The feasibility of smoking reduction: an update

Sex differences in cigarette smoking following a mindfulness-based cessation randomized controlled trial

Some interventions for smoking cessation such as quit smoking aids show sex-specific effects on outcomes, but behavioral interventions such as mindfulness-based interventions (MBIs) for smoking cessation lack formal reporting of sex-intervention tests of interaction to date. To address this gap, we conducted a secondary analysis of a RCT dataset (N = 213), recruiting participants from California, to statistically test a sex-intervention interaction effect on complete 7-day point prevalence abstinence (PPA), proportion of days abstinent, and daily cigarettes smoked. Smoking was assessed using the timeline follow back method spanning the four weeks following a daily 14-day app-based intervention and a planned smoking quit date immediately following the intervention phase. All models adjusted for baseline nicotine dependence. The study groups had comparable sex proportions (MBI: 56 % female; control: 55 % female) and the ratio of outcome assessment completion by group was not dependent on sex. Adjusted analyses revealed a significant sex-intervention interaction effect for daily cigarettes smoked ([female coded 1]: two-way interaction effect IRR = 0.59, 95 % CI: 0.46-0.77, p < 0.0001; effect for female: IRR = 0.68, 95 % CI: 0.57-0.81, effect for male: IRR = 1.14, 95 % CI: 0.95-1.37), but not for complete 7-day PPA ([female coded 1] two-way interaction effect OR = 1.24, 95 % CI: 0.31-4.89, p = 0.76) or proportion of total days abstinent ([female coded 1] two-way interaction effect OR = 1.97, 95 % CI: 0.53-7.37, p = 0.31). Females, but not males, allocated to a daily app-based MBI with a quit plan and quit aid workbook smoked fewer cigarettes per day compared to females in the control group. Males, but not females, showed significantly less use of the MBI app compared to the control app.

Probability and predictors of long-term smoking relapse among Chinese adult smokers: A longitudinal study

Numerous smokers attempt to quit smoking, but most cessation efforts prove unsuccessful. Scarce evidence exists regarding predictors of long-term relapse in China. This study aims to evaluate the probability of relapse and examine factors may contribute to relapse among Chinese adults. A dynamic cohort of 6,036 observations on 2,378 adult quitters was constructed from the China Family Panel Studies in 2010, 2012, 2014, 2016 and 2018. The life table method was employed to calculate the probability of relapse for long-term smoking abstinence. Multivariate complementary log-log survival models were developed to examine the predictors of smoking relapse. We found that the probability of relapse decreased as the duration of abstinence increased, with rates of 49.07 %, 20.05 %, 10.29 %, and 6.63 % at 2, 4, 6, and 8 years of abstinence, respectively. The cumulative probability of relapse within 8 years was 65.89 %. Age ≥65 years, higher educational attainment, respiratory disease, and a satisfying lifestyle were associated with a reduced likelihood of relapse. Conversely, higher occupational prestige, alcohol drinking, cohabitant smoking, and greater future confidence were associated with an increased risk of relapse. These findings demonstrated that the probability of relapse decreased progressively over time, with most relapses occurring in the initial two years following quit attempts. Predictors of Chinese quitters' relapse behavior in our study were similar to those in previous studies. Drinking and cohabitant smoking were identified as strong predictors of relapse in this population.

Comparison of in-person versus telephonic interview on tobacco cessation in an Indian dental setting

Oral health professionals in the dental office settings have a distinctive opportunity to increase tobacco abstinence rates among tobacco users as tobacco use has significant adverse effects on oral health. This review assesses the effectiveness of tobacco cessation interventions offered to cigarette smokers and smokeless tobacco users in the dental office setting. The following electronic retrieval systems and databases were searched for the identification of studies, The Cochrane Central Register of Controlled Trials, PUBMED, GOOGLE SCHOLAR, SCIENCE DIRECT and TRIP. The review included randomized clinical trials assessing tobacco cessation interventions conducted by oral health professionals in the dental office setting. Seven clinical trials met the criteria for inclusion in this review. All the studies have employed behavioral therapy, telephonic counseling's and pharmacotherapy as interventional component. The rate of abstinence and biochemical validation were the outcome measurements. Since all the studies included were randomized clinical trials, the level of evidence was II. Available evidence suggests that telephonic interventions for tobacco use conducted by oral health professionals in the dental office setting may increase tobacco abstinence rates among smokers and smokeless tobacco users. This review data suggests that telephone has a pragmatic effect on interactional aspects of psychological therapy. Further research should be carried out to make conclusive recommendations regarding the intervention components that can be incorporated in the dental office settings.

The Bucket Approach: Developing and Implementing an On-line Training Program in Tobacco Dependence Interventions Tailored for Behavioral Health Clinicians

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.

Effectiveness of personalized tobacco cessation intervention package among patients with schizophrenia and related psychotic disorders - A two-group experimental study

INTRODUCTION

Persons with schizophrenia and related psychotic disorders (PwS) smoke more, and have twice the rate of mortality, with 10-25 years lower life expectancy than the general population. Evidence-based tobacco cessation interventions would help in quitting.

AIM

To evaluate the effectiveness of a personalized tobacco cessation intervention package for patients attending the outpatient psychiatry department.

METHODS

The study adopted a two-group experimental design in PwS, using a simple randomization method. Eligible participants were randomly allocated to either the intervention group (n = 85) receiving the intervention package or the control group (n = 85) receiving brief advice to stop tobacco. The study outcomes were measured at baseline, 1, 3, and 6 months. SPSS 23 was used for data analysis. Intention-to-treat analysis was used to manage missing data. The p-value of < 0.05 is considered statistically significant.

RESULTS

At 6 months, there was a significant difference (p < 0.001) in 7 days point-prevalence abstinence (28 % vs 10.8 %), reduction of tobacco by at least 50 % (62.4 % vs 40.9 %) with an attrition rate of 15.3 % vs 30.5 % in intervention and control group respectively. Reduction in nicotine dependence and tobacco craving, an increase in motivation level, quit attempts and clinical improvement favored the intervention group. 16.5 % of participants expressed interest in pharmacotherapy for tobacco cessation, 3.5 % were referred to a specialized tobacco cessation center, two control group participants were hospitalized for drug default, and withdrawal symptoms reported were mild.

CONCLUSION

Implementing a tobacco cessation intervention based on the stage of motivation aids in abstinence and reduction of tobacco use in PwS.

Motivational support intervention to reduce smoking and increase physical activity in smokers not ready to quit: the TARS RCT

Background

Physical activity can support smoking cessation for smokers wanting to quit, but there have been no studies on supporting smokers wanting only to reduce. More broadly, the effect of motivational support for such smokers is unclear.

Objectives

The objectives were to determine if motivational support to increase physical activity and reduce smoking for smokers not wanting to immediately quit helps reduce smoking and increase abstinence and physical activity, and to determine if this intervention is cost-effective.

Design

This was a multicentred, two-arm, parallel-group, randomised (1 : 1) controlled superiority trial with accompanying trial-based and model-based economic evaluations, and a process evaluation.

Setting and participants

Participants from health and other community settings in four English cities received either the intervention (n = 457) or usual support (n = 458).

Intervention

The intervention consisted of up to eight face-to-face or telephone behavioural support sessions to reduce smoking and increase physical activity.

Main outcome measures

The main outcome measures were carbon monoxide-verified 6- and 12-month floating prolonged abstinence (primary outcome), self-reported number of cigarettes smoked per day, number of quit attempts and carbon monoxide-verified abstinence at 3 and 9 months. Furthermore, self-reported (3 and 9 months) and accelerometer-recorded (3 months) physical activity data were gathered. Process items, intervention costs and cost-effectiveness were also assessed.

Results

The average age of the sample was 49.8 years, and participants were predominantly from areas with socioeconomic deprivation and were moderately heavy smokers. The intervention was delivered with good fidelity. Few participants achieved carbon monoxide-verified 6-month prolonged abstinence [nine (2.0%) in the intervention group and four (0.9%) in the control group; adjusted odds ratio 2.30 (95% confidence interval 0.70 to 7.56)] or 12-month prolonged abstinence [six (1.3%) in the intervention group and one (0.2%) in the control group; adjusted odds ratio 6.33 (95% confidence interval 0.76 to 53.10)]. At 3 months, the intervention participants smoked fewer cigarettes than the control participants (21.1 vs. 26.8 per day). Intervention participants were more likely to reduce cigarettes by ≥ 50% by 3 months [18.9% vs. 10.5%; adjusted odds ratio 1.98 (95% confidence interval 1.35 to 2.90] and 9 months [14.4% vs. 10.0%; adjusted odds ratio 1.52 (95% confidence interval 1.01 to 2.29)], and reported more moderate-to-vigorous physical activity at 3 months [adjusted weekly mean difference of 81.61 minutes (95% confidence interval 28.75 to 134.47 minutes)], but not at 9 months. Increased physical activity did not mediate intervention effects on smoking. The intervention positively influenced most smoking and physical activity beliefs, with some intervention effects mediating changes in smoking and physical activity outcomes. The average intervention cost was estimated to be £239.18 per person, with an overall additional cost of £173.50 (95% confidence interval -£353.82 to £513.77) when considering intervention and health-care costs. The 1.1% absolute between-group difference in carbon monoxide-verified 6-month prolonged abstinence provided a small gain in lifetime quality-adjusted life-years (0.006), and a minimal saving in lifetime health-care costs (net saving £236).

Conclusions

There was no evidence that behavioural support for smoking reduction and increased physical activity led to meaningful increases in prolonged abstinence among smokers with no immediate plans to quit smoking. The intervention is not cost-effective.

Limitations

Prolonged abstinence rates were much lower than expected, meaning that the trial was underpowered to provide confidence that the intervention doubled prolonged abstinence.

Future work

Further research should explore the effects of the present intervention to support smokers who want to reduce prior to quitting, and/or extend the support available for prolonged reduction and abstinence.

Trial registration

This trial is registered as ISRCTN47776579.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 4. See the NIHR Journals Library website for further project information.

Spontaneous Smoking Cessation in Parents

Purpose

To determine the percentage of parents who report quitting spontaneously and examine the factors associated with these quits.

Methods

As part of a cluster randomized control trial addressing parental smoking in a pediatric outpatient setting, 12-month follow-up survey data were collected from parents who had self-identified as smokers when exiting from 10 control practices. Parents were considered to have made a spontaneous quit if they reported not smoking a cigarette, even a puff, in the last 7 days and chose the statement "I did not plan the quit in advance; I just did it" when describing how their quit attempt started.

Results

Of the 981 smoking parents enrolled at baseline, 710 (72%) completed the 12-month follow-up. Of these, 123 (17%) reported quitting, of whom 50 (41%) reported quitting spontaneously. In multivariable analysis, parents who reported smoking on some days vs. every day (OR 3.06 (95% CI 1.42, 6.62)) and that nobody had smoked in their home/car vs. someone had smoked in these settings in the past 3 months (OR 2.19 (95% CI 1.06, 4.54)) were more likely to quit spontaneously.

Conclusions

This study shows that, of parents who quit smoking, a substantial percentage report quitting spontaneously and that intermittent smoking and smoke-free home/car policies are associated with reports of quitting spontaneously. Promoting smoke-free home/car policies, especially when parents are not willing to make a plan to quit smoking, might increase the likelihood that parents decide to quit without advance planning. Pediatric healthcare providers are uniquely positioned to use the child's visit to motivate parents to quit smoking and eliminate their child's exposure to tobacco smoke, regardless of the frequency of smoking or a readiness to plan a quit attempt. Clinical Trial Registration. This trial is registered with NCT01882348.

Personalized Feedback for Smoking and Anxiety Sensitivity: A Randomized Controlled Trial

BACKGROUND

Cigarette smoking is the leading preventable cause of death and disability globally. Most smokers want to quit, and most make a serious quit attempt each year. Nevertheless, more than 95% of cessation attempters relapse within six months. Thus, alternative interventions are needed to combat this major public health concern. Objective: The current study was conducted to develop and test a smoking treatment among 95 (63.2% male; M_age = 46.20 years, SD = 10.90) adult daily cigarette smokers that targets a known risk factor for smoking maintenance and relapse: anxiety sensitivity (AS). Methods: The current study employed a randomized controlled trial design to test an integrated, brief, computer-delivered smoking and AS intervention among current, daily smokers. Participants completed four appointments: (a) phone-screener; (b) baseline (pre-intervention assessment, intervention [personalized feedback intervention (PFI) versus smoking information control], and post-intervention assessment); (c) 2-week follow-up; and (d) 4-week follow-up. Results: Participants indicated highly positive evaluations of both the PFI and control intervention. Between the baseline and 2-week follow-up, 44.2% [PFI: 46.9% (n = 23); control: 41.3% (n = 19)] of participants reported a quit attempt. At the 4-week follow-up, 49.5% [PFI: 57.1% (n = 28); control: 41.3% (n = 19)] of participants reported a quit attempt since their previous laboratory session. Conclusion: Within the context of an intervention development approach, the present investigation provides descriptive data on the feasibility, acceptability, and initial efficacy of a single-session, computer-delivered, AS/smoking PFI.

Changes in Cigarettes per Day and Biomarkers of Exposure Among US Adult Smokers in the Population Assessment of Tobacco and Health Study Waves 1 and 2 (2013-2015)

INTRODUCTION

Some studies have found some reduction in tobacco exposure and tobacco-related disease risk with decreased numbers of cigarettes smoked per day (CPD), but biomarker of exposure estimates by change in CPD are generally unavailable for the US population.

METHODS

We analyzed biomarker of exposure data by smoking status from over 1100 adult exclusive daily cigarette smokers in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study who were either exclusive daily smokers or had quit tobacco use entirely at Wave 2. Wave 1 smoking categories consisted of "very light" (1-4 CPD), "light" (5-9 CPD), "moderate" (10-19 CPD), and "heavy" (20+ CPD), and Wave 2 categories were "quitters" (stopped smoking entirely), exclusive cigarette "reducers" (CPD decreased ≥ 50%), "maintainers" (CPD within 50%-150% of Wave 1 value), and "increasers" (CPD increased ≥ 50%).

RESULTS

Complete quitters had significantly lower levels of TNE-2, NNAL, NNN, 2-Fluorene, HPMA, CYMA, and MHB3 at Wave 2 for all Wave 1 CPD categories, and decreases were often large. Moderate "reducers" had lower levels of NNAL and 1-Hydroxypyrene at Wave 2, and heavy "reducers" had lower levels of NNAL, 2-Fluorene, and MHB3. Light "increasers" had higher levels of TNE-2, NNAL, 2-Fluorene, CYMA, and cadmium at Wave 2, and heavy "increasers" had higher levels of NNAL and HPMA.

CONCLUSIONS

Smoking "reducers" and "increasers" had changes in some biomarker of tobacco exposure levels, but reductions were much greater and more consistent for complete quitters.

IMPLICATIONS

PATH longitudinal cohort study data show that some exclusive daily cigarette smokers increase or decrease CPD over time. These differences may result in moderate changes in the levels of some biomarkers such as NNAL. Even so, however, reductions in biomarker levels are much greater with complete smoking cessation.

Increasing Quit Attempts by Transitioning to Very Low Nicotine Content Cigarettes Versus Reducing Number of Cigarettes Per Day: A Secondary Analysis of an Exploratory Randomized Trial

Introduction

The Food and Drug Administration (FDA) has proposed reducing nicotine with very low nicotine content (VLNC) cigarettes. In contrast, reducing nicotine by reducing number of cigarettes per day (CPD) is common. Our prior findings demonstrate that VLNC cigarettes decreased dependence more and were more acceptable than reducing CPD. This secondary analysis explored which reduction strategy increased quit attempts (QA), self-efficacy, or intention to quit more.

Methods

This is a secondary analysis of 68 adult daily smokers not ready to quit randomized to smoke VLNC cigarettes versus reduce CPD over 5 weeks. All participants smoked study cigarettes with nicotine yield similar to most commercial cigarettes ad lib for 1 week (baseline). Participants were then randomized to gradually reduce to 70%, 35%, 15%, and 3% of baseline nicotine over 4 weeks by either (1) transitioning to lower nicotine VLNC cigarettes or (2) reducing the number of full nicotine CPD. All participants received nicotine patches to aid reduction. We assessed (1) QAs using nightly and weekly self-reports, (2) Velicer’s Self-Efficacy to Quit measure weekly, and (3) the Intention-to-Quit Ladder nightly.

Results

More CPD (41%) than VLNC (17%) participants made any QA (odds ratio = 3.4, 95% confidence interval = 1.1, 10.5). There was no difference in QAs ≥24 h. Self-efficacy increased for VLNC but not CPD participants (interaction: F = 3.7, p < .01). The condition by time interaction for intention-to-quit was not significant.

Conclusions

Reducing number of CPD increased QAs more than reducing nicotine via switching to VLNC cigarettes. The lack of difference in longer QAs suggests replication tests are needed.

Implications

Reducing the frequency of smoking behavior (ie, CPD) could be a more effective strategy to increase QAs than reducing the magnitude of nicotine in each cigarette (ie, VLNC) per se.

Quitting trajectories of Chinese women smokers following telephone smoking cessation counselling: A longitudinal study

AIMS AND OBJECTIVES

This study mapped the quitting patterns (trajectories) of Hong Kong Chinese women smokers who had received counselling via a quitline service and examined factors correlated with different trajectories.

BACKGROUND

Quitting smoking is always a gradual and progressive process. However, most existing studies on smoking cessation have adopted a cross-sectional approach to conduct evaluation. Little is known about the quitting trajectories of smokers, particularly those who are women after receiving smoking cessation counselling.

METHODS

We used a retrospective longitudinal design and analysed 474 women smokers who had called the quitline. Quitting trajectories were mapped using latent growth modelling. Multinomial logistic regression was performed to identify factors associated with class membership. A STROBE checklist was completed.

RESULTS

We identified three trajectory groups: 'quitters' who quit smoking at 6 months and abstained from cigarettes up to 6 years; 'reducers' who cut down cigarette consumption ≥50% at 3 years and maintained reduced levels up to 6 years; and 'increasers' who increased smoking ≥20% at 3 years and continued smoking up to 6 years. Participants who perceived more difficulties in quitting were more likely to be increasers. Those with higher daily cigarette consumption at baseline were more likely to be reducers.

CONCLUSIONS

We clarified three trajectory groups of women smokers. The results indicate that existing cessation services need to be improved, especially for women smokers who do not quit after receiving telephone counselling.

RELEVANCE TO CLINICAL PRACTICE

Existing cessation services need to be improved, especially for women smokers who do not quit after receiving telephone counselling. For those who reduce smoking but fail to quit, quit plans should be developed that provide step-by-step guidance in achieving abstinence through smoking reduction. Instant messages may complement telephone counselling to deliver cessation support for those who increase their cigarette consumption.

Practitioners' Views on Nicotine Replacement Therapy in Pregnancy during Lapse and for Harm Reduction: A Qualitative Study

Many countries, including the UK, recommend nicotine replacement therapy (NRT) for smoking cessation during pregnancy. However, adherence to NRT is generally low, smoking lapse or relapse is common and using NRT to reduce the harm from the number of cigarettes smoked is only advocated in non-pregnant smokers. Two focus groups were conducted with 13 professionals involved in antenatal stop smoking services (SSS). The data were analysed thematically. Two themes were extracted that describe health professionals' attitudes towards using NRT either during lapses or to reduce smoking in women who cannot quit (harm reduction). These are presented around a social-ecological framework describing three hierarchical levels of influence within smoking cessation support: (1) Organizational: providing NRT during lapses could be expensive for SSS though harm reduction could result in services helping a wider range of clients. (2) Interpersonal: participants felt using NRT for harm reduction was not compatible with cessation-orientated messages practitioners conveyed to clients. (3) Individual: practitioners' advice regarding using NRT during smoking lapses varied; many were generally uncomfortable about concurrent smoking and NRT use and had strong reservations about recommending NRT when smoking during all but the briefest lapses. Further evidence is required to guide policy and practice.

Effectiveness of switching to very low nicotine content cigarettes plus nicotine patch versus reducing daily cigarette consumption plus nicotine patch to decrease dependence: an exploratory randomized trial

BACKGROUND AND AIMS

The United States Food and Drug Administration has proposed regulation to require that cigarettes contain very low nicotine content (VLNC). In contrast, reducing the number of cigarettes per day (CPD) is the most common current method to reduce nicotine. This trial aims to explore whether gradually transitioning to VLNC cigarettes plus nicotine patch or reducing CPD plus nicotine patch is more effective at decreasing nicotine dependence.

DESIGN

A two-arm, individually randomized open-label trial.

SETTING

Community setting, Vermont, USA.

PARTICIPANTS

Sixty-eight adult daily smokers (40% female) of ≥ 10 cigarettes/day who were not planning to quit in the next 30 days.

INTERVENTIONS

All participants smoked study cigarettes with a nicotine yield similar to most commercial cigarettes ad libitum for 1 week (baseline). Participants then gradually reduced to 70, 35, 15 and 3% of baseline nicotine over 4 weeks by either (a) transitioning to lower nicotine content cigarettes (n = 36) or (b) reducing the number of full nicotine cigarettes (n = 32). All participants received nicotine patches.

MEASUREMENTS

The primary outcome was change in nicotine dependence assessed at baseline and weekly during the intervention with the Nicotine Dependence Syndrome Scale.

FINDINGS

Dependence declined over time for both VLNC and CPD participants, but declined more for VLNC (mean decrease in Z-score of 1.0) than CPD (mean decrease in Z-score of 0.5) participants over time (interaction P = 0.018).

CONCLUSIONS

Transitioning to very low nicotine content cigarettes reduced nicotine dependence over a 4-week period to a greater extent than reducing cigarettes per day when both conditions were aided by nicotine patch.

E-cigarette Use Among Young Adults in the U.S

INTRODUCTION

Use of e-cigarettes is increasing among young adults in the U.S. Whether e-cigarette use serves as an aid to smoking reduction or cessation among young adults remains a matter of contention. This analysis examines patterns of e-cigarette use in relation to cigarette smoking in a nationally representative sample of U.S. young adults.

METHODS

Data were analyzed from nationally representative U.S. adults, aged 18 to 35years (N=12,415), in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III. Logistic regression assessed associations between e-cigarette use and smoking intensity, continuity, and reduction while controlling for several potential confounding factors. Data were analyzed in 2018.

RESULTS

Among cigarette smokers, e-cigarette use was associated with higher odds of tobacco use disorder (AOR=2.58, 95% CI=1.73, 3.83) and daily cigarette smoking (AOR=1.67, 95% CI=1.73, 3.83). Among adults aged 26-35years, e-cigarette use was also associated with heavy cigarette smoking (AOR=2.01, 95% CI=1.09, 3.74). Among lifetime smokers, e-cigarette use was associated with lower odds of stopping smoking (AOR=0.14, 95% CI=0.08, 0.23) and lower odds of a 50% reduction in cigarettes smoked per day (AOR=0.63, 95% CI=0.43, 0.93). Only 13.1% of young adults who ever used e-cigarettes reported using them to help stop or quit smoking.

CONCLUSIONS

Use of e-cigarettes by U.S. young adults, most of which is not intended to help reduce smoking, is related to more rather than less frequent and intensive cigarette smoking.

Multi-method assessment of distress tolerance and smoking-related factors among adult daily smokers

Although distress tolerance (DT) is associated with smoking lapse and relapse outcomes, few studies have conducted a rigorous assessment of DT across domain and method in the context of acute abstinence. In a human laboratory-based study of 106 adult daily smokers, we examined between multiple indices of DT and smoking lapse, withdrawal processes, and motivation to quit. We expected that low DT would be associated with shorter latency to smoke, greater withdrawal severity, and lower motivation to quit. Following a smoking abstinence period (≥ 6 hr deprived), participants completed an assessment battery including both behavioral (mirror-tracing, serial addition, cold pressor, and breath-holding tasks) and self-report measures of DT (general and smoking-specific), withdrawal processes (craving, negative affect, and positive affect), and motivation to quit. Latency to smoke (range = 0-50 min) was assessed in a laboratory analogue task in which delaying smoking was monetarily rewarded. Behavioral and self-report DT indices displayed only modest intercorrelations, indicating different facets of this construct by domain and method of assessment. Tolerance of physical pain was uniquely associated with smoking choice. Both self-report DT measures were associated with abstinence-induced increases in negative affect, while only smoking-specific DT was positively associated with craving. Results are discussed within the context of guiding targeted behavioral interventions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Evaluating the temporal relationships between withdrawal symptoms and smoking relapse

Smokers attempting to quit often attribute smoking relapse to negative affect, craving, and other nicotine withdrawal symptoms. In addition, there is evidence that smoking relapse can increase these symptoms, particularly negative affect. To address this issue, we analyzed data from an 11-week smoking cessation clinical trial in which smokers (n = 1,246) were randomized to receive either nicotine replacement therapy (NRT), varenicline, or placebo, combined with behavioral counseling. Using cross-lagged analyses, we examined the temporal bidirectional relationships between self-reported measures of affect, craving, and composite withdrawal symptoms and biochemically verified smoking abstinence. The relative strength of these temporal relationships was examined by comparing the explained variances of the models. The results showed that higher negative affect, craving, and composite withdrawal symptoms increased the likelihood of subsequent smoking relapse, and that smoking relapse led to subsequent increases in these same symptoms. A comparison of the explained variances found symptom predicting subsequent relapse models to be stronger than those where relapse predicted subsequent symptoms. Although the explained variance findings generally support a negative reinforcement conceptualization of nicotine dependence, the bidirectional relationship between symptoms and smoking relapse suggests that struggling with quitting smoking leads to significant negative affect, craving, and other withdrawal symptoms that do not quickly resolve. These findings highlight the importance of addressing specific symptoms within the context of smoking cessation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Association Between Reductions of Number of Cigarettes Smoked per Day and Mortality Among Older Adults in the United States

Many smokers do not quit but instead reduce the number of cigarettes they smoke per day (CPD) over their lifetime. Yet the associations of such changes in CPD with health risks are unclear. We examined the association of changes in CPD with subsequent death in the period 2004-2011 among 253,947 participants of the National Institutes of Health-AARP Diet and Health Study. Using a questionnaire assessing responders' history of smoking cigarettes, we identified cigarette smokers who quit, decreased, maintained, or increased their CPD between ages 25-29 and 50-59 years. Hazard ratios and 95% confidence intervals were obtained from multivariable adjusted Cox proportional hazards regression models. Relative to never smokers, smokers who maintained a consistent CPD had 2.93 times (95% confidence interval (CI): 2.82, 3.05) higher all-cause mortality risk, and participants who increased their CPD had still higher risk (hazard ratio (HR) = 3.37, 95% CI: 3.23, 3.52). Death risk was lower among participants who decreased their CPD (HR = 2.38, 95% CI: 2.25, 2.52) or quit smoking (for quitting between ages 30 and 39 years, HR = 1.32, 95% CI: 1.25, 1.39). Similar patterns were observed for smoking-related causes of death, with particularly strong associations for lung cancer and respiratory disease. Reductions in CPD over the lifetime meaningfully decreased death risk; however, cessation provided a larger benefit than even large declines in CPD.

Helping Smokers with Severe Mental Illness Who Do Not Want to Quit

BACKGROUND

People with a severe and persistent mental illness are far more likely to smoke than others. While a large portion would like to quit, they are less likely to make quit attempts and succeed.

OBJECTIVE

This study used an Randomized Controlled Trial (RCT) to test an intervention designed to increase engagement in cessation treatment, quit attempts, and quitting in smokers who did not want to quit in the next 30 days. It also compared these smokers with those who were motivated to quit in the next 30 days.

METHODS

Participants (N = 222), were smokers with significant mental illness receiving intensive outpatient care from Wisconsin Community Support Programs who were not interested in quitting in the next 30 days. They were randomly assigned to either an intervention group or an attention control group. The intervention, administered during four weekly sessions, included a motivational element, components designed to prepare the smoker for a quit attempt, and pre-quit nicotine patch. Additionally, 48 smokers motivated to quit in the next 30 days served as a comparison group.

RESULTS

Compared to control participants, smokers receiving the intervention were more likely to be abstinent at the three month follow-up (biochemically verified, intent to treat, 8.5% vs. 1.0%, respectively, p = .01). They were also more likely to accept four more quitting preparation sessions (intent to treat, 50.8% vs 29.2%, respectively, p < .001) but were not more likely to call a telephone tobacco quit line. Conclusion/Importance: Brief motivational interventions increased engagement in cessation treatment and abstinence among smokers with signification mental illness.

Nicotine Intake in Pregnant Smokers and a General Population of Smokers

OBJECTIVE

The purpose of this study was to assess whether pregnant smokers have the same nicotine intake from cigarettes as a general population of smokers and whether the known lower daily cigarette consumption among pregnant smokers is associated with higher nicotine intake among pregnant smokers.

METHOD

The study was a cross-sectional comparison of pregnant smokers and a general population of smokers in smoking cessation clinics. Participants were treatment-seeking pregnant (n = 476), nonpregnant female (n = 116), and male (n = 195) smokers who participated in two independent smoking cessation trials. Nicotine intake was measured as saliva cotinine/ cigarette/kg body weight ratio.

RESULTS

The mean saliva cotinine (μg/L)/ cigarette/kg body weight (0.21, SD = 0.15) of pregnant smokers was similar to that of nonpregnant female smokers (0.24, SD = 0.14) and higher than that of male smokers (0.18, SD = 0.12, p = .002) despite a substantially lower number of cigarettes per day (pregnant smokers: 12, SD = 6; nonpregnant female smokers: 26.6, SD = 11.7; male smokers: 23.5, SD = 9.5, p < .001). Among pregnant smokers, saliva cotinine, as expected, increased in parallel with the number of cigarettes per day, but nicotine intake (cotinine/cigarette/kg body weight) was inversely associated with daily cigarette consumption (p < .001). No association between cigarettes per day and nicotine intake was observed in male and nonpregnant female smokers (p = .43).

CONCLUSIONS

This secondary analysis showed that pregnant smokers' nicotine intake was similar to that of a general population of smokers despite a lower cigarette consumption rate. Among pregnant smokers, lower daily cigarette consumption was associated with higher nicotine intake from cigarettes, suggesting compensatory smoking.

Effectiveness of continuing nicotine replacement after a lapse: A randomized trial

INTRODUCTION

Four post-hoc analyses of prior trials found smokers using nicotine patch following a lapse were less likely to progress to relapse compared to those using a placebo patch following a lapse. We attempted a conceptual replication test of these results via a randomized trial of instructions to continue vs. stop nicotine patch after a lapse.

METHODS

Smokers trying to quit (n=701) received nicotine patch (21/14/7mg) and brief phone counseling (six 15-min sessions). We randomized smokers to receive instructions for and rationale for stopping vs. continuing patch after a lapse. The messages were repeated before and after cessation and following lapses via counseling, phone and written instructions.

RESULTS

Among those who lapsed, those told to Continue Patch did not have a greater incidence of 7-day abstinence at 4months (primary outcome) than those told to Discontinue Patch (51% vs. 46%). Most (81%) participants in the Discontinue condition stopped patch for only 1-2days and then resumed abstinence and patch use. Analyses based on all participants randomized were similar. Adverse events were as expected and did not differ between conditions.

CONCLUSION

Instructions to continue nicotine patch after a lapse did not increase return to abstinence. These negative results may have occurred because actual use of patch after a lapse was similar in the two conditions. Also, allowing patch use while smoking may have reduced motivation to stay abstinent.

One-Year Smoking Trajectories Among Established Adult Smokers With Low Baseline Motivation to Quit

INTRODUCTION

The majority of smokers do not intend to quit in the near term, making unmotivated smokers a key group to target in public health efforts. Although it is often assumed that continuing smokers will have stable rates of smoking over time, limited research has addressed this issue, particularly among smokers not seeking treatment. In the current study, the aims were to (1) characterize the trajectory of naturalistic smoking among unmotivated smokers and (2) examine relationships between naturalistic smoking trajectories and other smoking-related variables.

METHODS

The study sample comprised 579 control-group (ie, untreated) smokers within a parent clinical trial, who completed a total of nine assessments over 1 year.

RESULTS

Trajectory modeling identified four smoking trajectory groups: stable (72%), shallow decreasers (20%), steep decreasers (5%), and increasers (3%). Membership in the decreasing groups was associated with higher motivation to quit, greater history of quit attempts, and higher cigarettes per day. Females were more likely to be in the increasing versus stable group.

CONCLUSIONS

Findings provide needed information on stability and change in cigarette consumption over the course of 1 year among an untreated sample of smokers and identified baseline sociodemographic and smoking-related predictors of smoking trajectory group. Refining understanding of these groups is critical in updating population-based tobacco policy modeling efforts and informing cessation induction efforts that capitalize on naturalistic changes in smoking rate over time.

IMPLICATIONS

In the current study, we found that approximately 25% of smokers who endorsed low quit motivation at baseline reduced their cigarette consumption over the course of a year, while 3% increased their cigarette consumption and the majority of smokers (72%) maintained a stable pattern. Refining understanding of smoking trajectories is critical in updating population-based tobacco policy modeling efforts and informing cessation induction efforts that capitalize on naturalistic changes in smoking rate over time.

Psychometric evaluation of the Barriers to Cessation Scale

The Barriers to Cessation Scale (BCS; Macnee & Talsma, 1995a) was developed to assess global and specific perceived barriers that may interfere with the quit process. Although the BCS is widely used in the literature, little scientific work has been devoted to examining the psychometric properties of the measure. Thus, the present study sought to address this gap by evaluating the BCS in a sample of 497 treatment-seeking smokers. The current study examined the factor structure of the BCS, measurement invariance of the BCS subscales across sex and over 2 time points, and evaluated construct validity. Results indicated that the BCS was best modeled by a higher order factor structure wherein the originally proposed 3-factor solution (Addiction, External, and Internal) constituted the lower order and a global factor constituted the higher order factor. The higher order BCS structure demonstrated partial measurement invariance across sex and full measurement invariance from baseline to quit day among treatment seeking smokers. Additionally, expected relations were observed between the BCS subscales and similar and divergent constructs, and predictive validity was partially supported. The current findings provide novel empirical evidence that the BCS is a reliable measure of perceived barriers to smoking cessation across multiple domains and is related to several affective and smoking processes the may interfere with the process of quitting. (PsycINFO Database Record

Harnessing Facebook for Smoking Reduction and Cessation Interventions: Facebook User Engagement and Social Support Predict Smoking Reduction

Background

Social media technologies offer a novel opportunity for scalable health interventions that can facilitate user engagement and social support, which in turn may reinforce positive processes for behavior change.

Objective

By using principles from health communication and social support literature, we implemented a Facebook group–based intervention that targeted smoking reduction and cessation. This study hypothesized that participants’ engagement with and perceived social support from our Facebook group intervention would predict smoking reduction.

Methods

We recruited 16 regular smokers who live in the United States and who were motivated in quitting smoking at screening. We promoted message exposure as well as engagement and social support systems throughout the intervention. For message exposure, we posted prevalidated, antismoking messages (such as national antismoking campaigns) on our smoking reduction and cessation Facebook group. For engagement and social support systems, we delivered a high degree of engagement and social support systems during the second and third week of the intervention and a low degree of engagement and social support systems during the first and fourth week. A total of six surveys were conducted via Amazon Mechanical Turk (MTurk) at baseline on a weekly basis and at a 2-week follow-up.

Results

Of the total 16 participants, most were female (n=13, 81%), white (n=15, 94%), and between 25 and 50 years of age (mean 34.75, SD 8.15). There was no study attrition throughout the 6-time-point baseline, weekly, and follow-up surveys. We generated Facebook engagement and social support composite scores (mean 19.19, SD 24.35) by combining the number of likes each participant received and the number of comments or wall posts each participant posted on our smoking reduction and cessation Facebook group during the intervention period. The primary outcome was smoking reduction in the past 7 days measured at baseline and at the two-week follow-up. Compared with the baseline, participants reported smoking an average of 60.56 fewer cigarettes per week (SD 38.83) at the follow-up, and 4 participants out of 16 (25%) reported 7-day point prevalence smoking abstinence at the follow-up. Adjusted linear regression models revealed that a one-unit increase in the Facebook engagement and social support composite scores predicted a 0.56-unit decrease in cigarettes smoked per week (standard error =.24, P=.04, 95% CI 0.024-1.09) when baseline readiness to quit, gender, and baseline smoking status were controlled (F_{4, 11}=8.85, P=.002).

Conclusions

This study is the first Facebook group–based intervention that systemically implemented health communication strategies and engagement and social support systems to promote smoking reduction and cessation. Our findings imply that receiving one like or posting on the Facebook-based intervention platform predicted smoking approximately one less cigarette in the past 7 days, and that interventions should facilitate user interactions to foster user engagement and social support.

Cigarette Smoking During Pregnancy: Do Complete Abstinence and Low Level Cigarette Smoking Have Similar Impact on Birth Weight?

OBJECTIVES

Despite awareness of negative health outcomes associated with smoking, pregnant smokers might reduce their tobacco consumption thinking that a low smoking rate reduces smoking-related negative birth outcomes. We aimed to assess in a clinical sample whether there is a smoking rate that would not impact on birth weight (BW).

METHODS

Pregnant smokers ≥18 years, gestational age of 9-20 weeks of amenorrhea, motivated to quit smoking, smoking ≥5 cigarettes/day (cpd) and their newborns (381 singleton, live births) were included in this secondary analysis of a French smoking cessation trial.

RESULTS

The mean BW when the mother quit smoking was 3417 g (95 % CI: 3098-3738 g); when smoking >0<5 cpd, 3081g (3003-3159 g); when smoking 5-9 cpd, 3043 g (2930-3157 g); and when smoking ≥10 cpd, 2831 g (2596-3157 g) (p = .006). The corresponding effect sizes ranged from medium to large (Cohen's d for BW: 0.54, 0.57 and 0.85) compared to BW when the mother quit. In the multivariable analysis, adjusted for all significant confounders, when the mother smoked on average >0<5 cpd, the loss in BW was 228 g; when smoking 5-9 cpd, 251 g; and when smoking ≥10 cpd, 262 g (all p ≤ .02) compared to newborns' BW of mothers who stopped smoking since quit date.

CONCLUSIONS

Even low cigarette consumption during pregnancy is associated with BW loss. All efforts should be made to help pregnant smokers quit completely during their pregnancy.

IMPLICATIONS

As an alternative to quitting smoking, pregnant smokers reduce their smoking rate thinking that this diminishes smoking-related negative health outcomes. No study has established whether low smoking rate (more than 0 but less than 5 cpd) during pregnancy impacts BW compared to abstinence from smoking. Among treatment-seeking pregnant smokers BW of newborns of mothers who smoked even less than 5 cpd was significantly lower than of those whose mothers quit; effect sizes of different consumption levels on BW ranged from moderate (>0<5 cpd) to large (≥10 cpd). Even low smoking rate is associated with reduced BW compared to complete maternal smoking abstinence.

Interventions to reduce harm from continued tobacco use

BACKGROUND

Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced-exposure tobacco products (PREPs), as an alternative to cigarettes.

OBJECTIVES

To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long-term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco?

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free-text and MeSH terms for harm reduction, smoking reduction and cigarette reduction.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention.

DATA COLLECTION AND ANALYSIS

We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long-term smoking abstinence), using fixed-effect models. Where it was not possible to meta-analyse data, we summarized findings narratively.

MAIN RESULTS

Twenty-four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically-heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as 'low' or 'very low', due to imprecision and indirectness. A 'low' grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A 'very low' grade means we are very uncertain about the estimate.

AUTHORS' CONCLUSIONS

People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking. This could simply be due to the lack of high-quality studies (our confidence in cessation outcomes for these aids is rated 'low' or 'very low' due to imprecision by GRADE standards), meaning that we may have missed a worthwhile effect, or due to a lack of effect on reduction or quit rates. It is therefore important that more high-quality RCTs are conducted, and that these also measure the long-term health effects of treatments.

Motivating smokers to quit using computer-generated letters that target either reduction or cessation: A population-based randomized controlled trial among smokers who do not intend to quit

BACKGROUND

This study examined the long-term efficacy of individualized counseling letters that targeted either smoking abstinence or reducing the number of cigarettes smoked per day to promote future cessation.

METHODS

A nationwide random-digit-dialing telephone sample was used to identify smokers from the general adult population (participation proportion: 54.5%). In total, 1462 participants (48% female) who did not intend to quit within the next six months and who smoked ten or more cigarettes a day were randomized to one of two intervention groups or an assessment-only control condition. The interventions consisted of three tailored letters that were sent after baseline and follow-up assessments after three and six months. Follow-up data on smoking status were provided by 82% and 77% of the participants 12 and 24 months after study inclusion, respectively. Generalized estimation equation (GEE) models adjusted for potential baseline confounders and multiple imputation of missing follow-up data were used to estimate intervention effects.

RESULTS

At 24-month follow-up prevalence of 7-day point abstinence was 8.4%, 12.9% and 14.7% in the control, abstinence intervention and reduction intervention condition, which corresponds to a number needed to treat of 22 (95%-CI: 11-707) and 16 (95%-CI: 9-53). Adjusted GEE analyses revealed that the smoking reduction intervention (ORadj=2.3, p<0.01) but not the abstinence intervention (ORadj=1.4, p=0.20) increased the odds of 6-month prolonged abstinence compared with the control condition. No significant differences appear when directly comparing both intervention groups.

CONCLUSION

Smoking reduction should be considered as an alternative intervention goal for smokers who are unable or unwilling to quit.

Determinants of intentions to quit smoking among adult smokers in Bangladesh: findings from the International Tobacco Control (ITC) Bangladesh wave 2 survey

Background

With about 22 million adult smokers, Bangladesh needs strong measures that would promote smoking cessation. Using data from Wave 2 of the International Tobacco Control (ITC) Survey, this study examined the factors associated with intention to quit smoking among Bangladeshi smokers.

Methods

Data from Wave 2 of the International Tobacco Control (ITC) Survey in Bangladesh, a face to face survey of adult smokers, were analysed. In the ITC survey, households were sampled using a stratified multistage design and interviewed using a structured questionnaire.

Results

Of the respondents (N = 2982), most were male (96 %), married (80 %), and Muslim (83 %); 33 % were illiterate and 54 % were aged below 40. Almost two-thirds were from areas outside Dhaka, 78 % smoked cigarettes exclusively; and 36 % had an intention to quit smoking in the future. This study identified several predictors, comparable to other international studies, of intention to quit smoking: area of residence, number of cigarettes smoked daily, previous quit attempt, visiting a doctor in the past, having child aged 5 or below at home, perceived benefit from quitting, being worried about own health, knowledge of SHS, not enjoying smoking and workplace smoking policy.

Conclusions

These findings suggest that the prevalence of intention to quit smoking is lower among Bangladeshi smokers than those among smokers in developed countries. However, the factors relating to quit intentions among Bangladeshi smokers are comparable to those found in Western countries. Population based tobacco control programs and policies should consider these predictors in the design of interventions to increase quitting among smokers in Bangladesh.

Model-based imputation of latent cigarette counts using data from a calibration study

In addition to dichotomous measures of abstinence, smoking studies may use daily cigarette consumption as an outcome variable. These counts hold the promise of more efficient and detailed analyses than dichotomous measures, but present serious quality issues - measurement error and heaping - if obtained by retrospective recall. A doubly-coded dataset with a retrospective recall measurement (timeline followback, TLFB) and a more precise instantaneous measurement (ecological momentary assessment, EMA) serves as a calibration dataset, allowing us to predict EMA given TLFB and baseline factors. We apply this model to multiply impute precise cigarette counts for a randomized, placebo-controlled trial of bupropion with only TLFB measurements available. To account for repeated measurements on a subject, we induce correlation in the imputed counts. Finally, we analyze the imputed data in a longitudinal model that accommodates random subject effects and zero inflation. Both raw and imputed data show a significant drug effect for reducing the odds of non-abstinence and the number of cigarettes smoked among non-abstainers, but the imputed data provide efficiency gains. This method permits the analysis of daily cigarette consumption data previously deemed suspect due to reporting error and is applicable to other self-reported count data sets for which calibration samples are available. Copyright © 2015 John Wiley & Sons, Ltd.

How Do Light and Intermittent Smokers Differ from Heavy Smokers in Young Adulthood: The Role of Smoking Restraint Strategies

Light and intermittent smoking has become a prevalent pattern of use among young adults. Little is known about which factors differentiate light and intermittent smokers (LITS) from heavy smokers (HS) in young adulthood. In this study, we compare young adult LITS with HS with regard to demographic- and smoking-related variables, self-control abilities, and concrete strategies of smoking restraint. The data were collected as part of an Ecological Momentary Assessment (EMA) study with 137 German young adult smokers (M Age = 21.1 years, 46.0% female; 76 HS [≥10 cigarettes/day] and 61 LITS [≤5 cigarettes/day]). Participants were recruited over the Internet and completed a baseline questionnaire online. Several variables differentiated LITS and HS in a multiple logistic regression analysis: LITS reported fewer smoking friends (p < .001) and a higher self-efficacy to resist smoking (p < .01). Further, LITS smoking status was associated with reporting a past quit attempt (p < .05) and the use of smoking restraint strategies (counting, limiting, and purposefully not smoking cigarettes; p < .05). Notably, nicotine dependence and trait self-control abilities did not differentiate between LITS and HS. Our results point to the role of smoking restraint strategies and self-monitoring of smoking to limit the daily number of cigarettes smoked.

Efficacy and tolerability of pharmacotherapy for smoking cessation in adults with serious mental illness: a systematic review and network meta-analysis

BACKGROUND AND AIMS

To assess the efficacy and tolerability of adjunctive pharmacotherapy for smoking cessation in adults with serious mental illness (SMI) by means of a systematic review and network meta-analysis.

METHOD

We searched Embase, Medline, PsychINFO and the Cochrane Central Register of Controlled Trials from database inception to 1 December 2014 for randomized controlled trials (RCTs) published in English. We included all studies of smokers with SMI (including schizophrenia, schizoaffective disorder, bipolar disorder, delusional disorder and depressive psychoses) who were motivated to quit smoking. Pharmacotherapies included nicotine replacement therapy (NRT), bupropion and varenicline delivered as monotherapy or in combination compared with each other or placebo. The efficacy outcome was self-reported sustained smoking cessation, verified biochemically at the longest reported time-point. The tolerability outcome was number of patients discontinuing the trial due to any adverse event.

RESULTS

Seventeen study reports were included, which represented 14 individual RCTs. No trials were found in patients with depressive psychoses, delusional disorder or that compared NRT monotherapy with placebo. A total of 356 and 423 participants were included in the efficacy and tolerability analyses, respectively. From the network meta-analysis, both bupropion and varenicline were more effective than placebo [odds ratio (OR) = 4.51, 95% credible interval (CrI) = 1.45-14.04 and OR = 5.17, 95% CrI = 1.78-15.06, respectively]. Data were insensitive to an assessment of varenicline versus bupropion (OR = 1.15, 95% CrI = 0.24-5.45). There were no significant differences in tolerability. All outcomes were rated by GRADE criteria as very low quality.

CONCLUSIONS

The limited evidence available to date suggests that bupropion and varenicline are effective and tolerable for smoking cessation in adults with serious mental illnesses.

Comparative effectiveness of motivation phase intervention components for use with smokers unwilling to quit: a factorial screening experiment

AIMS

To screen promising intervention components designed to reduce smoking and promote abstinence in smokers initially unwilling to quit.

DESIGN

A balanced, four-factor, randomized factorial experiment.

SETTING

Eleven primary care clinics in southern Wisconsin, USA.

PARTICIPANTS

A total of 517 adult smokers (63.4% women, 91.1% white) recruited during primary care visits who were willing to reduce their smoking but not quit.

INTERVENTIONS

Four factors contrasted intervention components designed to reduce smoking and promote abstinence: (1) nicotine patch versus none; (2) nicotine gum versus none; (3) motivational interviewing (MI) versus none; and (4) behavioral reduction counseling (BR) versus none. Participants could request cessation treatment at any point during the study.

MEASUREMENTS

The primary outcome was percentage change in cigarettes smoked per day at 26 weeks post-study enrollment; the secondary outcomes were percentage change at 12 weeks and point-prevalence abstinence at 12 and 26 weeks post-study enrollment.

FINDINGS

There were few main effects, but a significant four-way interaction at 26 weeks post-study enrollment (P = 0.01, β = 0.12) revealed relatively large smoking reductions by two component combinations: nicotine gum combined with BR and BR combined with MI. Further, BR improved 12-week abstinence rates (P = 0.04), and nicotine gum, when used without MI, increased 26-week abstinence after a subsequent aided quit attempt (P = 0.01).

CONCLUSIONS

Motivation-phase nicotine gum and behavioral reduction counseling are promising intervention components for smokers who are initially unwilling to quit.

Are Single-session Smoking Cessation Groups a Feasible Option for Rural Australia? – Outcomes From a Pilot Study

Introduction: Single-session group smoking cessation interventions have received little attention in the literature.

Aims: This study aimed to test the feasibility and outcomes of a single-session large group smoking cessation intervention in a rural area of New South Wales.

Methods: Participants from a smoking cessation course (N = 42) were asked about cigarette consumption, quit attempts, and readiness and confidence to quit at registration and six months. The two-hour intervention occurred in a group setting and comprised of cognitive behaviour therapy and pharmacotherapy advice.

Results: The analysis revealed a 26.2% (N = 11) quit rate based on self-report and/or carbon monoxide validation at 6 months (intention to treat). Those who quit all used pharmacotherapy: eight (73%) Nicotine Replacement Therapy (NRT); two (18%) varenicline and one (9%) bupropion with NRT. Seven people (17%) used medicines to reduce consumption of cigarettes. A paired samples t test of those still smoking showed a statistically significant decrease in the numbers of cigarettes smoked per day (p<.001).

Conclusion: The quit rate of 26.2% from this large single-session smoking cessation course is comparable to that expected from groups having multiple sessions. As a pilot study, these data suggest that a multi-faceted single-session two-hour smoking cessation intervention can successfully support quit attempts in a rural location.

Smoking cessation after an acute coronary syndrome: immediate quitters are successful quitters

BACKGROUND

Cardiovascular disease (CVD) prevention guidelines stress the importance of smoking cessation and recommend intensive follow-up. To guide the development of such cessation support strategies, we analysed the characteristics that are associated with successful smoking cessation after an acute coronary syndrome (ACS).

METHODS

We used data from the Randomised Evaluation of Secondary Prevention for ACS patients coordinated by Outpatient Nurse SpEcialists (RESPONSE) trial (n = 754). This was designed to quantify the impact of a nurse-coordinated prevention program, focusing on healthy lifestyles, traditional CVD risk factors and medication adherence. For the current analysis we included all smokers (324/754, 43 %). Successful quitters were defined as those who reported abstinence at 1 year of follow-up.

RESULTS

The majority of successful quitters quit immediately after the ACS event and remained abstinent through 1 year of follow-up, without extra support (128/156, 82 %). Higher education level (33 vs. 15 %, p < 0.01), no history of CVD (87 vs. 74 %, p < 0.01) and being on target for LDL-cholesterol level at 1 year (78 vs. 63 %, p < 0.01) were associated with successful quitting.

CONCLUSION

The majority of successful quitters at 1 year stopped immediately after their ACS. Patients in this group showed that it was within their own ability to quit, and they did not relapse through 1 year of follow-up. Our study indicates that in a large group of patients who quit immediately after a life-threatening event, no relapse prevention program is needed.

Does reduced smoking if you can't stop make any difference?

BACKGROUND

Promoting and supporting smoking reduction in smokers with no immediate intention of stopping smoking is controversial given existing fears that this will deter cessation and that reduction itself may not improve health outcomes.

DISCUSSION

Evidence shows that smokers who reduce the number of daily cigarettes smoked are more likely to attempt and actually achieve smoking cessation. Further, clinical trials have shown that nicotine replacement therapy benefits both reduction and cessation. Worldwide data suggests that 'non-medical' nicotine is more attractive to people who smoke, with electronic cigarettes now being widely used. Nevertheless, only one small trial has examined the use of electronic cigarettes to promote reduction, with direct evidence remaining inconclusive. It has been suggested that long-term reduced smoking may directly benefit health, although the benefits are small compared with cessation.

SUMMARY

The combined data imply that smoking reduction is a promising intervention, particularly when supported by clean nicotine; however, the benefits are only observed when it leads to permanent cessation.

Intervention study for smoking cessation in Spanish college students: pragmatic randomized controlled trial

AIM

To evaluate the effectiveness of a nurse intervention aimed at helping college student smokers quit smoking.

DESIGN

Single-blind, pragmatic randomized controlled trial which compares a multi-component intervention, tailored specifically to college students, with a brief advice session with a 6-month follow-up.

SETTINGS

This study was conducted at the University of Navarra, Spain.

PARTICIPANTS

A total of 255 college student smokers (age range = 18-24 years) were randomized to an intervention group (n = 133) or to a control group (n = 122).

INTERVENTION

A multi-component intervention based on the Theory of Triadic Influence of Flay was developed. The intervention consisted of a 50-minute motivational interview conducted by a nurse and online self-help material. The follow-up included a reinforcing e-mail and group therapy.

MEASUREMENTS

The primary outcome was self-reported abstinence, with biochemical verification at 6 months. The secondary outcomes consisted of the mean number of cigarettes smoked per day, self-reported attempts to quit smoking and stage of change at 6 months.

FINDINGS

At the 6-month follow-up, the smoking cessation incidence was 21.1% in the intervention group compared with 6.6% in the control group (difference = 14.5 confidence interval = 6.1-22.8; relative risk = 3.41, 95% confidence interval = 1.62-7.20). The difference in the mean number of cigarettes at 6 months was significantly different (difference = -2.2, confidence interval = -3.6 to -0.9).

CONCLUSIONS

A multi-component intervention tailored to college students and managed by a nurse is effective in increasing smoking cessation among college students.

Effect of Smoking Reduction Therapy on Smoking Cessation for Smokers without an Intention to Quit: An Updated Systematic Review and Meta-Analysis of Randomized Controlled

OBJECTIVE

Effective strategies are needed to encourage smoking cessation for smokers without an intention to quit. We systematically reviewed the literature to investigate whether smoking reduction therapy can increase the long-term cessation rates of smokers without an intention to quit.

METHODS

PubMed, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched for randomized controlled trials (RCTs) on the effect of smoking reduction therapy on long-term smoking cessation in smokers without an intention to quit. The primary outcome was the cessation rate at the longest follow-up period. A random effects model was used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

Fourteen trials with a total of 7981 smokers were included. The pooled analysis suggested that reduction support plus medication significantly increased the long-term cessation of smokers without an intention to quit compared to reduction support plus placebo (RR, 1.97; 95% CI, 1.44-2.7; I(2), 52%) or no intervention (RR, 1.93; 95% CI, 1.41-2.64; I(2), 46%). In a subgroup of smokers who received varenicline or nicotine replacement therapy (NRT), the differences were also statistically significant. This suggests the safety of using NRT. The percentage of smokers with serious adverse events who discontinued because of these events in the non-NRT group was slightly significantly different than in the control group. Insufficient evidence is available to test the efficacy of reduction behavioural support in promoting long-term cessation among this population.

CONCLUSIONS

The present meta-analysis indicated the efficacy of NRT- and varenicline-assisted reduction to achieve complete cessation among smokers without an intention to quit. Further evidence is needed to assess the efficacy and safety of reduction behavioural support and bupropion.

Does smoking reduction worsen mental health? A comparison of two observational approaches

OBJECTIVES

The association between smoking reduction and mental health is of particular interest given that many smokers report that smoking offers mental health benefits. We aimed to assess the association between smoking reduction and change in mental health using two different analytical approaches to determine if there was any evidence of an association. There were no prior hypotheses.

DESIGN

A secondary analysis of prospective individual level patient data from 5 merged placebo-controlled randomised trials of nicotine replacement therapy for smoking reduction.

PARTICIPANTS

All participants were adult smokers, selected because they wanted to reduce but not stop smoking, and had smoked for at least 3 years. Participants were excluded if they were pregnant, breastfeeding, under psychiatric care, deemed to be unfit by a general practitioner, or part of a cessation programme. 2066 participants were enrolled in the trials, 177 participants were biologically validated as prolonged reducers, and 509 as continuing smokers at both 6-week and 18-week follow-ups.

PRIMARY OUTCOME

Change in mental health from baseline to an 18-week follow-up was measured using the emotional well-being subscale on the Short Form Health Survey-36.

RESULTS

After adjustment for confounding variables, the differences for reducers compared with continuing smokers were: regression modelling -0.6 (95% CI -4.4 to 3.2) and propensity score matching 1.1 (95% CI -2.0 to 4.1).

CONCLUSIONS

Smoking reduction, sustained for at least 12 weeks, was not associated with change in mental health, suggesting that reducing smoking was no better or worse for mental health than continuing smoking. Clinicians offering smoking reduction as a route to quit can be confident that, on average, smoking reduction is not associated with negative change in mental health.

A Comprehensive Approach to Tobacco Dependence Interventions

Tobacco smoking remains the leading preventable cause of death and illness in the United States. Smoking cessation is particularly relevant for individuals with chronic obstructive pulmonary disease because it is known from multiple studies that individuals who quit smoking experience an initial improvement in pulmonary function, a decreased rate of normal age-related decline in FEV1, a lower risk of hospital admission, and improved survival. Tobacco dependence must be recognized as a chronic disease, and comprehensive treatment for the tobacco-dependent patient with chronic obstructive pulmonary disease begins with a physician's inquiry into smoking and encouragement to quit, followed by an assessment of the level of dependence and the severity of withdrawal symptoms during previous quit attempts. Combination pharmacotherapy is recommended for the initial treatment of most smokers, especially those with moderate to high baseline levels of tobacco dependence. The patient's history, combined with his or her personal preference, can guide the clinician in initiating an appropriate treatment regimen. Given the chronic nature of tobacco dependence, clinicians must anticipate relapses and the need for recurrent, long-term follow-up. Comprehensive tobacco treatment consultation should be sought whenever possible for patients with high levels of tobacco dependence and multiple relapses or failed quit attempts.

Study protocol: a stepped wedge cluster randomised controlled trial of a healthy lifestyle intervention for people attending residential substance abuse treatment

BACKGROUND

Cardiovascular disease and cancer are leading causes of mortality for people with a history of alcohol or other substance use disorders. These chronic diseases share the same four primary behavioural risk factors i.e. excessive alcohol use, smoking, low intake of fruit and vegetables and physical inactivity. In addition to addressing problematic alcohol use, there is the potential for substance abuse treatment services to also address these other behaviours. Healthy Recovery is an 8-session group-based intervention that targets these multiple behavioural health risk factors and was developed specifically for people attending substance abuse treatment. This protocol describes a Cancer Institute NSW funded study that assesses the effectiveness of delivering Healthy Recovery for people who are attending residential alcohol and other substance abuse treatment.

METHODS/DESIGN

The study uses a stepped wedge randomised controlled design, where randomisation occurs at the service level. Participants will be recruited from residential rehabilitation programs provided by The Australian Salvation Army. All participants who (1) currently smoke tobacco and (2) are expected to be in the residential program for the duration of the 5-week intervention will be asked to participate in the study. Those participants residing at the facilities assigned to the treatment condition will complete Healthy Recovery. The intervention is manual guided and will be delivered over a 5-week period, with participants attending 8 group sessions. All participants will continue to complete The Salvation Army residential program, a predominantly 12-step based, modified therapeutic community. Participants in the control condition will complete treatment as usual. Research staff blind to treatment allocation will complete the primary and secondary outcome assessments at baseline and then at weeks 8, 20 and 32 weeks post intervention.

DISCUSSION

This study will provide comprehensive data on the effect of delivering a healthy lifestyle intervention (i.e. Healthy Recovery) within a residential substance abuse setting. If shown to be effective, this intervention can be disseminated within other residential substance abuse programs.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Register (ANZCTR): ACTRN12615000165583. Registered 19(th) February 2015.

The effect of a very brief smoking-reduction intervention in smokers who have no intention to quit: study protocol for a randomized controlled trial

Background

Tobacco use is one of the most common preventable causes of death, but more than half of the Chinese men still use tobacco products. Moreover, 63.6% of Chinese smokers have stated that they would not consider quitting. Specialized and intensive smoking-cessation services are too expensive and passive to have major clinical and public health impacts in developing countries like China. Smoking cessation medications are not covered by medical insurance, and their high price prevents Chinese smokers from using them. Brief interventions are needed to provide cost-effective and timesaving tobacco dependence treatments in China mainland.

Methods/design

We describe a two-arm randomized controlled trial for smokers who have no intention to quit. The project will be conducted in outpatient clinics at a large hospital in Beijing, China. Both arms include one face-to-face interview plus five follow-up interventions. Each intervention will last approximately one minute. Subjects allocated to the smoking-reduction intervention arm (SRI) will be advised to reduce smoking consumption to at least half of their current consumption level within the next month. All subjects in the SRI will be warned to bear in mind that an attempt to reduce smoking is an intermediate step before complete cessation. Smokers who have successfully reduced their smoking consumption will be encouraged to completely cease smoking. Controls are subjects allocated to the exercise- and diet-advice arm (EDA) and will be given advice about healthy diet and physical activity, but the advice will not include smoking cessation or reduction. Data collection will be done at baseline and at each follow-up interview using standardized questionnaires. The primary outcomes include self-reported and biochemically verified 7-day point prevalence and prolonged abstinence rates at 12-month follow-up.

Discussion

We expect that an intention to quit in smoking outpatients can be motivated by physicians in the clinic setting. If this very brief smoking-reduction intervention can be demonstrated to have a positive impact on long-term smoking cessation, this strategy has the potential to be a viable and acceptable approach and may be used widely in China and elsewhere.

Clinical trial registration

ClinicalTrials.gov: NCT02370147 (date of registration: 23th February, 2015).

Readiness to quit as a predictor for outcomes of smoking-reduction programme with transdermal nicotine patch or bupropion in a sample of 308 patients with schizophrenia

Readiness to quit has been found to predict smoking-cessation outcomes in a general population. However, little is known about the relationship between the readiness to quit and smoking-reduction outcomes in patients with schizophrenia treated with pharmacological adjuvants. The aim of this study was to examine the association between readiness to quit and smoking-reduction outcomes in patients with schizophrenia. A total of 308 subjects using nicotine replacement therapy (NRT) (N = 242) or bupropion (N = 66) participated in an 8-week smoking-reduction programme. Participants were categorised into precontemplators (N = 127), contemplators (N = 76) and preparators (N = 105) to quit smoking based on the transtheoretical model. There was a significant difference in change in number of cigarettes (NOC) (p = 0.007) and Fagerstrom test for nicotine dependence (FTND) score (nicotine dependence level) (p = 0.029) across the stages of change. A linear regression model revealed trend of increasing reduction in NOC and FTND scores in different stages of change (NOC: B = -1.22, t = -2.81, p = 0.005; FTND: B = -0.43, t = -2.57, p = 0.011). However, the 7-day point prevalence of abstinence was 5.5% (18/308), but there was no significant association between stage of change and smoking cessation (p = 0.26), possibly due to a very small sample size of successful quitters. In summary, among a cohort of institutionalised chronic schizophrenia patients receiving 8-week NRT or bupropion, stage of change can predict smoking reduction and may serve as a useful indicator for patients' preparedness before a trial of smoking reduction.

E-cigarettes and smoking cessation: evidence from a systematic review and meta-analysis

Background

E-cigarettes are currently being debated regarding their possible role in smoking cessation and as they are becoming increasingly popular, the research to date requires investigation.

Objectives

To investigate whether the use of e-cigarettes is associated with smoking cessation or reduction, and whether there is any difference in efficacy of e-cigarettes with and without nicotine on smoking cessation.

Data Sources

A systematic review of articles with no limit on publication date was conducted by searching PubMed, Web of Knowledge and Scopus databases.

Methods

Published studies, those reported smoking abstinence or reduction in cigarette consumption after the use of e-cigarettes, were included. Studies were systematically reviewed, and meta-analyses were conducted using Mantel-Haenszel fixed-effect and random-effects models. Degree of heterogeneity among studies and quality of the selected studies were evaluated.

Results

Six studies were included involving 7,551 participants. Meta-analyses included 1,242 participants who had complete data on smoking cessation. Nicotine filled e-cigarettes were more effective for cessation than those without nicotine (pooled Risk Ratio 2.29, 95%CI 1.05-4.97). Amongst 1,242 smokers, 224 (18%) reported smoking cessation after using nicotine-enriched e-cigarettes for a minimum period of six months. Use of such e-cigarettes was positively associated with smoking cessation with a pooled Effect Size of 0.20 (95%CI 0.11-0.28). Use of e-cigarettes was also associated with a reduction in the number of cigarettes used.

Limitations

Included studies were heterogeneous, due to different study designs and gender variation. Whilst we were able to comment on the efficacy of nicotine vs. non-nicotine e-cigarettes for smoking cessation, we were unable to comment on the efficacy of e-cigarettes vs. other interventions for cessation, given the lack of comparator groups in the studies included in this meta-analysis.

Conclusions

Use of e-cigarettes is associated with smoking cessation and reduction. More randomised controlled trials are needed to assess effectiveness against other cessation methods.

Quit and smoking reduction rates in vape shop consumers: a prospective 12-month survey

Aims: Here, we present results from a prospective pilot study that was aimed at surveying changes in daily cigarette consumption in smokers making their first purchase at vape shops. Modifications in products purchase were also noted. Design: Participants were instructed how to charge, fill, activate and use their e-cigarettes (e-cigs). Participants were encouraged to use these products in the anticipation of reducing the number of cig/day smoked. Settings: Staff from LIAF contacted 10 vape shops in the province of the city of Catania (Italy) that acted as sponsors to the 2013 No Tobacco Day. Participants: 71 adult smokers (≥18 years old) making their first purchase at local participating vape shops were asked by professional retail staff to complete a form. Measurements: Their cigarette consumption was followed-up prospectively at 6 and 12 months. Details of products purchase (i.e., e-cigs hardware, e-liquid nicotine strengths and flavours) were also noted. Findings: Retention rate was elevated, with 69% of participants attending their final follow-up visit. At 12 month, 40.8% subjects could be classified as quitters, 25.4% as reducers and 33.8% as failures. Switching from standard refillables (initial choice) to more advanced devices (MODs) was observed in this study (from 8.5% at baseline to 18.4% at 12 month) as well as a trend in decreasing the e-liquid nicotine strength, with more participants adopting low nicotine strength (from 49.3% at baseline to 57.1% at 12 month). Conclusions: We have found that smokers purchasing e-cigarettes from vape shops with professional advice and support can achieve high success rates.