking; discontinued smoking; relapsed (ex-smokers at W1 who were smoking at W2). Transitions focused on vaping were: initiated vaping; switched from smoking to vaping. Overall, this study found that the vast majority of smokers were smoking 18 months later. Non-daily smokers were more likely than daily smokers to have discontinued smoking (p < 0.0001) and to have switched to exclusive vaping (p = 0.034). Exclusive non-daily smokers were more likely than exclusive daily smokers to have initiated vaping (p = 0.04). Among all W1 daily smokers, there were no differences in discontinued smoking between daily smokers who vaped (concurrent users) and exclusive daily smokers; however, concurrent users were more likely than exclusive daily smokers to have decreased to non-daily smoking (p < 0.001) or to have switched to vaping by W2 (p < 0.001). Among all W1 non-daily smokers, there were no significant differences in increased smoking or discontinued smoking between concurrent users or exclusive smokers. Most ex-smokers remained abstinent from smoking, and there was no difference in relapse back to smoking between those who vaped and those who did not.

Psychological and Behavioral Correlates of Readiness to Stop Smoking

Accruing evidence strongly suggests that the motivation to give up smoking is a crucial predictor of tobacco cessation attempt. However, even motivated people often fail in their attempts and relapse is very common, even if most people who smoke are confident that the desire to quit is enough to change and maintain abstinence. According to this framework, the main objective of the current study was to identify psychological and lifestyle patterns that might characterize people who smoke cigarettes with different motivations to quit. A secondary aim was to compare the characteristics of people who are currently smoking with people who stopped or never smoked. A convenient sample of 360 volunteers (179 women, 181 men), with a mean age of 55 years (SD = 14.33), participated in this study. Participants completed a battery of psychological and behavioral scales aimed at assessing psychological characteristics as well as dependence level and readiness to stop. Our results strongly suggest that the behavior of people who smoke differs as a function of specific psychological variables. People who currently smoke may fall into two different clusters: In the first one, they have a healthy lifestyle and high self-perceived vitality and vigor, whereas those who fall in the second report lower psychological well-being and an unhealthier lifestyle. Unfortunately, the actual lifestyle does not seem to modulate the motivation to quit, and consequently, people keep on smoking anyway, although some participants tend to adopt compensative behaviors. However, the adoption of a healthier lifestyle might favor a successful cessation attempt once a ready-to-stop motivation level is achieved.

Prevalence and determinants of cigarette smoking relapse among US adult smokers: a longitudinal study

OBJECTIVES

This research project aims at estimating the prevalence of cigarette smoking relapse and determining its predictors among adult former smokers in the USA.

SETTING

This research analysed secondary data retrieved from the Tobacco Use Supplement-Current Population Survey 2010-2011 cohort in the USA.

PARTICIPANTS

Out of 18 499 participants who responded to the survey in 2010 and 2011, the analysis included a total sample size of 3258 ever smokers, who were living in the USA and reported quitting smoking in 2010. The survey's respondents who never smoked or reported current smoking in 2010 were excluded from the study sample.

PRIMARY AND SECONDARY OUTCOME MEASURES

Smoking relapse was defined as picking up smoking in 2011 after reporting smoking abstinence in 2010. The prevalence of relapse over the 12-month follow-up period was estimated among different subgroups. Multivariable logistic regression models were applied to determine factors associated with relapse.

RESULTS

A total of 184 former smokers reported smoking relapse by 2011 (weighted prevalence 6.8%; 95% CI 5.7% to 8.1%). Prevalence and odds of relapse were higher among young people compared with elders. Former smokers living in smoke-free homes (SFHs) had 60% lower odds of relapse compared with those living in homes that allowed smoking inside (adjusted OR 0.40; 95% CI 0.25 to 0.64). Regarding race/ethnicity, only Hispanics showed significantly higher odds of relapse compared with Whites (non-Hispanics). Odds of relapse were higher among never married, widowed, divorced and separated individuals, compared with the married group. Continuous smoking cessation for 6 months or more significantly decreased odds of relapse.

CONCLUSIONS

Wider health determinants, such as race and age, but also living in SFHs showed significant associations with smoking relapse, which could inform the development of more targeted programmes to support those smokers who successfully quit, although further longitudinal studies are required to confirm our findings.

Mental health disorders and alcohol use are associated with increased likelihood of smoking relapse among people living with HIV attending routine clinical care

BACKGROUND

People living with HIV (PLWH) have a high level of interest in quitting smoking, but only a small proportion have sustainable abstinence 6 months after cessation. Few investigations have focused on relapse to smoking among PLWH. In this investigation, we evaluated the prevalence of relapse after smoking cessation and the characteristics associated with smoking relapse using a retrospective, longitudinal cohort of PLWH during an eight-year observation.

METHODS

All patients aged ≥19 years that reported current smoking during the study period and then reported not smoking on a subsequent tobacco use questionnaire (quitters) were eligible for the study. In addition, patients required at least one subsequent follow-up visit after quitting where smoking status was again reported to allow for assessment of relapse. A Cox proportional hazard model was fit to evaluate factors associated with smoking relapse in PLWH attending routine clinical care.

RESULTS

Of the 473 patients who quit smoking in the study, 51% relapsed. In multivariable analysis, factors significantly associated with a higher likelihood of relapse were anxiety symptoms (HR = 1.55, 95% CI [1.11, 2.17]) and at-risk alcohol use (HR = 1.74, 95% CI [1.06, 2.85]), whereas antiretroviral therapy (ART) adherence (HR = 0.65, 95% CI [0.49, 0.99]) and longer time in care (HR = 0.94, 95% CI [0.91, 0.98]) were associated with a reduced likelihood of relapse after cessation.

CONCLUSION

Our study underscores the high prevalence of smoking relapse that exists among PLWH after they quit smoking. Successful engagement in mental health care may enhance efforts to reduce relapse in the underserved populations of PLWH.

Association Between Electronic Cigarette Use and Smoking Reduction in France

IMPORTANCE

The electronic cigarette (EC) has become popular among smokers who wish to reduce their tobacco use levels or quit smoking, but its effectiveness as a cessation aid is uncertain.

OBJECTIVE

To examine the association of regular EC use with the number of cigarettes smoked per day, smoking cessation among current smokers, and smoking relapse among former smokers.

DESIGN, SETTING, AND PARTICIPANTS

The CONSTANCES (Consultants des Centres d'Examens de Santé) cohort study, based in France, began recruiting participants January 6, 2012, and is currently ongoing. Participants were enrolled in CONSTANCES through 2015, and included 5400 smokers (mean [SD] follow-up of 23.4 [9.3] months) and 2025 former smokers (mean [SD] follow-up of 22.1 [8.6] months) at baseline who quit smoking in 2010, the year in which ECs were introduced in France, or afterward. Analyses were performed from February 8, 2017, to October 15, 2018.

MAIN OUTCOMES AND MEASURES

The association between EC use and the number of cigarettes smoked during follow-up was studied using mixed regression models. The likelihood of smoking cessation was studied using Poisson regression models with robust sandwich variance estimators. The association between EC use and smoking relapse among former smokers was studied using Cox proportional hazards regression models. All statistical analyses were adjusted for sociodemographic characteristics, duration of follow-up, and smoking characteristics.

RESULTS

Among the 5400 daily smokers (2906 women and 2494 men; mean [SD] age, 44.9 [12.4] years), regular EC use was associated with a significantly higher decrease in the number of cigarettes smoked per day compared with daily smokers who did not use ECs (-4.4 [95% CI, -4.8 to -3.9] vs -2.7 [95% CI, -3.1 to -2.4]), as well as a higher adjusted relative risk of smoking cessation (1.67; 95% CI, 1.51-1.84]). At the same time, among the 2025 former smokers (1004 women and 1021 men; mean [SD] age, 43.6 [12.1] years), EC use was associated with an increase in the rate of smoking relapse among former smokers (adjusted hazard ratio, 1.70; 95% CI, 1.25-2.30).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that, among adult smokers, EC use appears to be associated with a decrease in smoking level and an increase in smoking cessation attempts but also with an increase in the level of smoking relapse in the general population after approximately 2 years of follow-up.

The Attentional Bias in Current and Former Smokers

Attentional bias has been defined as the propensity of a person to allocate selective attention automatically to salient cues (Field and Powell, 2007). In the case of smoking, this bias implies that smokers are implicitly attracted by smoking-related stimuli, which produce behavioral, memory, and emotional effects (Volkow et al., 2006; Giardini et al., 2009). In more detail, scientific evidence pointed out that smoking is strongly supported by attentional bias that activates craving and urgency to smoke a cigarette. However, poor and conflicting data are available regarding the role of this cognitive bias on former smokers. The main aim of this study is to explore the occurrence of the attentional bias on of both current and former smokers, also with the aim to identify associations with behavioral, psychological and cognitive characteristic of participants. We collected data on 245 current, volunteers (male 50.6%; female 49.4%) aged 54.81 (SD = 14.352, range = 18–63), divided in current smokers (98), former smokers (102) and non-smokers (45). A combination of neuropsychology tests (Emotional Smoke Stroop Task and Go/no-Go task), and standardized questionnaires [Behavioral Inhibition System-Behavioral Approach System (BIS-BAS), Fagerström Test for Nicotine Dependence (FTND), Barratt Impulsiveness Scale, Motivational questionnaire] were used to assess the attentional bias, psychological variables, and smoking-related characteristics. Responses at the Emotional Smoke Stroop task revealed that current and former smokers are actually slower than non-smokers are when facing smoking cues, while performances at other Stroop conditions and at the Go/no-Go task are not statistically different. These results confirmed the occurrence of the attentional bias in current smokers, and above all points out that the same effect is present in former smokers. We found only small and selective correlations between attentional bias and psychological variables (e.g., impulsiveness and inhibition). In particular, impulsivity is not directly associated with the AB intensity. Also, smoking characteristics (e.g., years of smoking and dependence level) and the length of the period of abstinence do not seem to modulate implicit cognition of smoking cue. Our data support the idea that the attentional bias may be considered relevant in sustaining smoking and favoring relapse.

Evaluation of a culturally appropriate peer coaching program for smoking cessation

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of a peer coaching smoking cessation program in a high-risk Medicaid population.

DESIGN AND SAMPLE

In this manuscript, we present an evaluation of a pilot program. Participants (N = 138) were recruited out of a larger smoking cessation program administered statewide and funded by the Center for Medicare and Medicaid Services. The participant sample was diverse, with 52% self-identifying as White, 39% as Black, and 56% Latino ethnicity (any race).

METHODS

Motivational interviewing techniques were utilized by peer coaches in clinical and community settings to achieve smoking cessation using face-to-face, telephone, and text/email encounters over a period of 6 months.

RESULTS

There was a statistically significant increase in the number of participants who had quit smoking from program enrollment to discharge (5.1%-18.5%, p = 0.02). Number of peer coaching encounters predicted quitting in program participants.

CONCLUSIONS

This study adds to the literature that community-based smoking cessation services led by peer coaches can be effective in a diverse, high-risk population.