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Schlam TR, Baker TB, Piper ME, Cook JW, Smith SS, Zwaga D, Jorenby DE, Almirall D, Bolt DM, Collins LM, Mermelstein R, Fiore MC. What to do after smoking relapse? A sequential multiple assignment randomized trial of chronic care smoking treatments. Addiction 2024; 119:898-914. [PMID: 38282258 PMCID: PMC11098029 DOI: 10.1111/add.16428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 11/30/2023] [Indexed: 01/30/2024]
Abstract
AIM To compare effects of three post-relapse interventions on smoking abstinence. DESIGN Sequential three-phase multiple assignment randomized trial (SMART). SETTING Eighteen Wisconsin, USA, primary care clinics. PARTICIPANTS A total of 1154 primary care patients (53.6% women, 81.2% White) interested in quitting smoking enrolled from 2015 to 2019; 582 relapsed and were randomized to relapse recovery treatment. INTERVENTIONS In phase 1, patients received cessation counseling and 8 weeks nicotine patch. Those who relapsed and agreed were randomized to a phase 2 relapse recovery group: (1) reduction counseling + nicotine mini-lozenges + encouragement to quit starting 1 month post-randomization (preparation); (2) repeated encouragement to quit starting immediately post-randomization (recycling); or (3) advice to call the tobacco quitline (control). The first two groups could opt into phase 3 new quit treatment [8 weeks nicotine patch + mini-lozenges plus randomization to two treatment factors (skill training and supportive counseling) in a 2 × 2 design]. Phase 2 and 3 interventions lasted ≤ 15 months. MEASUREMENTS The study was powered to compare each active phase 2 treatment with the control on the primary outcome: biochemically confirmed 7-day point-prevalence abstinence 14 months post initiating phase 2 relapse recovery treatment. Exploratory analyses tested for phase 3 counseling factor effects. FINDINGS Neither skill training nor supportive counseling (each on versus off) increased 14-month abstinence rates; skills on versus off 9.3% (14/151) versus 5.2% (8/153), P = 0.19; support on versus off 6.6% (10/152) versus 7.9% (12/152), P = 0.73. Phase 2 preparation did not produce higher 14-month abstinence rates than quitline referral; 3.6% (8/220) versus 2.1% [3/145; risk difference = 1.5%, 95% confidence interval (CI) = -1.8-5.0%, odds ratio (OR) = 1.8, 95% CI = 0.5-6.9]. Recycling, however, produced higher abstinence rates than quitline referral; 6.9% (15/217) versus 2.1% (three of 145; risk difference, 4.8%, 95% CI = 0.7-8.9%, OR = 3.5, 95% CI = 1.0-12.4). Recycling produced greater entry into new quit treatment than preparation: 83.4% (181/217) versus 55.9% (123/220), P < 0.0001. CONCLUSIONS Among people interested in quitting smoking, immediate encouragement post-relapse to enter a new round of smoking cessation treatment ('recycling') produced higher probability of abstinence than tobacco quitline referral. Recycling produced higher rates of cessation treatment re-engagement than did preparation/cutting down using more intensive counseling and pharmacotherapy.
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Affiliation(s)
- Tanya R Schlam
- Center for Tobacco Research and Intervention, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
- Department of Kinesiology, School of Education, University of Wisconsin-Madison, Madison, WI, USA
| | - Timothy B Baker
- Center for Tobacco Research and Intervention, Division of General Internal Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Megan E Piper
- Center for Tobacco Research and Intervention, Division of General Internal Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jessica W Cook
- Center for Tobacco Research and Intervention, Division of General Internal Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Stevens S Smith
- Center for Tobacco Research and Intervention, Division of General Internal Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Deejay Zwaga
- Center for Tobacco Research and Intervention, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Douglas E Jorenby
- Center for Tobacco Research and Intervention, Division of General Internal Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Daniel Almirall
- Institute for Social Research and Department of Statistics, University of Michigan, Ann Arbor, MI, USA
| | - Daniel M Bolt
- Department of Educational Psychology, School of Education, University of Wisconsin-Madison, Madison, WI, USA
| | - Linda M Collins
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY, USA
| | - Robin Mermelstein
- Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Michael C Fiore
- Center for Tobacco Research and Intervention, Division of General Internal Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
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Theodoulou A, Chepkin SC, Ye W, Fanshawe TR, Bullen C, Hartmann-Boyce J, Livingstone-Banks J, Hajizadeh A, Lindson N. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2023; 6:CD013308. [PMID: 37335995 PMCID: PMC10278922 DOI: 10.1002/14651858.cd013308.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Nicotine replacement therapy (NRT) aims to replace nicotine from cigarettes. This helps to reduce cravings and withdrawal symptoms, and ease the transition from cigarette smoking to complete abstinence. Although there is high-certainty evidence that NRT is effective for achieving long-term smoking abstinence, it is unclear whether different forms, doses, durations of treatment or timing of use impacts its effects. OBJECTIVES To determine the effectiveness and safety of different forms, deliveries, doses, durations and schedules of NRT, for achieving long-term smoking cessation. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group trials register for papers mentioning NRT in the title, abstract or keywords, most recently in April 2022. SELECTION CRITERIA We included randomised trials in people motivated to quit, comparing one type of NRT use with another. We excluded studies that did not assess cessation as an outcome, with follow-up of fewer than six months, and with additional intervention components not matched between arms. Separate reviews cover studies comparing NRT to control, or to other pharmacotherapies. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods. We measured smoking abstinence after at least six months, using the most rigorous definition available. We extracted data on cardiac adverse events (AEs), serious adverse events (SAEs) and study withdrawals due to treatment. MAIN RESULTS: We identified 68 completed studies with 43,327 participants, five of which are new to this update. Most completed studies recruited adults either from the community or from healthcare clinics. We judged 28 of the 68 studies to be at high risk of bias. Restricting the analysis only to those studies at low or unclear risk of bias did not significantly alter results for any comparisons apart from the preloading comparison, which tested the effect of using NRT prior to quit day whilst still smoking. There is high-certainty evidence that combination NRT (fast-acting form plus patch) results in higher long-term quit rates than single form (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.17 to 1.37; I2 = 12%; 16 studies, 12,169 participants). Moderate-certainty evidence, limited by imprecision, indicates that 42/44 mg patches are as effective as 21/22 mg (24-hour) patches (RR 1.09, 95% CI 0.93 to 1.29; I2 = 38%; 5 studies, 1655 participants), and that 21 mg patches are more effective than 14 mg (24-hour) patches (RR 1.48, 95% CI 1.06 to 2.08; 1 study, 537 participants). Moderate-certainty evidence, again limited by imprecision, also suggests a benefit of 25 mg over 15 mg (16-hour) patches, but the lower limit of the CI encompassed no difference (RR 1.19, 95% CI 1.00 to 1.41; I2 = 0%; 3 studies, 3446 participants). Nine studies tested the effect of using NRT prior to quit day (preloading) in comparison to using it from quit day onward. There was moderate-certainty evidence, limited by risk of bias, of a favourable effect of preloading on abstinence (RR 1.25, 95% CI 1.08 to 1.44; I2 = 0%; 9 studies, 4395 participants). High-certainty evidence from eight studies suggests that using either a form of fast-acting NRT or a nicotine patch results in similar long-term quit rates (RR 0.90, 95% CI 0.77 to 1.05; I2 = 0%; 8 studies, 3319 participants). We found no clear evidence of an effect of duration of nicotine patch use (low-certainty evidence); duration of combination NRT use (low- and very low-certainty evidence); or fast-acting NRT type (very low-certainty evidence). Cardiac AEs, SAEs and withdrawals due to treatment were all measured variably and infrequently across studies, resulting in low- or very low-certainty evidence for all comparisons. Most comparisons found no clear evidence of an effect on these outcomes, and rates were low overall. More withdrawals due to treatment were reported in people using nasal spray compared to patches in one study (RR 3.47, 95% CI 1.15 to 10.46; 1 study, 922 participants; very low-certainty evidence) and in people using 42/44 mg patches in comparison to 21/22 mg patches across two studies (RR 4.99, 95% CI 1.60 to 15.50; I2 = 0%; 2 studies, 544 participants; low-certainty evidence). AUTHORS' CONCLUSIONS There is high-certainty evidence that using combination NRT versus single-form NRT and 4 mg versus 2 mg nicotine gum can result in an increase in the chances of successfully stopping smoking. Due to imprecision, evidence was of moderate certainty for patch dose comparisons. There is some indication that the lower-dose nicotine patches and gum may be less effective than higher-dose products. Using a fast-acting form of NRT, such as gum or lozenge, resulted in similar quit rates to nicotine patches. There is moderate-certainty evidence that using NRT before quitting may improve quit rates versus using it from quit date only; however, further research is needed to ensure the robustness of this finding. Evidence for the comparative safety and tolerability of different types of NRT use is limited. New studies should ensure that AEs, SAEs and withdrawals due to treatment are reported.
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Affiliation(s)
- Annika Theodoulou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Samantha C Chepkin
- NHS Hertfordshire and West Essex Integrated Care Board, Welwyn Garden City, UK
| | - Weiyu Ye
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Anisa Hajizadeh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Christiansen B, Riemer D, Conner KL, Fiore MC. The Bucket Approach: Developing and Implementing an On-line Training Program in Tobacco Dependence Interventions Tailored for Behavioral Health Clinicians. Community Ment Health J 2023; 59:439-450. [PMID: 36050593 PMCID: PMC9436731 DOI: 10.1007/s10597-022-01021-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/14/2022] [Indexed: 11/03/2022]
Abstract
People coping with a mental illness and/or addictive disorders have a very high prevalence of smoking cigarettes. The Bucket Approach, a free online training, tailors evidence-based tobacco dependence interventions for behavioral health clinicians to increase the likelihood that they will also address the tobacco use of their patients. From October 2019 through August 2021, 999 people enrolled in and 447 people completed the training. Individuals who completed the training evaluated it highly with an overall mean score of 8.4 (scale = 1 for very poor to 10 for very good). 3- and 6-month follow-up surveys documented continued impact. The training resulted in substantial changes in beliefs about treating tobacco dependence. For example, before training, 18.3% of trainees strongly agreed with the statement, "The skills currently possessed by behavioral health clinicians can be easily applied to the treatment of tobacco dependence." This increased to 40.7% at the end of training.
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Affiliation(s)
- Bruce Christiansen
- Center for Tobacco Research and Intervention, University of Wisconsin School of Medicine and Public Health, 1930 Monroe St., Suite 200, Madison, WI 53711 USA
| | - Donna Riemer
- WI Department Health Services, Bureau of Prevention Treatment and Recovery, 1 West Wilson Street, Madison, WI 53703 USA
| | - Karen L. Conner
- Center for Tobacco Research and Intervention, University of Wisconsin School of Medicine and Public Health, 1930 Monroe St., Suite 200, Madison, WI 53711 USA
| | - Michael C. Fiore
- Center for Tobacco Research and Intervention, University of Wisconsin School of Medicine and Public Health, 1930 Monroe St., Suite 200, Madison, WI 53711 USA
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Klemperer EM, Streck JM, Lindson N, West JC, Su A, Hughes JR, Carpenter MJ. A systematic review and meta-analysis of interventions to induce attempts to quit tobacco among adults not ready to quit. Exp Clin Psychopharmacol 2023; 31:541-559. [PMID: 35771496 PMCID: PMC10106992 DOI: 10.1037/pha0000583] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The prevalence of past-year smoking cessation remains below 10% in the U.S. Most who smoke are not ready to quit in the near future. Cessation requires both (a) initiating a quit attempt (QA) and (b) maintaining abstinence. Most research has focused on abstinence among people already motivated to quit. We systematically reviewed interventions to promote QAs among people not motivated to quit tobacco. We searched PubMed, CENTRAL, PsycINFO, Embase, and our personal libraries for randomized trials of tobacco interventions that reported QAs as an outcome among adults not ready to quit. We screened studies and extracted data in duplicate. We pooled findings of the 25 included studies using Mantel-Haenszel random effects meta-analyses when ≥ 2 studies tested the same intervention. Most (24) trials addressed cigarettes and one addressed smokeless tobacco. Substantial heterogeneity among trials resulted in a series of small meta-analyses. Findings indicate varenicline may increase QAs more than no varenicline, n = 320; RR = 1.4, 95% CI [1.1, 1.7]; I² = 0%, and nicotine replacement therapy (NRT) may increase QAs more than no NRT, n = 2,568; RR = 1.1, 95% CI [1.02, 1.3]; I² = 0%. Pooled effects for motivational counseling, reduction counseling, and very low nicotine content cigarettes showed no clear evidence of benefit or harm. The evidence was judged to be of medium to very low certainty due to imprecision, inconsistency, and risk of bias, suggesting that further research is likely to change interpretation of our results. Findings demonstrate the need for more high-quality research on interventions to induce QAs among adults not ready to quit tobacco. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Elias M. Klemperer
- Vermont Center on Behavior & Health, Department of Psychiatry, University of Vermont
- Department of Psychological Science, University of Vermont
| | - Joanna M. Streck
- Tobacco Research & Treatment Center, Division of General Internal Medicine and Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School
| | - Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Julia C. West
- Vermont Center on Behavior & Health, Department of Psychiatry, University of Vermont
- Department of Psychological Science, University of Vermont
| | - Alan Su
- University of Vermont Medical Center
| | - John R. Hughes
- Vermont Center on Behavior & Health, Department of Psychiatry, University of Vermont
- Department of Psychological Science, University of Vermont
| | - Matthew J. Carpenter
- Department of Psychiatry and Behavioral Sciences & Hollings Cancer Center, Medical University of South Carolina
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5
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Taylor AH, Thompson TP, Streeter A, Chynoweth J, Snowsill T, Ingram W, Ussher M, Aveyard P, Murray RL, Harris T, Callaghan L, Green C, Greaves CJ, Price L, Creanor S. Effectiveness and cost-effectiveness of behavioural support for prolonged abstinence for smokers wishing to reduce but not quit: Randomised controlled trial of physical activity assisted reduction of smoking (TARS). Addiction 2023; 118:1140-1152. [PMID: 36871577 DOI: 10.1111/add.16129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/13/2022] [Indexed: 03/07/2023]
Abstract
AIMS For smokers unmotivated to quit, we assessed the effectiveness and cost-effectiveness of behavioural support to reduce smoking and increase physical activity on prolonged abstinence and related outcomes. DESIGN A multi-centred pragmatic two-arm parallel randomised controlled trial. SETTING Primary care and the community across four United Kingdom sites. PARTICIPANTS Nine hundred and fifteen adult smokers (55% female, 85% White), recruited via primary and secondary care and the community, who wished to reduce their smoking but not quit. INTERVENTIONS Participants were randomised to support as usual (SAU) (n = 458) versus multi-component community-based behavioural support (n = 457), involving up to eight weekly person-centred face-to-face or phone sessions with additional 6-week support for those wishing to quit. MEASUREMENTS Ideally, cessation follows smoking reduction so the primary pre-defined outcome was biochemically verified 6-month prolonged abstinence (from 3-9 months, with a secondary endpoint also considering abstinence between 9 and 15 months). Secondary outcomes included biochemically verified 12-month prolonged abstinence and point prevalent biochemically verified and self-reported abstinence, quit attempts, number of cigarettes smoked, pharmacological aids used, SF12, EQ-5D and moderate-to-vigorous physical activity (MVPA) at 3 and 9 months. Intervention costs were assessed for a cost-effectiveness analysis. FINDINGS Assuming missing data at follow-up implied continued smoking, nine (2.0%) intervention participants and four (0.9%) SAU participants achieved the primary outcome (adjusted odds ratio, 2.30; 95% confidence interval [CI] = 0.70-7.56, P = 0.169). At 3 and 9 months, the proportions self-reporting reducing cigarettes smoked from baseline by ≥50%, for intervention versus SAU, were 18.9% versus 10.5% (P = 0.009) and 14.4% versus 10% (P = 0.044), respectively. Mean difference in weekly MVPA at 3 months was 81.6 minutes in favour of the intervention group (95% CI = 28.75, 134.47: P = 0.003), but there was no significant difference at 9 months (23.70, 95% CI = -33.07, 80.47: P = 0.143). Changes in MVPA did not mediate changes in smoking outcomes. The intervention cost was £239.18 per person, with no evidence of cost-effectiveness. CONCLUSIONS For United Kingdom smokers wanting to reduce but not quit smoking, behavioural support to reduce smoking and increase physical activity improved some short-term smoking cessation and reduction outcomes and moderate-to-vigorous physical activity, but had no long-term effects on smoking cessation or physical activity.
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Affiliation(s)
| | | | - Adam Streeter
- Faculty of Health, University of Plymouth, Plymouth, UK.,Institut für Epidemiologie und Sozialmedizin, University of Münster, Munster, Germany
| | | | - Tristan Snowsill
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Wendy Ingram
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - Michael Ussher
- Institute for Social Marketing and Health, University of Stirling, Stirling, UK.,Population Health Research Institute, St. George's University of London, London, UK
| | - Paul Aveyard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Rachael L Murray
- Lifespan and Population Health, Clinical Science Building, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tess Harris
- Population Health Research Institute, St. George's University of London, London, UK
| | | | - Colin Green
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Colin J Greaves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Lisa Price
- Sport and Health Sciences, University of Exeter, Exeter, UK
| | - Siobhan Creanor
- University of Exeter Medical School, University of Exeter, Exeter, UK
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Znyk M, Wężyk-Caba I, Kaleta D. The Frequency of Tobacco Smoking and E-Cigarettes Use among Primary Health Care Patients-The Association between Anti-Tobacco Interventions and Smoking in Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11584. [PMID: 36141847 PMCID: PMC9517004 DOI: 10.3390/ijerph191811584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 06/16/2023]
Abstract
The aim of this study was to assess the prevalence of smoking and e-cigarette use among primary care patients during the COVID-19 pandemic and to assess the frequency of minimal anti-tobacco interventions by family doctors. A cross-sectional study was conducted from January 2020 to December 2021 encompassing 896 patients over 18 years of age who used primary health care in the city of Lodz, Poland. In total, 21.2% of the respondents were smokers, 11.6% were e-cigarette users, and 7.3% dual users. In addition, 68.4% of smokers had been asked about smoking, while 62.9% of non-smokers and 33.7% of smokers were advised to quit smoking; furthermore, 71.1% of e-cigarette users and 72.3% of dual users were asked about tobacco use, and 17.3% and 21.5%, respectively, had been advised to quit smoking. Multivariate logistic regression analysis found men and alcohol users to receive more minimal anti-tobacco advice than women and non-alcohol users (OR = 1.46; p < 0.05 and OR = 1.45; p < 0.05), socio-demographic and health correlates did not increase the chances of obtaining minimal anti-tobacco interventions among smokers. People with a medium level of education had a higher chance of receiving minimal anti-tobacco intervention from their family doctor when using e-cigarettes and when they were dual users (OR = 2.06; p < 0.05 and OR = 2.51; p < 0.05). Smokers were less likely to receive minimal anti-tobacco interventions than reported in previous studies. Measures should be implemented to increase the minimum interventions provided by GPs in their daily work among all patients, not only those who use tobacco. Non-smokers should be encouraged to abstain.
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