Factors associated with the use of aids to cessation in English smokers

Attempts to quit smoking, use of smoking cessation methods, and associated characteristics among COPD patients

We explored past-year quit attempts, cessation methods used, and associations with sociodemographic, smoking, and health-related characteristics among smoking patients with chronic obstructive pulmonary disease (COPD) in Germany. Cross-sectional survey data of 509 past-year smokers (current smokers and ≤12 months abstinent) with COPD (ICD-10 code J44.x and FEV1/FVC <0.70) from 19 pulmonary primary care practices were used. Associations were explored between age, sex, educational qualification, lung function, urges to smoke, psychological distress, and (a) ≥1 past-year quit attempt (yes/no), (b) use of ≥1 evidence-based smoking cessation method (yes/no). Of all patients, 48.5% (n = 247, 95% confidence interval (CI) 44.2–52.9) reported ≥1 past-year quit attempt. Such an attempt was positively associated with the male sex (Odds Ratio (OR) = 1.50, 95% CI 1.01–2.24) and negatively associated with time spent with urges to smoke (OR = 0.69, 95% CI 0.52–0.91). During the most recent past-year quit attempt, one-third of the patients used ≥1 evidence-based smoking cessation method (31.2%, 95% CI 25.4–37.0), which was positively associated with the strength of urges to smoke (OR = 1.62, 95% CI 1.09–2.41). Combined behavioural and pharmacological treatments were used by 4.0% (n = 10, 95% CI 1.6–6.5). Electronic cigarettes were used most frequently (21.5%, 95% CI 16.3–26.6). Although a high proportion of COPD patients in German pulmonary primary care attempt to quit smoking, only a few of them use evidence-based methods as assistance for quitting.

Psychosocial determinants of quit motivation in older smokers from deprived backgrounds: a cross-sectional survey

OBJECTIVES

To identify psychosocial determinants of quit motivation in older deprived smokers. The evidence may be used to optimise smoking cessation interventions for the target population.

DESIGN

Cross-sectional survey using online recruitment methods including Facebook-targeted advertising.

SETTING

UK, 2019.

PARTICIPANTS

Current smokers aged 50 years or older and from a socioeconomically deprived background.

MAIN OUTCOME MEASURES

Measures included motivation to stop smoking, smoking history, perceived social support, self-efficacy for quitting, self-exempting beliefs and lung cancer risk perception. Multivariable regression was used to analyse factors associated with quit motivation.

RESULTS

Of a total 578 individuals who consented to take part, 278 (48.1%) did not meet the inclusion criteria. Of the 300 eligible participants, most were recruited using Facebook (94.0%), were aged 50-64 years (83.7%) and women (85.7%). Most participants were renting from a housing association (72.0%) and had low education (61.0%). Higher motivation to quit was statistically significantly associated with a higher intensity of previous quit attempts (p=0.03), higher quit confidence (p=0.01), higher smoking self-efficacy (p=0.01), a lower risk-minimising beliefs score (p=0.01) and using traditional nicotine replacement therapy (NRT) when trying to stop smoking or cut down (p<0.001).

CONCLUSION

Older smokers from deprived backgrounds face complex barriers to quitting smoking. Interventions are needed to increase self-efficacy for quitting, modify risk-minimising beliefs and target elements of previous quit attempts (ie, the use of NRT) that are associated with motivation to stop smoking.

Prevalence and correlates of receipt by smokers of general practitioner advice on smoking cessation in England: a cross-sectional survey of adults

BACKGROUND AND AIMS

Advice from a general practitioner (GP) can encourage smokers to quit. This study aimed to estimate the prevalence and correlates of receipt of GP advice on smoking, what type of advice and support was offered and characteristics and quitting activity associated with different types of advice.

DESIGN/SETTING

Data were collected between 2016 and 2019 in a series of monthly cross-sectional surveys of representative samples of the adult population in England.

PARTICIPANTS

A total of 11 588 past-year smokers.

MEASUREMENTS

Participants reported whether they had received advice or offer of support for smoking cessation from their GP in the last year. Socio-demographic and behavioural characteristics and past-year quit attempts and cessation were also recorded.

FINDINGS

One in two [47.2%, 95% confidence interval (CI) = 46.1-48.3%] past-year smokers who reported visiting their GP in the last year recalled receiving advice on smoking, and one in three (30.1%, 95% CI = 29.1-31.1%) reported being offered cessation support. The most common form of support offered was stop smoking services (16.5%, 95% CI = 15.7-17.3%) followed by prescription medication (8.1%, 95% CI = 7.5-8.7%); 3.7% (95% CI = 3.3-4.1%) reported having been recommended to use e-cigarettes. Smokers who were older, non-white, more addicted, and smoked five or more cigarettes/day had consistently higher odds of receiving advice or support. There were some differences by region, housing tenure, presence of children in the home and high-risk drinking in the types of advice/support received. There were no significant differences by sex, occupational social grade, disability, type of cigarettes smoked, or survey year. Advice with any offer of support was associated with higher odds of attempting to quit than advice alone [adjusted odds ratio (ORadj ) = 1.52, 95% CI = 1.30-1.76]. Advice alone was associated with higher odds of quit attempts than no advice in smokers with higher (ORadj  = 1.34, 95% CI = 1.10-1.64) but not lower occupational social grade (ORadj  = 0.90, 95% CI = 0.75-1.08).

CONCLUSIONS

In England, a minority of smokers receive support from their GP to stop smoking. Those who do are more likely to be older, non-white and more addicted to cigarettes. Advice plus offer of support appears to be associated with increased odds of making a quit attempt, while advice without offer of support appears only to be associated with increased odds of making a quit attempt in higher occupational social grade smokers.

Interest in and Use of Smoking Cessation Support Across Pregnancy and Postpartum

Background

Limited research exists on interest in and use of smoking cessation support in pregnancy and postpartum.

Methods

A longitudinal cohort of pregnant smokers and recent ex-smokers were recruited in Nottinghamshire, United Kingdom (N = 850). Data were collected at 8–26 weeks gestation, 34–36 weeks gestation, and 3 months postpartum and used as three cross-sectional surveys. Interest and use of cessation support and belief and behavior measures were collected at all waves. Key data were adjusted for nonresponse and analyzed descriptively, and multiple regression was used to identify associations.

Results

In early and late pregnancy, 44% (95% CI 40% to 48%) and 43% (95% CI 37% to 49%) of smokers, respectively, were interested in cessation support with 33% (95% CI 27% to 39%) interested postpartum. In early pregnancy, 43% of smokers reported discussing cessation with a midwife and, in late pregnancy, 27% did so. Over one-third (38%) did not report discussing quitting with a health professional during pregnancy. Twenty-seven percent of smokers reported using any National Health Service (NHS) cessation support and 12% accessed NHS Stop Smoking Services during pregnancy. Lower quitting confidence (self-efficacy), higher confidence in stopping with support, higher quitting motivation, and higher age were associated with higher interest in support (ps ≤ .001). A recent quit attempt and greater interest in support was associated with speaking to a health professional about quitting and use of NHS cessation support (ps ≤ .001).

Conclusions

When asked in early or late pregnancy, about half of pregnant smokers were interested in cessation support, though most did not engage. Cessation support should be offered throughout pregnancy and after delivery.

Implications

There is relatively high interest in cessation support in early and late pregnancy and postpartum among smokers; however, a much smaller proportion of pregnant or postpartum women access any cessation support, highlighting a gap between interest and engagement. Reflecting women’s interest, offers of cessation support should be provided throughout pregnancy and after delivery. Increasing motivation to quit and confidence in quitting with assistance may enhance interest in support, and promoting the discussion of stopping smoking between women and health practitioners may contribute to higher support engagement rates.

Smoking Cessation Attempts and Common Strategies Employed

BACKGROUND

Clinical guidelines on smoking cessation contain recommendations for various evidence-based methods. The goal of this study was to provide a represen- tative analysis for Germany of the percentage of smokers who try to quit smoking at least once per year, the use of evidence-based methods and other methods of smoking cessation, and potential associations of the use of such methods with the degree of tobacco dependence and with socioeconomic features.

METHODS

Data from 19 waves of the German Smoking Behavior Questionnaire (Deutsche Befragung zum Rauchverhalten, DEBRA), from the time period June/July 2016 to June/July 2019, were analyzed. Current smokers and recent ex-smokers (<12 months without smoking) were asked about their smoking cessation attempts in the past year and the methods they used during the last attempt (naming more than one method was permitted). The degree of tobacco dependence in current smokers was assessed with the Heaviness of Smoking Index.

RESULTS

Out of 11 109 current smokers and 407 recent ex-smokers, 19.9% (95% confidence interval: [19.1; 20.6]) had tried to quit smoking at least once in the preceding year. 13.0% of them [11.6; 14.5] had used at least one evidence-based method during their last attempt. The stronger the tobacco dependence, the more likely the use of an evidence-based method (odds ratio [OR] = 1.27 [1.16; 1.40]). Pharmacotherapy (nicotine replacement therapy, medication) was used more com- monly by persons with higher incomes (OR = 1.44 per 1000 euro/month [1.28; 1.62]). Electronic cigarettes were the most commonly used single type of smoking cessation support (10.2 % [9.0; 11.6]).

CONCLUSION

In Germany, only one in five smokers tries to quit smoking at least once per year. Such attempts are only rarely supported by evidence-based methods and are thus likely to fail. The high cost of treatment must be borne by the individual and thus fall disproportionately on poorer smokers. It follows that there is an urgent need for vered by health insurance pro- viders, in order to give all smokers fair and equal access to the medical care they need.

Reducing health inequalities in England: does the demise of NHS Stop Smoking Services matter? Analysis of mandatory monitoring data

BACKGROUND

Tobacco smoking is a key cause of mortality, morbidity and health inequalities. The unprecedented English health inequalities strategy (1999-2010) sought to reduce health inequalities, by, in part, instigating NHS Stop Smoking Services (SSS), initially targeted in deprived 'Spearhead' localities. Performance of SSS is assessed here in light of its role supporting the strategy, which evidence suggests achieved a reduction in health inequalities.

METHODS

SSS enrolment and four-week quits in Spearhead and non-Spearhead localities were compared during and after the strategy period, using regression models and routine monitoring data. Changes in SSS expenditure were estimated.

RESULTS

After similar increases in enrolment and quits between Spearhead and other localities between 2003/4 and 2008/9, SSS in Spearhead localities experienced a 2-fold better rate of improvement in enrolment and quit performance over the 4 years to 2011/12. Since 2011/12, SSS have dramatically reduced, and expenditure had fallen by half in Spearhead localities by 2016/17.

CONCLUSIONS

SSS, particularly in Spearhead localities, were expanded up to 2011/12, and this broadly coincides with the reduction in health inequalities. This suggests that although SSS did not achieve the scale anticipated, they have important potential, and the current demise of SSS should not be tolerated.

Pragmatic randomised trial of a smartphone app (NRT2Quit) to improve effectiveness of nicotine replacement therapy in a quit attempt by improving medication adherence: results of a prematurely terminated study

BACKGROUND

Nicotine replacement therapy (NRT) bought over the counter (OTC) appears to be largely ineffective for smoking cessation, which may be partially explained by poor adherence. We developed and evaluated the NRT2Quit smartphone app (for iOS) designed to improve quit attempts with OTC NRT by improving adherence to the medications.

METHODS

This study was a pragmatic double-blind randomised controlled trial with remote recruitment through leaflets distributed to over 300 UK-based community pharmacies. The study recruited adult daily smokers (≥10 cigarettes per day) who bought NRT, wanted to quit smoking, downloaded NTR2Quit and completed the registration process within the app. Participants were automatically randomly assigned within the app to the intervention (full) version of NRT2Quit or to its control (minimal) versions. The primary outcome was biochemically verified 4-week abstinence assessed at 8-week follow-up using Russell Standard criteria and intention to treat. Bayes factors were calculated for the cessation outcome. Secondary outcomes were self-reported abstinence, NRT use, app use and satisfaction with the app.

RESULTS

The study under-recruited. Only 41 participants (3.5% of the target sample) were randomly assigned to NRT2Quit (n = 16) or the control (n = 25) app versions between March 2015 and September 2016. The follow-up rate was 51.2%. The intervention participants had numerically higher biochemically verified quit rates (25.0% versus 8.0%, P = 0.19, odds ratio = 3.83, 0.61-24.02). The calculated Bayes factor, 1.92, showed that the data were insensitive to test for the hypothesis that the intervention app version aided cessation. The intervention participants had higher median logins (2.5 versus 0, P = 0.01) and were more likely to use NRT at follow-up (100.0% versus 28.6%, P = 0.03) and recommend NRT2Quit to others (100.0% versus 28.6%, P = 0.01).

CONCLUSIONS

Despite very low recruitment, there was preliminary but inconclusive evidence that NRT2Quit may improve short-term abstinence and adherence among smokers using NRT. Well-powered studies on NRT2Quit are needed, but different recruitment methods will be required to engage smokers through community pharmacies or other channels.

TRIAL REGISTRATION

ISRCTN ISRCTN33423896 , prospectively registered on 22 March 2015.

Socioeconomic inequalities in the delivery of brief interventions for smoking and excessive drinking: findings from a cross-sectional household survey in England

OBJECTIVES

Brief interventions (BI) for smoking and risky drinking are effective and cost-effective policy approaches to reducing alcohol harm currently used in primary care in England; however, little is known about their contribution to health inequalities. This paper aims to investigate whether self-reported receipt of BI is associated with socioeconomic position (SEP) and whether this differs for smoking or alcohol.

DESIGN

Population survey of 8978 smokers or risky drinkers in England aged 16+ taking part in the Alcohol and Smoking Toolkit Studies.

MEASURES

Survey participants answered questions regarding whether they had received advice and support to cut down their drinking or smoking from a primary healthcare professional in the past 12 months as well as their SEP, demographic details, whether they smoke and their motivation to cut down their smoking and/or drinking. Respondents also completed the Alcohol Use Disorders Identification Test (AUDIT). Smokers were defined as those reporting any smoking in the past year. Risky drinkers were defined as those scoring eight or more on the AUDIT.

RESULTS

After adjusting for demographic factors and patterns in smoking and drinking, BI delivery was highest in lower socioeconomic groups. Smokers in the lowest social grade had 30% (95% CI 5% to 61%) greater odds of reporting receipt of a BI than those in the highest grade. The relationship for risky drinking appeared stronger, with those in the lowest social grade having 111% (95% CI 27% to 252%) greater odds of reporting BI receipt than the highest grade. Rates of BI delivery were eight times greater among smokers than risky drinkers (48.3% vs 6.1%).

CONCLUSIONS

Current delivery of BI for smoking and drinking in primary care in England may be contributing to a reduction in socioeconomic inequalities in health. This effect could be increased if intervention rates, particularly for drinking, were raised.

Factors associated with Quitline and pharmacotherapy utilisation among low-socioeconomic status smokers

AIMS

To examine factors associated with Quitline and pharmacotherapy utilisation in low socioeconomic status (low-SES) smokers enrolled in a smoking cessation trial.

METHODS

Baseline data was used from a large-scale smoking cessation randomised controlled trial (RCT). Logistic regression models were used to examine predictors of treatment utilisation prior to entering the RCT and perceived effectiveness of past and future use.

RESULTS

A total of 1047 smokers consented and prior to enrolment 92% had previously tried to quit smoking, 86% had ever used quit support, 83% had used pharmacotherapy at least once and 38% had ever utilised Quitline. For those who had used pharmacotherapies, 71% used NRT, of which 21% had used dual NRT products. In the last 12-months, 27% utilised Quitline and 50% utilised NRT. Ever use of Quitline was negatively associated with self-efficacy to quit (OR: 0.80; 95% CI: 0.68, 0.94 p < .01) and positively associated with being diagnosed with a mental health condition (OR: 1.50; 95% CI: 1.01, 2.25 p < .05). Recent use of NRT was positively associated with mental health condition (OR: 1.39; 95% CI: 1.02, 1.90 p < .05) and negatively associated with alcohol consumption (OR: 0.69; 95% CI: 0.52, 0.92 p < .01).

CONCLUSION

Past use of Quitline and pharmacotherapy treatment was associated with self-efficacy to quit, sociodemographic variables, mental health conditions and alcohol consumption. Community-based strategies that target smoking, mental health and drug and alcohol problems may overcome some of the barriers that prevent low-SES populations from engaging with smoking cessation support.

Facebook recruitment of smokers: comparing gain- and loss-framed ads for the purposes of an Internet-based smoking cessation intervention

Abstract: Gain- and loss-framed messages about smoking behavior have commonly been used to promote cessation. However, there are still no clear conclusions as to what kind of message is more effective for motivating smokers to quit. This study compared the effectiveness of loss- and gain-framed messages in the online recruitment of smokers via Facebook Advertising. Loss- and gain-framed messages about smoking were created and released as Facebook ads. Users who clicked on the ads were automatically redirected to the “Live Without Tobacco” intervention (http://www.vivasemtabaco.com.br). The amount spent on the ads was BRL 647.64. Data were collected from the Facebook Ads platform and from a relational database. Analyses were performed on the 6,350 users who clicked on one of the ads and 1,731 who were successfully redirected to the intervention. Gain-framed ads reached 174,029 people and loss-framed ads reached 180,527. The former received 2,688 clicks, while the latter received 3,662. The cost of the click was BRL 0.12 per gain-framed ad and BRL 0.09 per loss-framed ad. Loss-framed ads reached more users, got more clicks (and website accesses), and led to more accounts and quit plans being created. Loss-framed messages about smoking appear to be more cost-effective for both initial recruitment and intervention engagement. Facebook has proven to be a good outreach and recruitment tool and can be a solution for the difficulty in reaching smokers for cessation interventions.

An exploration of the barriers to attendance at the English Stop Smoking Services

Introduction

Despite the availability of effective stop smoking assistance, most smokers do not utilise formal cessation programmes such as the English Stop Smoking Services (SSS). We modified the Treatment Barriers Questionnaire (TBQ), developed in the USA, and distributed it to a sample of English smokers to explore the most important barriers to the use of the SSS.

Methods

Participants of Start2quit, a randomised controlled trial aiming to increase attendance at the SSS using tailored risk information and 'taster' sessions, who reported at follow-up that they had not attended the SSS, were asked to complete the TBQ; 672 (76.9% response rate) were retained for analysis. Principal Component Analysis (PCA) was conducted to examine the structure of the data. Multiple linear regressions were used to determine whether any participant characteristics were associated with particular barriers.

Results

The most commonly endorsed items related to a lack of information on and a lack of confidence in the efficacy of the SSS. PCA yielded seven factors: Work and time constraints (Factor1); Smokers should quit on their own (Factor2); Nothing can help in quitting smoking(Factor3); Disinterest in quitting (Factor4); Lack of social support to attend (Factor5); Lack of privacy at programmes (Factor6); Lack of information and perceived availability (Factor7). Age was associated with Factors 1, 3 and 4, motivation to quit with Factors 2 and 4, and confidence in quitting with Factors 1, 2, and 3.

Conclusions

The findings suggest that many barriers exist, and they vary according to smoker demographics and characteristics, pointing to the need for tailored recruitment strategies.

Trial registration

ISRCTN76561916.

Association Between Socioeconomic Status and Access to Care and Quitting Smoking With and Without Assistance

Introduction

Socio-economic disparities in smoking rates persist, in Ontario, despite public health care and universal tobacco control policies. Mechanisms for continuing disparities are not fully understood. Unequal access or utilization of assistance for cessation may contribute. The objective of this research was to use longitudinal data on smokers to examine the associations between socioeconomic status (SES) and access to care measures and assisted and unassisted quit attempts.

Methods

Data were taken from 3578 smokers with at least one follow-up interview participating in the Ontario Tobacco Survey (OTS). Multinomial regression models with imputed missing values were run for each measure of SES and access to care to assess the association with quitting behavior and use of assistance, unadjusted and while adjusting for smoking history and demographic covariates.

Results

Adjusted analyses found smokers living in areas with the lowest ethnic concentration were more likely to make an assisted quit attempt compared to unassisted quitting (RR = 1.64; 95% CI = 1.08-2.50) or making no quit attempt (RR = 1.65; 95% CI = 1.15-2.37). Smokers who reported visiting a doctor in the previous 6 months were more likely to quit with assistance versus unassisted compared to those not visiting a doctor, whether they were advised (RR = 1.89, 95% CI = 1.43-2.48) or not advised to quit (OR = 1.32, 95% CI = 1.01-1.74). Similar results were seen when comparing assisted quit attempts with no quit attempts.

Conclusions

Adjusted analyses showed that quitting with assistance was unrelated to measures of SES except ethnic concentration. Physician intervention with patients who smoke is important for increasing assisted quit attempts.

Implications

For most measures of SES there were no significant associations with either assisted or unassisted quitting adjusting for demographic and smoking history. Smokers who live in areas with the lowest ethnic concentration were most likely to use assistance as were smokers who visited their doctor and were advised to quit smoking. Interventions to increase the delivery of effective quitting methods in smokers living in areas with high ethnic concentrations and to increase physician compliance with asking and advising patients to quit may increase assisted quit attempts.

Predicting Engagement in Smoking Cessation Treatment Following a Brief Telephone Evaluation and Referral Session

Introduction: Smoking cessation treatment combining medication and counselling yields the best outcomes; however, few smokers employ both modalities.

Aims: The purpose of this study was to examine variables predicting treatment attendance.

Methods: This was a chart review of US military Veterans (N = 340; 89% male, 59% non-Hispanic white) referred for smoking cessation, who completed a telephone call to encourage treatment utilization. Treatment engagement was defined as attending a smoking cessation session within 30 days following telephone contact. A logistic regression analysis examined predictors (demographics, smoking variables, and psychiatric diagnoses) of treatment engagement.

Results/Findings: Greater age (Odds Ratio [OR] = 1.04, 95% confidence interval [CI] 1.01–1.06), more cigarettes (OR = 1.03, 95% CI 1.00–1.06), and higher perceived importance of quitting (OR = 1.11, 95% CI 1.00–1.23) predicted engaging in treatment within 30 days (all p values < 0.05).

Conclusion: Veterans who attended treatment were older, smoked more cigarettes, and perceived quitting as more important than those who did not attend. These findings are consistent with prior studies examining factors associated with treatment utilization. Results highlight the need to identify strategies for engaging into treatment smokers who are younger, smoke fewer cigarettes, and view quitting as less important.

The Use of Tobacco, E-Cigarettes, and Methods to Quit Smoking in Germany

BACKGROUND

Current data on tobacco use are a necessary prerequisite for the study of the implementation of tobacco control measures in the general population. The German Study on Tobacco Use (Deutsche Befragung zum Rauchverhalten, DEBRA) provides previously lacking data on key indicators of smoking behavior and on the consumption of new products such as e-cigarettes. The continual acquisition and accumulation of data permits the analysis of trends and precise statistical evaluation.

METHODS

Data were obtained by repeated face-to-face interviews, at 2-month intervals, of representative samples of approximately 2000 persons across Germany aged 14 years and above. For this article, data from 12 273 persons that were acquired in 6 waves of the survey (June/July 2016 to April/May 2017) were aggregated and weighted.

RESULTS

The one-year prevalence of current tobacco consumption was 28.3% (95% confidence interval: [27.5; 29.1]) in the overall survey population and 11.9% [8.9; 14.9] among persons under age 18. Higher tobacco consumption was correlated with lower educational attainment and lower income. 28.1% of the smokers had tried to quit smoking in the past year; the most commonly used method of quitting was e-cigarettes (9.1%). Brief physician advice or pharmacotherapy for smoking cessation were tried by 6.1% and 7.0%, respectively. 1.9% of the overall survey population but only 0.3% of persons who had never smoked were current consumers of e-cigarettes.

CONCLUSION

Tobacco consumption is very high in Germany compared to other countries in Western and Northern Europe, and its distribution across the population is markedly uneven, with a heavy influence of socioeconomic status.

Smokers' Views on Personal Carbon Monoxide Monitors, Associated Apps, and Their Use: An Interview and Think-Aloud Study

Smartphone-based personal carbon monoxide (CO) monitors and associated apps, or "CO Smartphone Systems" (CSSs) for short, could enable smokers to independently monitor their smoking and quitting. This study explored views and preferences regarding CSSs and their use among 16 adult, UK-based smokers. First, semi-structured interviews explored participants' expectations of CSSs. Secondly, a think-aloud study identified participants' reactions to a personal CO monitor and to existing or prototype apps. Framework Analysis identified five themes: (1) General views, needs, and motivation to use CSSs; (2) Views on the personal CO monitor; (3) Practicalities of CSS use; (4) Desired features in associated apps; and (5) Factors affecting preferences for CSSs and their use. Participants had high expectations of CSSs and their potential to increase motivation. Priority app features included: easy CO testing journeys, relevant and motivating feedback, and recording of contextual data. Appearance and usability of the personal CO monitor, and accuracy and relevance of CO testing were considered important for engagement. Participants differed in their motivation to use and preferences for CSSs features and use, which might have non-trivial impact on evaluation efforts. Personal CO monitors and associated apps may be attractive tools for smokers, but making CSSs easy to use and evaluating these among different groups of smokers may be challenging.

What factors are associated with abstinence amongst socioeconomically disadvantaged smokers? A cross-sectional survey of use of cessation aids and quitting approach

INTRODUCTION AND AIMS

This study aimed to compare current and ex-smokers' sociodemographic and psychosocial characteristics, use of cessation aids and abrupt versus gradual quitting approaches.

DESIGN AND METHODS

A cross-sectional survey of financially disadvantaged adults attending a community service organisation was conducted in New South Wales, Australia, between February 2012 and December 2013. Sociodemographic and psychosocial factors, use of cessation aids and gradual versus abrupt quit approach were assessed. χ2 tests and logistic regression compared characteristics of current and ex-smokers.

RESULTS

Of 905 individuals who completed the survey, 639 (71%) were current smokers and 107 (12%) were ex-smokers. Ex-smokers were older [odds ratio (OR) = 1.03, 95% confidence interval (CI) = 1.01, 1.05], had higher odds of being female (OR = 1.67, 95% CI = 1.06, 2.65), lower odds of being financially stressed (OR = 0.87, 95% CI = 0.76, 0.99), lower odds of anxiety and depression symptoms (OR = 0.91, 95% CI = 0.84, 0.98) and lower odds of having friends and family who were smokers (ORs ranged from 0.30-0.43). Ex-smokers had lower odds of using cessation aids and higher odds of reporting abrupt quitting during their last quit attempt (OR = 4.48, 95% CI = 2.66, 7.54).

CONCLUSIONS

Lower levels of disadvantage, less smoking in social networks, less use of cessation aids and abrupt (vs. gradual) quitting approaches were associated with being an ex-smoker. Lower use of evidence based methods to quit by disadvantaged ex-smokers requires further exploration. [Twyman L, Bonevski B, Paul C, Bryant J, West R, Siahpush M, D'este C, Oldmeadow C, Palazzi K. What factors are associated with abstinence amongst socioeconomically disadvantaged smokers? A cross-sectional survey of use of cessation aids and quitting approach. Drug Alcohol Rev 2017;00:000-000].

What are older smokers' attitudes to quitting and how are they managed in primary care? An analysis of the cross-sectional English Smoking Toolkit Study

OBJECTIVES

To investigate whether age is associated with access to smoking cessation services.

DESIGN

Data from the Smoking Toolkit Study 2006-2015, a repeated multiwave cross-sectional household survey (n=181 157).

SETTING

England.

PARTICIPANTS

Past-year smokers who participated in any of the 102 waves stratified into age groups.

OUTCOME MEASURES

Amount smoked and nicotine dependency, self-reported quit attempts and use of smoking cessation interventions. Self-report of whether the general practitioner (GP) raised the topic of smoking and made referrals for pharmacological support (prescription of nicotine replacement therapies (NRTs)) or other support (counselling or support groups).

RESULTS

Older smokers (75+ years) were less likely to report that they were attempting to quit smoking or seek help from a GP, despite being less nicotine-dependent. GPs raised smoking as a topic equally across all age groups, but smokers aged 70+ were more likely not to be referred for NRT or other support (ORs relative to 16-54 years; 70-74 years 1.27, 95% CI 1.03 to 1.55; 75-79 years 1.87, 95% CI 1.43 to 2.44; 80+ years 3.16, 95% CI 2.20 to 4.55; p value for trend <0.001).

CONCLUSIONS

Our findings suggest that there are potential missed opportunities in facilitating smoking cessation in older smokers. In this large population-based study, older smokers appeared less interested in quitting and were less likely to be offered support, despite being less addicted to nicotine than younger smokers. It is unclear whether this constitutes inequitable access to services or reflects informed choices by older smokers and their GPs. Future research is needed to understand why older smokers and GPs do not pursue smoking cessation. Service provision should consider how best to reduce these variations, and a stronger effectiveness evidence base is required to support commissioning for this older population so that, where appropriate, older smokers are not missing out on smoking cessation therapies and the health benefits of cessation at older ages.

Measured, opportunistic, unexpected and naïve quitting: a qualitative grounded theory study of the process of quitting from the ex-smokers' perspective

BACKGROUND

To better understand the process of quitting from the ex-smokers' perspective, and to explore the role spontaneity and planning play in quitting.

METHODS

Qualitative grounded theory study using in-depth interviews with 37 Australian adult ex-smokers (24-68 years; 15 males, 22 females) who quit smoking in the past 6-24 months (26 quit unassisted; 11 used assistance).

RESULTS

Based on participants' accounts of quitting, we propose a typology of quitting experiences: measured, opportunistic, unexpected and naïve. Two key features integral to participants' accounts of their quitting experiences were used as the basis of the typology: (1) the apparent onset of quitting (gradual through to sudden); and (2) the degree to which the smoker appeared to have prepared for quitting (no evidence through to clear evidence of preparation). The resulting 2 × 2 matrix of quitting experiences took into consideration three additional characteristics: (1) the presence or absence of a clearly identifiable trigger; (2) the amount of effort (cognitive and practical) involved in quitting; and (3) the type of cognitive process that characterised the quitting experience (reflective; impulsive; reflective and impulsive).

CONCLUSIONS

Quitting typically included elements of spontaneity (impulsive behaviour) and preparation (reflective behaviour), and, importantly, the investment of time and cognitive effort by participants prior to quitting. Remarkably few participants quit completely out-of-the-blue with little or no preparation. Findings are discussed in relation to stages-of-change theory, catastrophe theory, and dual process theories, focusing on how dual process theories may provide a way of conceptualising how quitting can include elements of both spontaneity and preparation.

Study protocol of the German Study on Tobacco Use (DEBRA): a national household survey of smoking behaviour and cessation

BACKGROUND

The prevalence of tobacco smoking in Germany is high (~27%). Monitoring of national patterns of smoking behaviour and data on the "real-world" effectiveness of cessation methods are needed to inform policies and develop campaigns aimed at reducing tobacco-related harm. In England, the Smoking Toolkit Study (STS) has been tracking such indicators since 2006, resulting in the adaptation of tobacco control policies. However, findings cannot be directly transferred into the German health policy context. The German Study on Tobacco Use (DEBRA: "Deutsche Befragung zum Rauchverhalten") aims to provide such nationally representative data.

METHODS/DESIGN

In June 2016, the study started collecting data from computer-assisted, face-to-face household interviews in people aged 14 years and older. Over a period of 3 years, a total of ~36,000 respondents will complete the survey with a new sample of ~2000 respondents every 2 months (=18 waves). This sample will report data on demographics and the use of tobacco and electronic (e-)cigarettes. Per wave, about 500-600 people are expected to be current or recent ex-smokers (<12 months since quitting). This sample will answer detailed questions about smoking behaviour, quit attempts, exposure to health professionals' advice on quitting, and use of cessation aids. Six-month follow-up data will be collected by telephone.

DISCUSSION

The DEBRA study will be an important source of data for tobacco control policies, health strategies, and future research. The methodology is closely aligned to the STS, which will allow comparisons with data from England, a country with one of the lowest smoking prevalence rates in Europe (18%).

TRIAL REGISTRATION

This study has been registered at the German Clinical Trials Register ( DRKS00011322 ) on 25th November 2016.

Characteristics of first-time varenicline users - A cross-sectional study in Finnish quitters

BACKGROUND

Varenicline is an efficacious medicine for smoking cessation (SC) but little is known about the characteristics of varenicline users. This study examined the characteristics of first-time (naïve) varenicline users in Finland and compared those who had previously used SC pharmacotherapy to those who were trying SC pharmacotherapy for the first time.

METHODS

A cross-sectional survey was conducted in Finnish community pharmacies between February 2014 and January 2015. Pharmacy customers purchasing a varenicline starter package for the first time ever were asked to complete a questionnaire or to participate in a structured interview conducted by the pharmacist (identical questions). The questionnaire included questions about demographic characteristics, smoking habits, previous cessation attempts and factors associated with varenicline use.

RESULTS

Altogether 98 people completed the survey. The majority were daily smokers (96%, n = 94), with a history of over 10 years of regular smoking (94%, n = 92), and a strong/very strong nicotine dependence (67%, n = 66). Half of the participants (54%, n = 53) were trying a SC pharmacotherapy for the first time. Demographic characteristics and smoking habits were similar between first-time and previous users of SC medications (p > 0.05). Health centers (42%, n = 41) and occupational health care clinics (37%, n = 36) were the most common sources of varenicline prescriptions. The majority of participants received the prescription for varenicline after mentioning their desire for quitting to a physician (70%, n = 69).

CONCLUSIONS

Considering the relatively large proportion of SC naïve medicine users among new users of varenicline, smokers who have previously been reluctant to quit smoking, to use other pharmacological SC interventions, or perhaps unaware of these options may be interested in attempting cessation with varenicline. Most participants made the initiative to discuss their smoking with the physician, which led to varenicline prescribing. This suggests that physicians may not satisfactorily recognize their patients' nicotine dependence and desire to quit, and they should more actively support patients' smoking cessation.

Access to Subsidized Smoking Cessation Medications by Australian Smokers Aged 45 Years and Older: A Population-Based Cohort Study

Introduction

The principal aim of this study was to assess the accessibility of subsidized cessation medications to socioeconomically disadvantaged smokers, including smokers living in regional and remote communities.

Methods

Analyses used baseline questionnaire and linked Pharmaceutical Benefits Scheme data for 18 686 regular smokers participating in the 45 and Up Study, a large-scale Australian cohort study of people aged 45 years and older. Participants who were dispensed nicotine replacement therapy, varenicline, or bupropion were identified from the Pharmaceutical Benefits Scheme data, which provide an essentially complete record of participants' access to subsidized pharmaceuticals. Associations between the supply of each pharmacotherapy and a range of sociodemographic and health-related variables were evaluated using multiple logistic regression.

Results

The odds that participants were supplied with a cessation medication declined markedly with increasing age for participants older than 60 years and were substantially higher for participants who smoked 20 or more cigarettes/day than for participants who smoked fewer than 10 cigarettes/day. Participants with no formal qualification and those residing in socioeconomically disadvantaged areas had higher odds of receiving nicotine replacement therapy or varenicline than university-educated participants and participants living in the least disadvantaged areas. There was no evidence that participants residing in regional and remote communities had lower odds of receiving a cessation medication than participants residing in major cities.

Conclusions

Older Australian smokers' access to cessation pharmacotherapies is determined predominantly by age and daily cigarette consumption and does not appear to be limited by educational achievement, socioeconomic disadvantage, or remoteness.

Implications

Promoting the use of cessation medications is a principal measure proposed to achieve Australia's National Tobacco Strategy 2012-2018 goal of reducing cigarette consumption among socioeconomically disadvantaged smokers. The results of this large-scale cohort study indicate that access to cessation pharmacotherapies is determined primarily by age and daily cigarette consumption, and is not limited by socioeconomic circumstances, providing some reassurance that existing government subsidies are sufficient to ensure that pharmaceutical aids are accessible to all Australian smokers.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Comparison of brief interventions in primary care on smoking and excessive alcohol consumption: a population survey in England

BACKGROUND

Brief interventions have a modest but meaningful effect on promoting smoking cessation and reducing excessive alcohol consumption. Guidelines recommend offering such advice opportunistically and regularly but incentives vary between the two behaviours.

AIM

To use representative data from the perspective of patients to compare the prevalence and characteristics of people who smoke or drink excessively and who receive a brief intervention.

DESIGN AND SETTING

Data was from a representative sample of 15,252 adults from household surveys in England.

METHOD

Recall of brief interventions on smoking and alcohol use, sociodemographic information, and smoking and alcohol consumption patterns were assessed among smokers and those who drink excessively (AUDIT score of ≥8), who visited their GP surgery in the previous year.

RESULTS

Of 1775 smokers, 50.4% recalled receiving brief advice on smoking in the previous year. Smokers receiving advice compared with those who did not were more likely to be older (odds ratio [OR] 17-year increments 1.19, 95% confidence interval [CI] =1.06 to 1.34), female (OR 1.35, 95% CI =1.10 to 1.65), have a disability (OR 1.44, 95% CI = 1.11 to 1.88), have made more quit attempts in the previous year (compared with no attempts: one attempt, OR 1.65, 95% CI = 1.32 to 2.08; ≥2 attempts, OR 2.02, 95% CI =1.49 to 2.74), and have greater nicotine dependence (OR 1.17, 95% CI =1.05 to 1.31) but were less likely to have no post-16 qualifications (OR 0.81, 95% CI = 0.66 to 1.00). Of 1110 people drinking excessively, 6.5% recalled receiving advice in their GP surgery on their alcohol consumption in the previous year. Those receiving advice compared with those who did not had higher AUDIT scores (OR 1.17, 95% CI =1.12 to 1.23) and were less likely to be female (OR 0.44, 95% CI = 0.23 to 0.87).

CONCLUSION

Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, <10% of those who drink excessively report having received advice on their alcohol consumption.

Use of aids for smoking cessation and alcohol reduction: A population survey of adults in England

Background

It is important for policy planning to chart the methods smokers and high-risk drinkers use to help them change their behaviour. This study assessed prevalence of use, and characteristics of users, of support for smoking cessation and alcohol reduction in England.

Methods

Data were used from the Smoking and Alcohol Toolkit Studies, which involve monthly face-to-face computer-assisted interviews of adults aged 16+ in England. We included data collected between June 2014 and July 2015 on 1600 smokers who had made at least one quit attempt and 911 high-risk drinkers (defined as scores >8+ on the full AUDIT or 5+ on questions 1–3 of the AUDIT-C) who had made an attempt to cut down in the past 12 months. Participants provided information on their socio-demographic characteristics and use of aids during their most recent quit attempt including pharmacotherapy, face-to-face counselling, telephone support, self-help materials (digital and printed), and complementary medicine.

Results

A total of 60.3% of smokers used aids in the past year, compared with just 14.9% of high-risk drinkers. Use of pharmacotherapy was high among smokers and very low among drinkers (56.0%_versus1.2%). Use of other aids was low for both behaviours: face-to-face counselling (2.6%_versus4.8%), self-help materials (1.4%_versus4.1%) and complementary medicine (1.0%_versus0.5%). Use of aids was more common among smokers aged 25–54 compared with 16–24 year olds (25–34,OR_adj1.49,p = 0.012; 35–44,OR_adj1.93,p < 0.001; 35–44,OR_adj1.93,p < 0.001; 45–54,OR_adj1.66,p = 0.008), with cigarette consumption >10 relative to <1 (10–20,OR_adj2.47,p = 0.011; >20,OR_adj4.23,p = 0.001), and less common among ethnic minorities (OR_adj0.69,p = 0.026). For alcohol reduction, use of aids was higher among ethnic minority groups (OR_adj2.41;p = 0.015), and those of social-grade D/E relative to AB (OR_adj2.29,p = 0.012&OR_adj3.13,p < 0.001).

Conclusion

In England, the use of pharmacotherapy is prevalent for smoking cessation but not alcohol reduction. Other aids are used at a low rate, with face-to-face counselling being more common for alcohol reduction than smoking cessation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3862-7) contains supplementary material, which is available to authorized users.

New Pharmacological Agents to Aid Smoking Cessation and Tobacco Harm Reduction: What Has Been Investigated, and What Is in the Pipeline?

A wide range of support is available to help smokers to quit and to aid attempts at harm reduction, including three first-line smoking cessation medications: nicotine replacement therapy, varenicline and bupropion. Despite the efficacy of these, there is a continual need to diversify the range of medications so that the needs of tobacco users are met. This paper compares the first-line smoking cessation medications with (1) two variants of these existing products: new galenic formulations of varenicline and novel nicotine delivery devices; and (2) 24 alternative products: cytisine (novel outside Central and Eastern Europe), nortriptyline, other tricyclic antidepressants, electronic cigarettes, clonidine (an anxiolytic), other anxiolytics (e.g. buspirone), selective serotonin reuptake inhibitors, supplements (e.g. St John's wort), silver acetate, Nicobrevin, modafinil, venlafaxine, monoamine oxidase inhibitors (MAOIs), opioid antagonists, nicotinic acetylcholine receptor (nAChR) antagonists, glucose tablets, selective cannabinoid type 1 receptor antagonists, nicotine vaccines, drugs that affect gamma-aminobutyric acid (GABA) transmission, drugs that affect N-methyl-D-aspartate (NMDA) receptors, dopamine agonists (e.g. levodopa), pioglitazone (Actos; OMS405), noradrenaline reuptake inhibitors and the weight management drug lorcaserin. Six 'ESCUSE' criteria-relative efficacy, relative safety, relative cost, relative use (overall impact of effective medication use), relative scope (ability to serve new groups of patients) and relative ease of use-are used. Many of these products are in the early stages of clinical trials; however, cytisine looks most promising in having established efficacy and safety with low cost. Electronic cigarettes have become very popular, appear to be efficacious and are safer than smoking, but issues of continued dependence and possible harms need to be considered.

Development and application of culturally appropriate decision aids for smoking cessation in Korea: a pragmatic clustered randomization crossover trial

INTRODUCTION

In Asian countries, reluctance to seek pharmacological intervention is a major barrier for smoking cessation. Culturally appropriate decision aids are expected to help people in the decision making for the use of smoking cessation medication.

OBJECTIVE

The aim of this study was to develop a culturally tailored decision aid for smoking cessation and evaluate its effect on the use of smoking cessation medication.

PATIENTS AND METHODS

A 7-minute video on smoking cessation information and options was developed. Physicians were randomized into intervention and control groups. The decision aid was provided to patients in the intervention group, and they watched it, while those in the control group were provided usual medical care for smoking cessation. The primary outcome was the proportion of smokers who were prescribed smoking cessation medication within 1 month after consultation. The secondary outcomes were abstinence rate and use of smoking cessation medication within 6 months. A logistic regression analysis was used to assess the effect of the decision aid on the outcomes.

RESULTS

In total, 414 current smokers (intervention group: 195; control group: 219) were enrolled. The mean age of the participants was 48.2 years, and 381 subjects (92%) were males. In total, 11.8% of the participants in the intervention group and 10.5% in the control group were prescribed smoking cessation medications within 1 month. The odds ratio was 1.02 (95% CI: 0.40-2.63) after adjustment for baseline characteristics. Within 6 months, 17.4% of the participants in the intervention group and 15% in the control group were prescribed medication (adjusted odds ratio 1.12, 95% CI: 0.59-2.13).

CONCLUSION

The culturally tailored smoking cessation decision aid developed in this study did not show a significant impact on the decision to use smoking cessation medication. Further research to develop more effective and more interactive interventions is expected.

Factors Associated With Accepting Assistance for Smoking Cessation Among Military Veterans

INTRODUCTION

Cigarette smoking remains a significant health risk for Veterans. Increased understanding of factors that influence the tobacco cessation referral process within Veterans Affairs medical facilities is useful for enhancing utilization of smoking cessation treatment. The present study examined the association of demographic and health variables with whether smokers accepted referral for medication and/or tobacco cessation clinic.

METHODS

Electronic medical record data (2011-2013) were obtained for a sample of US military Veterans who accepted cessation assistance from their health care provider. Demographic and diagnostic variables were examined to identify predictors of the types of assistance accepted (medication only, clinic referral only, or both).

RESULTS

The sample includes 2941 Veterans, 10.3% female, 19.9% African American, 10.7% Hispanic, and 57.9% non-Hispanic white. Veterans averaged of 50.69 years of age (SD = 14.01), 31.5% had a substance use disorder diagnosis and 54.1% had a psychiatric diagnosis. Demographic and diagnostic information was compared across types of assistance accepted. Significant differences were found between those who accepted medications only and those who accepted either clinic referral or both medication and clinic referral. Veterans in the latter two categories were younger and more likely to have a psychiatric diagnosis than those accepting medication only. Women Veterans were significantly more likely than men to accept clinic referral plus medication. However, in contrast to men, almost none of the variables examined were associated with the type of assistance accepted by women.

CONCLUSION

These findings indicate significant gender differences in influences on accepting assistance for smoking cessation among Veterans.

IMPLICATIONS

Existing research identifies factors associated with unassisted quitting. However, little is known regarding the referral process, which is critical in connecting smokers with treatment. The present work is unique in employing electronic medical record data to examine factors associated with accepting different types of smoking cessation treatment referrals. This study represents an initial effort to elucidate the smoking cessation treatment referral process. These findings highlight the need to examine sex specific influences on smoking cessation treatment utilization and the importance of focusing on smokers with psychiatric disorders.

Systematic review and meta-analysis of Internet interventions for smoking cessation among adults

BACKGROUND

The aim of this systematic review was to determine the effectiveness of Internet interventions in promoting smoking cessation among adult tobacco users relative to other forms of intervention recommended in treatment guidelines.

METHODS

This review followed Cochrane Collaboration guidelines for systematic reviews. Combinations of "Internet," "web-based," and "smoking cessation intervention" and related keywords were used in both automated and manual searches. We included randomized trials published from January 1990 through to April 2015. A modified version of the Cochrane risk of bias assessment tool was used. We calculated risk ratios (RRs) for each study. Meta-analysis was conducted using random-effects method to pool RRs. Presentation of results follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

Forty randomized trials involving 98,530 participants were included. Most trials had a low risk of bias in most domains. Pooled results comparing Internet interventions to assessment-only/waitlist control were significant (RR 1.60, 95% confidence interval [CI] 1.15-2.21, I (2)=51.7%; four studies). Pooled results of largely static Internet interventions compared to print materials were not significant (RR 0.83, 95% CI 0.63-1.10, I (2)=0%; two studies), whereas comparisons of interactive Internet interventions to print materials were significant (RR 2.10, 95% CI 1.25-3.52, I (2)=41.6%; two studies). No significant effects were observed in pooled results of Internet interventions compared to face-to-face counseling (RR 1.35, 95% CI 0.97-1.87, I (2)=0%; four studies) or to telephone counseling (RR 0.95, 95% CI 0.79-1.13, I (2)=0%; two studies). The majority of trials compared different Internet interventions; pooled results from 15 such trials (24 comparisons) found a significant effect in favor of experimental Internet interventions (RR 1.16, 95% CI 1.03-1.31, I (2)=76.7%).

CONCLUSION

Internet interventions are superior to other broad reach cessation interventions (ie, print materials), equivalent to other currently recommended treatment modes (telephone and in-person counseling), and they have an important role to play in the arsenal of tobacco-dependence treatments.

Financial incentives to promote extended smoking abstinence in opioid-maintained patients: a randomized trial

BACKGROUND AND AIMS

Prior studies by our group demonstrated the efficacy of a brief but intensive behavioral intervention for producing initial smoking abstinence among opioid-dependent patients. In the present study, our aim was to promote longer-duration abstinence in this population. Following an initial 2-week incentive intervention for smoking abstinence, we examined whether a 10-week maintenance arm involving continuation of contingent reinforcement will produce greater smoking abstinence than a similar duration of noncontingent reinforcement.

DESIGN

Randomized, 12-week, parallel-group study.

SETTING

Out-patient research clinic in Burlington, Vermont, USA.

PARTICIPANTS

Opioid-maintained smokers (n = 88) who provided breath carbon monoxide and urinary cotinine specimens and received contingent reinforcement for smoking abstinence during weeks 1-2 (phase 1), with 63 randomized on day 14 to an extended contingent (EC; n = 31) or extended noncontingent (EN; n = 32) experimental condition for weeks 3-12 (phase 2).

INTERVENTION AND CONTROL

The EC condition consisted of voucher values that escalated across consecutive negative samples until they reached $30, after which they remained at $30 per negative sample. A positive or a missing sample resulted in no vouchers for that day and reset the value of the next negative same to $9. Two consecutive negatives returned the schedule to the pre-reset value. The EN control condition consisted of vouchers delivered for providing scheduled samples, but independent of smoking status.

MEASUREMENTS

The primary outcome was percentage of biochemically abstinent samples during phase 2. Secondary measures included abstinence status at final study visit, complete abstinence, participants' longest duration of continuous abstinence, cotinine and carbon monoxide (CO) levels and self-reported cigarettes per day.

FINDINGS

EC participants achieved greater smoking abstinence during phase 2 than EN participants [46.7 versus 23.5% negative samples, respectively; odds ratio (OR) = 2.98, 95% confidence interval (CI) = 1.16-7.65, χ(2) 1  (=)  5.0, P = 0.02]. When longest duration of continuous abstinence was compared between experimental groups, EC participants achieved twice the mean duration of continuous abstinence compared with EN participants (3.31 versus 1.68 weeks; t61  = 1.83, P = 0.07). An effect of experimental condition was also seen on mean cotinine levels (42.5 versus 210.6 ng/ml, respectively; F1,61 =5.9, P = 0.02).

CONCLUSIONS

Among opioid-maintained smokers receiving an initial period of daily contingent incentives, a contingent reinforcement intervention appears to be more effective at extending smoking abstinence than noncontingent reinforcement over 10 weeks.

Quitting Without Reporting Having Tried: Findings From a National Survey

Background: It is assumed that smokers rarely quit without ‘attempting’ to do so but the assumption does not appear to have been adequately tested. This study assessed the prevalence of reporting having stopped without reporting a quit attempt and the reasons given for this discrepancy.

Methods: Data were collected from ex-smokers who said they had quit within the last 12 months during nationally representative household surveys conducted monthly between 2006–12.

Results: Of the 1,892 ex-smokers who said that they had quit within the last 12 months, 13.9% (95%CI = 12.4%–15.5%) reported having made no serious quit attempts in that period. In a sub-group of 24 smokers who were asked why they had reported stopping without also reporting an attempt, nine cited inconsistency over timing; three reported stopping without attempting to do so; four did not consider it an ‘attempt’ because they had succeeded; and six had not ruled out the occasional cigarette in the future.

Conclusions: A substantial minority of people who report having stopped in the past year may fail to report a corresponding quit attempt. However, quitting smoking without considering that one has tried appears to be rare. Instead, the most common reason for the discrepancy is inconsistent reporting of the timing of quit attempts.

Rates and predictors of renewed quitting after relapse during a one-year follow-up among primary care patients

BACKGROUND

Most people who quit smoking relapse within a year of quitting. Little is known about what prompts renewed quitting after relapse or how often this results in abstinence.

PURPOSE

This study seeks to identify rates, efficacy, and predictors of renewed quit attempts after relapse during a 1-year follow-up.

METHODS

Primary care patients in a comparative effectiveness trial of smoking cessation pharmacotherapies reported daily smoking every 6-12 weeks for 12 months to determine relapse, renewed quitting, and 12-month abstinence rates.

RESULTS

Of 894 known relapsers, 291 (33%) renewed quitting for at least 24 h, and 99 (34%) of these were abstinent at follow-up. The average latency to renewed quitting was 106 days and longer latencies predicted greater success. Renewed quitting was more likely for older, male, less dependent smokers, and later abstinence was predicted by fewer depressive symptoms and longer past abstinence.

CONCLUSIONS

Renewed quitting is common and produces meaningful levels of cessation.

Health-care interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development

AIMS

This paper provides a concise review of the efficacy, effectiveness and affordability of health-care interventions to promote and assist tobacco cessation, in order to inform national guideline development and assist countries in planning their provision of tobacco cessation support.

METHODS

Cochrane reviews of randomized controlled trials (RCTs) of major health-care tobacco cessation interventions were used to derive efficacy estimates in terms of percentage-point increases relative to comparison conditions in 6-12-month continuous abstinence rates. This was combined with analysis and evidence from 'real world' studies to form a judgement on the probable effectiveness of each intervention in different settings. The affordability of each intervention was assessed for exemplar countries in each World Bank income category (low, lower middle, upper middle, high). Based on World Health Organization (WHO) criteria, an intervention was judged as affordable for a given income category if the estimated extra cost of saving a life-year was less than or equal to the per-capita gross domestic product for that category of country.

RESULTS

Brief advice from a health-care worker given opportunistically to smokers attending health-care services can promote smoking cessation, and is affordable for countries in all World Bank income categories (i.e. globally). Proactive telephone support, automated text messaging programmes and printed self-help materials can assist smokers wanting help with a quit attempt and are affordable globally. Multi-session, face-to-face behavioural support can increase quit success for cigarettes and smokeless tobacco and is affordable in middle- and high-income countries. Nicotine replacement therapy, bupropion, nortriptyline, varenicline and cytisine can all aid quitting smoking when given with at least some behavioural support; of these, cytisine and nortriptyline are affordable globally.

CONCLUSIONS

Brief advice from a health-care worker, telephone helplines, automated text messaging, printed self-help materials, cytisine and nortriptyline are globally affordable health-care interventions to promote and assist smoking cessation. Evidence on smokeless tobacco cessation suggests that face-to-face behavioural support and varenicline can promote cessation.

Community-based navigators for tobacco cessation treatment: a proof-of-concept pilot study among low-income smokers

BACKGROUND

A majority of continuing smokers in the United States are socioeconomically disadvantaged (SED) adults, who are less likely than others to achieve and maintain abstinence despite comparable quit-attempt rates. A national research initiative seeks effective new strategies for increasing successful smoking cessation outcomes among SED populations. There is evidence that chronic and acute stressors may interfere with SED smokers who try to quit on their own. Patient navigators have been effectively used to improve adherence to chronic disease treatment. We designed and have pilot-tested an innovative, non-clinical community-based intervention--smoking cessation treatment navigators--to determine feasibility (acceptance, adherence, and uncontrolled results) for evaluation by randomized controlled trial (RCT).

METHODS

The intervention was developed for smokers among parents and other household members of inner city pre-school for low-income children. Smoking cessation treatment navigators were trained and deployed to help participants choose and adhere to evidence-based cessation treatment (EBCT). Navigators provided empathy, resource-linking, problem-solving, and motivational reinforcement. Measures included rates of study follow-up completion, EBCT utilization, navigation participation, perceived intervention quality, 7-day point abstinence and longest abstinence at three months. Both complete-case and intent-to-treat analyses were performed.

RESULTS

Eighty-five percent of study participants (n = 40) completed final data collection. More than half (53%) enrolled in a telephone quitline and nearly three-fourths (71%) initiated nicotine replacement therapy. Participants completed a mean 3.4 navigation sessions (mean 30 min duration) and gave the intervention very high quality and satisfaction ratings. Self-reported abstinence was comparable to rates for evidence-based cessation strategies (21% among study completers, 18% using intent-to-treat analysis; median 21 days abstinent among relapsers).

CONCLUSIONS

The pilot results suggest that smoking cessation treatment navigators are feasible to study in community settings and are well-accepted for increasing use of EBCT among low-income smokers. Randomized controlled trial for efficacy is warranted.

Effect of pay-for-outcomes and encouraging new providers on national health service smoking cessation services in England: a cluster controlled study

Background

Payment incentives are known to influence healthcare but little is known about the impact of paying directly for achieved outcomes. In England, novel purchasing (commissioning) of National Health Service (NHS) stop smoking services, which paid providers for quits achieved whilst encouraging new market entrants, was implemented in eight localities (primary care trusts (PCTs)) in April 2010. This study examines the impact of the novel commissioning on these services.

Methods

Accredited providers were paid standard tariffs for each smoker who was supported to quit for four and 12 weeks. A cluster-controlled study design was used with the eight intervention PCTs (representing 2,138,947 adult population) matched with a control group of all other (n=64) PCTs with similar demographics which did not implement the novel commissioning arrangements. The primary outcome measure was changes in quits at four weeks between April 2009 and March 2013. A secondary outcome measure was the number of new market entrants within the group of the largest two providers at PCT-level.

Results

The number of four-week quits per 1,000 adult population increased per year on average by 9.6% in the intervention PCTs compared to a decrease of 1.1% in the control PCTs (incident rate ratio 1∙108, p<0∙001, 95% CI 1∙059 to 1∙160). Eighty-five providers held ‘any qualified provider’ contracts for stop smoking services across the eight intervention PCTs in 2011/12, and 84% of the four-week quits were accounted for by the largest two providers at PCT-level. Three of these 10 providers were new market entrants. To the extent that the intervention incentivized providers to overstate quits in order to increase income, caution is appropriate when considering the findings.

Conclusions

Novel commissioning to incentivize achievement of specific clinical outcomes and attract new service providers can increase the effectiveness and supply of NHS stop smoking services.

Predicting use of assistance when quitting: a longitudinal study of the role of quitting beliefs

BACKGROUND

A growing literature addresses the need to reduce cigarette smoking prevalence by increasing the use of assistance when quitting. A key focus is to identify strategies for enhancing adoption of effective interventions in order to increase utilization of evidence-based treatments.

PURPOSE

To examine the effect of beliefs regarding ability to quit on utilization of assistance for smoking cessation. A mediation model was hypothesized whereby the relationship between smoking and use of assistance is influenced by beliefs in ability to quit.

METHODS

The present study includes 474 of 1000 respondents to baseline and follow-up California Smokers Cohort surveys conducted from 2011 to 2013. Included were baseline smokers who reported a 24-h quit attempt at follow-up. Baseline variables were used to predict use of assistance when quitting.

RESULTS

The hypothesized model was tested using a product of coefficients method, controlling for demographics. Greater heaviness of smoking and lower belief in ability to quit were significantly related to use of assistance. Quitting beliefs significantly mediated the relationship between nicotine dependence and use of assistance.

CONCLUSIONS

The present data support a mechanism whereby the effect of smoking rate on treatment utilization is mediated by beliefs in ability to quit. Greater belief in one's ability to quit may represent an obstacle to treatment utilization by reducing the likelihood of successful cessation. The present findings suggest the value of targeted messages from health care providers that normalize the need for assistance when attempting to change an addictive behavior and emphasize the difficulty of quitting without assistance.

Associations between use of pharmacological aids in a smoking cessation attempt and subsequent quitting activity: a population study

BACKGROUND AND AIMS

Modelling the population impact and cost-effectiveness of smoking cessation aids is limited by lack of knowledge about how the use of aids changes across quit attempts. Here we test whether the quit method used in a previous attempt influences (i) future decisions to quit and/or (ii) treatment/s used during subsequent attempts.

DESIGN AND SETTING

Data came from the Smoking Toolkit Study, a United Kingdom national household survey.

PARTICIPANTS AND MEASURES

Smokers (n = 5489) who completed a baseline and 6-month follow-up questionnaire. Respondents were asked what treatment/s, grouped as: prescription medication/s [bupropion, varenicline or nicotine replacement therapy (NRT)], over-the-counter NRT or unaided that they had used in their most recent quit attempt (at baseline), and any use of treatment/s for a quit attempt in the last 3 months at follow-up.

RESULTS

Smokers who had tried to quit at baseline were more likely to report having tried to quit again prior to follow-up [all odds ratios ≥ 2.19 relative to no attempt at baseline, P < 0.001]. Smokers who tried to quit using pharmacological aids were more likely to try to quit again at follow-up (all ORs ≥ 2.19 relative to no attempt at baseline, P < 0.001). Smokers tended to re-try aids used in baseline attempts in future attempts (all ORs ≥ 1.48 relative to no attempt at baseline, P < 0.01).

CONCLUSIONS

Smokers who have tried to quit in the past year are more likely to try to quit again within 6 months regardless of whether they used a pharmacological aid, and they are more likely to re-try aids they had used previously.

A mobile app to aid smoking cessation: preliminary evaluation of SmokeFree28

BACKGROUND

Little is known about the effectiveness of mobile apps in aiding smoking cessation or their validity for automated collection of data on smoking cessation outcomes.

OBJECTIVE

We conducted a preliminary evaluation of SF28 (SF28 is the name of the app, short for SmokeFree28)-an app aimed at helping smokers to be smoke-free for 28 days.

METHODS

Data on sociodemographic characteristics, smoking history, number of logins, and abstinence at each login were uploaded to a server from SF28 between August 2012 and August 2013. Users were included if they were aged 16 years or over, smoked cigarettes at the time of registration, had set a quit date, and used the app at least once on or after their quit date. Their characteristics were compared with data from a representative sample of smokers trying to stop smoking in England. The percentage of users recording 28 days of abstinence was compared with a value of 15% estimated for unaided quitting. Correlations were assessed between recorded abstinence for 28 days and well-established abstinence predictors.

RESULTS

A total of 1170 users met the inclusion criteria. Compared with smokers trying to quit in England, they had higher consumption, and were younger, more likely to be female, and had a non-manual rather than manual occupation. In total, 18.9% (95% CI 16.7-21.1) were recorded as being abstinent from smoking for 28 days or longer. The mean number of logins was 8.5 (SD 9.0). The proportion recording abstinence for 28 days or longer was higher in users who were older, in a non-manual occupation, and in those using a smoking cessation medication.

CONCLUSIONS

The recorded 28-day abstinence rates from the mobile app, SF28, suggest that it may help some smokers to stop smoking. Further evaluation by means of a randomized trial appears to be warranted.

Differential Efficacy of Nicotine Replacement Among Overweight and Obese Women Smokers

INTRODUCTION

Rates of obesity are higher among more dependent smokers and 37%-65% of smokers seeking cessation treatment are overweight or obese. Overweight or obese smokers may possess metabolic and neurobiological features that contribute to difficulty achieving cessation using front-line nicotine replacement products. Attention to factors that facilitate effective cessation treatment in this vulnerable population is needed to significantly reduce mortality risk among overweight and obese smokers.

METHOD

This secondary analysis of 2 large trials of transdermal nicotine replacement in general medical practices evaluated the hypothesis that higher body mass index (BMI) would moderate the efficacy of the nicotine patch. We examined the potential for gender to further moderate the relationship between BMI and treatment efficacy.

RESULTS

In the placebo controlled trial (N = 1,621), 21-mg patch was no more effective than placebo for assisting biochemically verified point prevalence abstinence up to 1 year after quitting for women with higher BMI, but appeared to be effective for men at normal or high BMI (gender × BMI beta = -0.22, p = .004). We did not find differential long-term cessation outcomes among male or female smokers in the 15-mg patch trial (n = 705). However, we observed significantly higher rates of early lapse among women with higher BMI treated with nicotine patch across both trials.

CONCLUSION

These results suggest that increased BMI may affect the efficacy of nicotine patch on reducing risk of early lapse in women. Additional research is needed to explore mechanisms of risk for decreased efficacy of this commonly used cessation aid.

Changes in success rates of smoking cessation treatment associated with take up of a national evidencebased training programme

OBJECTIVE

The English 'stop smoking services' provide behavioural support to some 700,000 smokers annually. Success rates of the services varied considerably before 2010 and had been in slight decline so, to improve performance, a national programme of evidence-based practitioner training was developed to improve knowledge and skills-based competences. This study evaluated whether uptake of the training was associated with improvements in success rates of services.

METHODS

Mean 4-week biochemically verified abstinence rates were compared for 146 (of 151) stop smoking services between 2008-10 (before roll-out of training) and 2011-13 (after roll-out), and the change in success rates for each service was regressed on to the number of practitioners per service trained in a) knowledge (online) and b) skills (face-to-face).

RESULTS

Success rate across all services improved between the two periods (34.1% to 36.5%, p=0.01 1-tailed; 95% CI for difference 0.44-4.48). The magnitude of improvement for each service was associated with the number of practitioners who completed the knowledge and skills training (beta=0.22, p=0.005 1-tailed), and marginally with the number who completed the knowledge training (beta=0.14, p=0.047 1-tailed).

CONCLUSION

English stop smoking services that have greater uptake of a national evidence-based training programme showed greater improvements in success rates.

Facilitators and barriers to effective smoking cessation: counselling services for inpatients from nurse-counsellors' perspectives--a qualitative study

Tobacco use has reached epidemic levels around the World, resulting in a world-wide increase in tobacco-related deaths and disabilities. Hospitalization presents an opportunity for nurses to encourage inpatients to quit smoking. This qualitative descriptive study was aimed to explore nurse-counsellors' perspectives of facilitators and barriers in the implementation of effective smoking cessation counselling services for inpatients. In-depth interviews were conducted with 16 nurses who were qualified smoking cessation counsellors and who were recruited from eleven health promotion hospitals that were smoke-free and located in the Greater Taipei City Area.  Data were collected from May 2012 to October 2012, and then analysed using content analysis based on the grounded theory approach. From nurse-counsellors' perspectives, an effective smoking cessation program should be patient-centred and provide a supportive environment. Another finding is that effective smoking cessation counselling involves encouraging patients to modify their lifestyles. Time constraints and inadequate resources are barriers that inhibit the effectiveness of smoking cessation counselling programs in acute-care hospitals. We suggest that hospitals should set up a smoking counselling follow-up program, including funds, facilities, and trained personnel to deliver counselling services by telephone, and build a network with community smoking cessation resources.

Characterization of long-term users of nicotine replacement therapy: evidence from a national survey

INTRODUCTION

Harm reduction involving partial or complete substitution of cigarettes with nicotine replacement therapy (NRT) is likely to benefit smokers by reducing exposure to carcinogens and by increasing the likelihood of permanent cessation. This article aimed to assess the determinants of short- and long-term NRT use for harm reduction in order to inform interventions aimed at helping smokers struggling to quit to switch to complete NRT substitution.

METHODS

Data were used from the Smoking Toolkit Study, a population-based survey of adults in England aged 16 years and older (n = 9,224). Participants were asked about their sociodemographic characteristics and tobacco use. Attitudes toward smoking were also assessed using questions covering 4 factors: motives, identity, evaluations, and plans.

RESULTS

Concurrent short-term (<3 months) and long-term (≥ 3 months) NRT use was uncommon among smokers at 10.8% (95% confidence interval [CI] = 10.1-11.4) and 5.0% (95% CI = 4.6-5.4), respectively. Long-term NRT users had higher odds of being older, in nonmanual occupations, and more addicted than smokers with short-term or no NRT use (all p < .01). They reported lower odds of attempting to stop and higher odds of exhibiting a positive smoker identity than short-term users (p < .001). Conversely, long-term NRT users had higher odds of having made a recent quit attempt, to have plans to stop, and lower odds of a positive smoker identity than smokers not using NRT (all p < .001).

CONCLUSIONS

While users of NRT for harm-reduction purposes are a heterogeneous group, it appears they are more critical of smoking than never users and tend to positively modulate their behavior, setting them on a path toward cessation.

'Real-world' effectiveness of smoking cessation treatments: a population study

BACKGROUND AND AIMS

There is a need for more evidence on the 'real-world' effectiveness of commonly used aids to smoking cessation from population-level studies. This study assessed the association between abstinence and use of different smoking cessation treatments after adjusting for key potential confounding factors.

DESIGN

Cross-sectional data from aggregated monthly waves of a household survey: the Smoking Toolkit Study.

SETTING

England.

PARTICIPANTS

A total of 10 335 adults who smoked within the previous 12 months and had made at least one quit attempt during that time.

MEASUREMENTS

Participants were classified according to their use of cessation aids in their most recent quit attempt: (i) medication (nicotine replacement therapy, bupropion or varenicline) in combination with specialist behavioural support delivered by a National Health Service Stop Smoking Service; (ii) medication provided by the prescribing health-care professional without specialist behavioural support; (iii) nicotine replacement therapy (NRT) bought over the counter; and (iv) none of these. The main outcome measure was self-reported abstinence up to the time of the survey, adjusted for key potential confounders including tobacco dependence.

FINDINGS

Compared with smokers using none of the cessation aids, the adjusted odds of remaining abstinent up to the time of the survey were 3.25 [95% confidence interval (CI) = 2.05-5.15] greater in users of prescription medication in combination with specialist behavioural support, 1.61 (95% CI = 1.33-1.94) greater in users of prescription medication combined with brief advice and 0.96 (95% CI = 0.81-1.13) in users of NRT bought over the counter.

CONCLUSIONS

After adjusting for major confounding variables such as tobacco dependence, smokers in England who use a combination of behavioural support and pharmacotherapy in their quit attempts have almost three times the odds of success than those who use neither pharmacotherapy nor behavioural support. Smokers who buy nicotine replacement therapy over the counter with no behavioural support have similar odds of success in stopping as those who stop without any aid.

A pilot randomized controlled trial to increase smoking cessation by maintaining National Health Service Stop Smoking Service attendance

OBJECTIVES

The National Health Service (NHS) Stop Smoking Service (SSS) is an extremely cost-effective method of enabling smoking cessation. However, the SSS is only used by a minority of smokers. Developing interventions to maintain service attendance may help to increase the number of quitters. This study pilots an intervention aimed at maintaining attendance by (1) increasing motivation to attend through a booklet providing evidence of service effectiveness and (2) strengthening the link between motivation to attend and attendance through forming an implementation intention.

DESIGN

A factorial randomized controlled trial.

METHODS

A total of 160 newly enrolled smokers at the Surrey NHS SSS were recruited and randomly assigned to one of four conditions: (1) standard care (SC), (2) SC + effectiveness booklet, (3) SC + implementation intention, and (4) SC + effectiveness booklet + implementation intention. The outcome measures included attendance at the SSS and the 4-week quit rate.

RESULTS

The booklet increased service attendance (OR = 2.93, p < .01, 95% CI = 1.45-5.93; Number Needed to Treat = 3.3) but had no impact on the 4-week quit rate (OR = 1.55, 95% CI = 0.75-3.21). Forming an implementation intention had no impact on service attendance or the 4-week quit rate. Attending the service was associated with a higher 4-week quit rate (ρ = 87.52, p < .001).

CONCLUSIONS

Presenting information about the effectiveness of the service improved service attendance. A larger trial now needs to evaluate whether this intervention can also increase the quit rate.

STATEMENT OF CONTRIBUTION

What is already known on this subject? The NHS Stop Smoking Service is an effective yet underused method of enabling smoking cessation. Low uptake levels may be due to smokers' misconception that the service will not improve their chances of quitting successfully. Improving smokers' perceptions of service efficacy may be valuable for maintaining service attendance, and subsequently improving smoking cessation levels in the United Kingdom. What does this study add? This pilot randomized controlled trial is the first to target service attendance rather than cessation levels. The results demonstrate that providing evidence of service efficacy in a simple icon array format can significantly improve service attendance.

Behavioural therapy for smoking cessation: the effectiveness of different intervention types for disadvantaged and affluent smokers

BACKGROUND

Disadvantaged smokers are less likely to be successful when trying to stop smoking than more affluent smokers. In the UK, NHS Stop Smoking Services (SSS) provide a range of pharmacotherapy and behavioural support, delivered by advisors with a range of backgrounds. Whether the types of support provided and who provides it influence differences in quit rates amongst low SES smokers compared with high SES smokers has not previously been examined.

METHODS

202,084 records of smokers in England who attended a NHS Stop Smoking Service between July 2010 and June 2011 were acquired. Smokers were followed-up by services at four weeks post quit date. Multilevel logistic regression models of CO validated quits were employed. Disadvantage was explored through the National Statistics Socio-Economic Classification (NS-SEC) and by eligibility for free prescriptions, an indicator of low income amongst adults aged between 19 and 59 in England.

RESULTS

Affluent smokers were more likely to quit than disadvantaged smokers (OR 1.38 (1.35 to 1.42) for clients who paid for prescriptions compared to those eligible for free prescriptions). 80% of service clients received one-to-one counselling but open group forms of behavioural therapy were more successful (main effect OR 1.26 (1.12 to 1.41)) except amongst some of the most disadvantaged clients (long-term unemployed and prisoners). Closed groups were little deployed and they were not significantly more successful than one-to-one behavioural therapy after controls. Who delivered treatment did make a difference for some clients, with all but the most affluent less likely to be successful if they had been treated by a nurse compared with other types of advisers, including smoking cessation specialists (main effect OR 0.73 (0.65 to 0.83)).

CONCLUSION

This study provides further evidence that disadvantaged smokers find quitting more difficult even when they have attended a smoking cessation programme. The findings suggest that open groups should be promoted, although they may not be as effective as other forms of behavioural therapy for the long-term unemployed or prisoners. Further research is required to explore why most groups of smokers who attended services staffed by nurses were less likely to quit than those who received treatment from other types of advisors.

The prevalence of and factors associated with the use of smoking cessation medication in Korea: trend between 2005-2011

Background

In Korea, nicotine replacement therapy (NRT) has been widely used in government-led, public health center-based smoking cessation services since 2004 and varenicline has become available from 2007 but without reimbursement. In this study which used a series of nationwide cross-sectional surveys in Korea performed from 2005 to 2011, we examined the prevalence of smoking cessation medication use and factors associated with it.

Methods

We analyzed data from the third to fifth waves of Korean National Health and Nutrition Examination Survey (2005–2011). Prevalence of each smoking cessation method use was calculated for each year, and its secular trend was tested by multivariate logistic regression.

Results

Among smokers who made quit attempt during the previous year, 15.7% had used smoking cessation medications,15.3% had used NRT, and 0.7% had used prescription medication. There was a significant increasing trend for NRT use (P<0.001) during the study period, but use of prescription medication did not show any increase over time (P = 0.654) Education on smoking prevention and cessation was associated with smoking cessation medications use (OR 2.08, 95% CI 1.58–2.75).

Conclusions

While the use of NRT has increased over years through government-sponsored smoking cessation programs, use of prescription drugs remained very low and flat probably due to lack of reimbursement. Education of smokers about effective smoking cessation methods and change in reimbursement policy are suggested to stimulate evidence-based smoking cessation practice.

Research priorities for Article 14--demand reduction measures concerning tobacco dependence and cessation

INTRODUCTION

Tobacco dependence treatment (TDT) interventions are often seen as expensive with little impact on the prevalence of tobacco use. However, activities that promote the cessation of tobacco use and support abstinence have an important role in any comprehensive tobacco control program and as such are recognized within Article 14 (A14) of the Framework Convention on Tobacco Control.

OBJECTIVES

To review current evidence for TDT and recommend research priorities that will contribute to more people being helped to stop tobacco use.

METHODS

We used the recommendations within the A14 guidelines to guide a review of current evidence and best practice for promotion of tobacco cessation and TDT, identify gaps, and propose research priorities.

RESULTS

We identified nine areas for future research (a) understanding current tobacco use and the effect of policy on behavior, (b) promoting cessation of tobacco use, (c) implementation of TDT guidelines, (d) increasing training capacity, (e) enhancing population-based TDT interventions, (f) treatment for different types of tobacco use, (g) supply of low-cost pharmaceutical devices/ products, (h) investigation use of nonpharmaceutical devices/ products, and (i) refinement of current TDTs. Specific research topics are suggested within each of these areas and recognize the differences needed between high- and low-/middle-income countries.

CONCLUSIONS

Research should be prioritized toward examining interventions that (a) promote cessation of tobacco use, (b) assist health care workers provide better help to smokers (e.g., through implementation of guidelines and training), (c) enhance population-based TDT interventions, and (d) assist people to cease the use of other tobacco products.

An updated algorithm for choosing among smoking cessation treatments

Although meta-analyses have documented the efficacy of treatments for smoking cessation, and guidelines have outlined treatment elements, few algorithms for choosing among treatments have been described. The current algorithm updates the author's prior algorithm. The major decisions in the algorithm are (a) use a motivational treatment if the smoker is not currently interested in quitting, (b) assess factors that influence choice of treatment, (c) consider both gradual and abrupt cessation, (d) use combined patch+gum/inhaler/lozenge or varenicline as first line medications, (e) use individual, group, Internet, and phone counseling as first line psychosocial treatments, and (f) continue treatment after a lapse or relapse. Further research is needed to determine whether algorithms improve treatment outcomes.

Prevalence and characteristics of smokers interested in internet-based smoking cessation interventions: cross-sectional findings from a national household survey

Background

An accurate and up-to-date estimate of the potential reach of Internet-based smoking cessation interventions (ISCIs) would improve calculations of impact while an understanding of the characteristics of potential users would facilitate the design of interventions.

Objective

This study reports the prevalence and the sociodemographic, smoking, and Internet-use characteristics of smokers interested in using ISCIs in a nationally representative sample.

Methods

Data were collected using cross-sectional household surveys of representative samples of adults in England. Interest in trying an Internet site or “app” that was proven to help with stopping smoking was assessed in 1128 adult smokers in addition to sociodemographic characteristics, dependence, motivation to quit, previous attempts to quit smoking, Internet and handheld computer access, and recent types of information searched online.

Results

Of a representative sample of current smokers, 46.6% (95% CI 43.5%-49.6%) were interested in using an Internet-based smoking cessation intervention. In contrast, only 0.3% (95% CI 0%-0.7%) of smokers reported having used such an intervention to support their most recent quit attempt within the past year. After adjusting for all other background characteristics, interested smokers were younger (OR=0.98, 95% CI 0.97-0.99), reported stronger urges (OR=1.29, 95% CI 1.10-1.51), were more motivated to quit within 3 months (OR=2.16, 95% CI 1.54-3.02), and were more likely to have made a quit attempt in the past year (OR=1.76, 95% CI 1.30-2.37), access the Internet at least weekly (OR=2.17, 95% CI 1.40-3.36), have handheld computer access (OR=1.65, 95% CI 1.22-2.24), and have used the Internet to search for online smoking cessation information or support in past 3 months (OR=2.82, 95% CI 1.20-6.62). There was no association with social grade.

Conclusions

Almost half of all smokers in England are interested in using online smoking cessation interventions, yet fewer than 1% have used them to support a quit attempt in the past year. Interest is not associated with social grade but is associated with being younger, more highly motivated, more cigarette dependent, having attempted to quit recently, having regular Internet and handheld computer access, and having recently searched for online smoking cessation information and support.

Does Use of Nicotine Replacement Therapy While Continuing to Smoke Undermine Cessation?: A Systematic Review

Aims: To review population surveys to assess (a) prevalence of the use of NRT for smoking reduction (SR) and temporary abstinence (TA) and (b) how far this is associated with attempts to stop smoking, smoking cessation and reduction in cigarette consumption.

Methods: An electronic search was undertaken of EMBASE, MEDLINE, Web of Science and PsycINFO. Articles were selected if they (1) assessed whether smokers had used or were currently using NRT for SR and/or TA; (2) involved smokers who had not taken part in a harm reduction programme; and (3) assessed prevalence and/or association of SR and/or TA with reductions in cigarette consumption and/or attempts to stop smoking and/or with smoking cessation. Twelve studies met the inclusion criteria and results were extracted independently by two researchers.

Results: Data were available from five countries (US, UK, Canada, Switzerland and Australia). Between 1% and 23% of smokers reported having ever used NRT for smoking reduction and between 2% and 14% during periods of temporary abstinence. Use of NRT for SR and/or TA was associated with little or no reduction in cigarette consumption. There was some evidence that it was positively associated with attempts to stop smoking and smoking cessation.

Conclusion: In smoking populations use of NRT to aid SR and in situations where smoking is not permitted appears to be having little effect on achieving a reduction in cigarette consumption but does not undermine cessation and may promote it.

Effectiveness of stop-smoking medications: findings from the International Tobacco Control (ITC) Four Country Survey

AIM

To evaluate the population effectiveness of stop-smoking medications while accounting for potential recall bias by controlling for quit attempt recency.

DESIGN

Prospective cohort survey.

SETTING

United Kingdom, Canada, Australia and the United States.

PARTICIPANTS

A total of 7436 adult smokers (18+ years) selected via random digit dialling and interviewed as part of the International Tobacco Control Four Country Survey (ITC-4) between 2002 and 2009. Primary analyses utilized the subset of respondents who participated in 2006 or later (n = 2550).

MEASUREMENTS

Continuous abstinence from smoking for 1 month/6 months.

FINDINGS

Among participants who recalled making a quit attempt within 1 month of interview, those who reported using varenicline, bupropion or nicotine patch were more likely to maintain 6-month continuous abstinence from smoking compared to those who attempted to quit without medication [adjusted odds ratio (OR) 5.84, 95% confidence interval (CI) (2.12-16.12), 3.94 (0.87-17.80), 4.09 (1.72-9.74), respectively]; there were no clear effects for oral NRT use. Those who did not use any medication when attempting to quit tended to be younger, to be racial/ethnic minorities, to have lower incomes and to believe that medications do not make quitting easier.

CONCLUSIONS

Consistent with evidence from randomized controlled trials, smokers in the United Kingdom, Canada, Australia and the United States are more likely to succeed in quit attempts if they use varenicline, bupropion or nicotine patch. Previous population studies that failed to find an effect failed to control adequately for important sources of bias.