Characteristics and smoking cessation outcomes of patients returning for repeat tobacco dependence treatment

Comparison between success rates for smokers re-treated by a smokers' clinic and success rates for smokers treated for the first time

AIMS

To compare success rates and characteristics of smokers treated a second time by a smokers' clinic with success rates of their first treatment.

DESIGN

Retrospective cohort study.

SETTING

Tobacco Dependence Treatment clinic in Prague, Czech Republic, between 2005 and 2017.

PARTICIPANTS

A total of 5225 smokers treated either once (n = 5006, single treatment sample, SS) or also second time (n = 219, re-treated sample, RS), on average 4.47 years after the first visit.

INTERVENTION

Smokers received intensive treatment of tobacco dependence with pharmacotherapy options. Outcomes were evaluated after 1 year. In case of failure or relapse, participants could undergo re-treatment in the same setting at least 1 year after the start of the first treatment.

MEASUREMENTS

Twelve-month self-reported continuous abstinence; CO-validated (≤ 6 parts per million); number of visits; type of pharmacotherapy; mental health history; Fagerström Test for Cigarette Dependence; time between first and second treatment.

RESULTS

The abstinence rate in the SS was 34.8% [95% confidence interval (CI) = 33.4%, 36.1%] and in the RS was 37% (95% CI = 30.6%, 43.8%) and 39.7% (95% CI = 33.2%, 45.5%) for their first and second treatments, respectively. The samples were comparable on smoking and socio-demographic characteristics and pharmacotherapy used, but the RS in the second treatment had a higher prevalence of diagnosed mental health disorder at 39.3% (95% CI = 32.8%; 46.1%) compared with 23.7% (95% CI = 22.5%; 24.9%) in the SS. Participants who initiated their second quit attempt 1 to 2 years after the first one were less successful than those who initiated their second quit attempt later (25 versus 43%; P < 0.05). The results of the first treatment cycle were not found to be a reliable predictor for outcomes of the second cycle of treatment in univariate or multivariate logistic regression (odds ratio = 1.35, 95% CI = 0.70-2.63, P = 0.373).

CONCLUSION

In Prague, Czech Republic, smokers re-attending stop-smoking treatment more than 2 years after their previous quit attempt appear to achieve similar success rates to those being treated for the first time.

Factors Predicting Client Re-Enrollment in Tobacco Cessation Services in a State Quitline

Introduction

Quitlines are an integral part of tobacco treatment programs and reach groups of smokers who have a wide range of barriers to cessation. Although tobacco dependence is chronic and relapsing, little research exists on factors that predict the likelihood of clients re-engaging and reconnecting with quitlines for treatment. The objective of this study was to describe factors that predict the re-enrollment of clients in Arizona’s state quitline.

Methods

This was a retrospective analysis of data collected from clients (N = 49,284) enrolled in the Arizona Smokers’ Helpline from January 2011 through June 2016. We used logistic regression to analyze predictors of re-enrollment in services after controlling for theoretically relevant baseline variables (eg, nicotine dependence, smokers in the home) and follow-up variables (eg, program use, quit outcome).

Results

Compared with clients who reported being quit after their first enrollment, clients who reported not being quit were almost 3 times as likely to re-enroll (odds ratio = 2.89; 95% confidence interval, 2.54–3.30). Other predictors were having a chronic condition or a mental health condition, greater nicotine dependence, and lower levels of social support. Women and clients not having other smokers in the home were more likely to re-enroll than were men and clients not living with other smokers.

Conclusion

Understanding baseline and in-program factors that predict client-initiated re-enrollment can help quitlines tailor strategies to proactively re-engage clients who may have difficulty maintaining long-term abstinence.

Scientific Evidence for the Addictiveness of Tobacco and Smoking Cessation in Tobacco Litigation

Smokers keep smoking despite knowing that tobacco claims many lives, including their own and others’. What makes it hard for them to quit smoking nonetheless? Tobacco companies insist that smokers choose to smoke, according to their right to self-determination. Moreover, they insist that with motivation and willpower to quit smoking, smokers can easily stop smoking. Against this backdrop, this paper aims to discuss the addictive disease called tobacco use disorder, with an assessment of the addictiveness of tobacco and the reasons why smoking cessation is challenging, based on neuroscientific research. Nicotine that enters the body via smoking is rapidly transmitted to the central nervous system and causes various effects, including an arousal response. The changes in the nicotine receptors in the brain due to continuous smoking lead to addiction symptoms such as tolerance, craving, and withdrawal. Compared with other addictive substances, including alcohol and opioids, tobacco is more likely to cause dependence in smokers, and smokers are less likely to recover from their dependence. Moreover, the thinning of the cerebral cortex and the decrease in cognitive functions that occur with aging accelerate with smoking. Such changes occur in the structure and functions of the brain in proportion to the amount and period of smoking. In particular, abnormalities in the neural circuits that control cognition and decision-making cause loss of the ability to exert self-control and autonomy. This initiates nicotine dependence and the continuation of addictive behaviors. Therefore, smoking is considered to be a behavior that is repeated due to dependence on an addictive substance, nicotine, instead of one’s choice by free will.

Using Diverse Communication Strategies to Re-Engage Relapsed Tobacco Quitline Users in Treatment, New York State, 2014

Introduction

Most smoking cessation programs lack strategies to reach relapsed participants and encourage a new quit attempt. We used a multimodal intervention to encourage past quitline registry participants to recycle into services.

Methods

We invited 3,510 past quitline participants back to quitline services, using messages consecutively delivered through Interactive Voice Response (IVR), followed by postcard and email reminders, 2 Short Messaging Services (SMS) texts, and a final cycle of IVR. The primary study outcome was recycling into a new quitline-assisted quit attempt. We used statistical analyses to assess rates and predictors of recycling (socioeconomic, health- and tobacco-related variables) with study participants and compared the study sample with registry participants not selected for the study (comparison group).

Results

Quitline services were re-initiated by 12.2% of the intervention sample and 1.9% of the comparison group (z = 6.03, P < .001, effect size of 0.44). Most re-enrollments were done via direct IVR-transfer to the quitline. Predictors of re-enrollment were age (odds ratio [OR] = 1.45 for every 10 years of age; 95% confidence interval [CI], 1.34–1.57), number of years smoking (OR = 1.27; 95% CI, 1.18–1.36), and reporting cancer (OR = 2.32; 95% CI, 1.47–3.68) or chronic obstructive pulmonary disease (OR = 1.55; 95% CI, 1.16–2.10). Living with other smokers was correlated with a lower chance of recycling into treatment (OR = 0.72; 95% CI, 0.57–0.91).

Conclusion

Recycling previous quitline participants using a proactive, IVR-based intervention is effective in reinitiating quitline-assisted quit attempts. Older, long-term smokers reporting chronic conditions are more likely than younger smokers to re-engage in quitline support when these methods are used.

Smokers with behavioral health comorbidity should be designated a tobacco use disparity group

Smokers with co-occurring mental illness or substance use disorders are not designated a disparity group or priority population by most national public health and tobacco control groups. These smokers fulfill the criteria commonly used to identify groups that merit special attention: targeted marketing by the tobacco industry, high smoking prevalence rates, heavy economic and health burdens from tobacco, limited access to treatment, and longer durations of smoking with less cessation. A national effort to increase surveillance, research, and treatment is needed. Designating smokers with behavioral health comorbidity a priority group will bring much-needed attention and resources. The disparity in smoking rates among persons with behavioral health issues relative to the general population will worsen over time if their needs remain unaddressed.

Maternal cigarette smoke exposure contributes to glucose intolerance and decreased brain insulin action in mice offspring independent of maternal diet

BACKGROUND

Maternal smoking leads to intrauterine undernutrition and is associated with low birthweight and higher risk of offspring obesity. Intrauterine smoke exposure (SE) may alter neuroendocrine mediators regulating energy homeostasis as chemicals in cigarette smoke can reach the fetus. Maternal high-fat diet (HFD) consumption causes fetal overnutrition; however, combined effects of HFD and SE are unknown. Thus we investigated the impact of combined maternal HFD and SE on adiposity and energy metabolism in offspring.

METHOD

Female Balb/c mice had SE (2 cigarettes/day, 5 days/week) or were sham exposed for 5 weeks before mating. Half of each group was fed HFD (33% fat) versus chow as control. The same treatment continued throughout gestation and lactation. Female offspring were fed chow after weaning and sacrificed at 12 weeks.

RESULTS

Birthweights were similar across maternal groups. Faster growth was evident in pups from SE and/or HFD dams before weaning. At 12 weeks, offspring from HFD-fed dams were significantly heavier than those from chow-fed dams (chow-sham 17.6±0.3 g; chow-SE 17.8±0.2 g; HFD-sham 18.7±0.3 g; HFD-SE 18.8±0.4 g, P<0.05 maternal diet effect); fat mass was significantly greater in offspring from chow+SE, HFD+SE and HFD+sham dams. Both maternal HFD and SE affected brain lactate transport. Glucose intolerance and impaired brain response to insulin were observed in SE offspring, and this was aggravated by maternal HFD consumption.

CONCLUSION

While maternal HFD led to increased body weight in offspring, maternal SE independently programmed adverse health outcomes in offspring. A smoke free environment and healthy diet during pregnancy is desirable to optimize offspring health.

Varenicline for tobacco dependence: panacea or plight?

INTRODUCTION

This review examines the postmarketing experience with varenicline, including case reports, newer clinical trials and secondary analyses of large clinical datasets.

AREAS COVERED

Varenicline has been shown to be an effective treatment in a broad range of tobacco users with medical, behavioral and diverse demographic characteristics. Recent studies finding excellent safety and efficacy in groups of smokers with diseases including chronic obstructive pulmonary disease are particularly encouraging and call for increased use of this medication for smoking cessation. Despite case reports of serious neuropsychiatric symptoms in patients taking varenicline, including changes in behavior and mood, causality has not been established. Recent analyses of large datasets from clinical trials have not demonstrated that varenicline is associated with more depression or suicidality than other treatments for smoking cessation.

EXPERT OPINION

Now that additional clinical trials in specific populations and observational studies on treatment-seeking smokers outside of clinical trials have been published, we can be confident that varenicline remains the most efficacious monotherapy for smoking cessation and that its side-effect profile remains good. The risk-to-benefit ratio of receiving varenicline to quit smoking must include the increased chances of quitting smoking and avoiding the sizeable risks of smoked-caused disease and death that remain if tobacco addiction is not properly treated.

Lower quit rates among African American and Latino menthol cigarette smokers at a tobacco treatment clinic

BACKGROUND

Lower rates of smoking cessation and higher rates of lung cancer in African American (AA) smokers may be linked to their preference for mentholated cigarettes.

AIM

This study assessed the relationship between menthol smoking, race/ethnicity and smoking cessation among a diverse cohort of 1688 patients attending a specialist smoking cessation service.

RESULTS

46% of the patients smoked mentholated cigarettes, but significantly more AA (81%) and Latino (66%) patients than Whites (32%) smoked menthols. AA and Latino menthol smokers smoked significantly fewer cigarettes per day (CPD) than non-menthol smokers (15.7 vs. 20.3, for AA, and 17.0 vs. 22.1, for Latinos), with no differences among White menthol and non-menthol smokers. At 4-week follow up, AA, Latino and White non-menthol smokers had similar quit rates (54%, 50% and 50% respectively). In contrast, among menthol smokers, AAs and Latinos had lower quit rates (30% and 23% respectively) compared with Whites (43%, p < 0.001). AA and Latino menthol smokers had significantly lower odds of quitting [odds ratio (OR) = 0.34; 95% CI = 0.17, 0.69 for AA, and OR = 0.32; 95% CI = 0.16, 0.62 for Latinos] than their non-menthol counterparts. At 6-month follow up, a similar trend was observed for the race/ethnicity subgroups, with AA menthol smokers having half the odds of being abstinent compared with AA non-menthol smokers (OR = 0.48; 95% CI = 0.25, 0.9).

CONCLUSIONS

Despite smoking fewer CPD, AA and Latino menthol smokers experience reduced success in quitting as compared with non-menthol smokers within the same ethnic/racial groups.

Long-term cigarette smoke exposure increases uncoupling protein expression but reduces energy intake

The appetite suppressing effect of tobacco is a major driver of smoking behaviour; however few studies have addressed the effects of chronic cigarette smoke exposure (SE) on appetite, body weight and metabolic markers. We compared the effects of SE to equivalent food restriction (pair-fed, PF), against sham-exposure, on body weight, adiposity, cytokines, and levels of uncoupling proteins (UCP) and brain neuropeptide Y (NPY) in male Balb/C mice. SE rapidly induced anorexia, and after 12 weeks, SE and PF groups were lighter than control animals (23.9+/-0.2, 25.5+/-0.5, 26.8+/-0.4 g respectively, P<0.05). White fat (WAT) masses were reduced by both SE and PF. Plasma leptin and insulin were reduced in SE mice; insulin was further reduced by PF. Brown fat UCP1 and 3 mRNA were increased in SE animals relative to PF animals, possibly promoting thermogenesis. WAT mRNA expression of the inflammatory cytokine, TNFalpha was doubled by SE, while IL-6 was reduced by both PF and SE. Hypothalamic NPY content was increased by SE (89.3+/-2.8 vs. 75.9+/-2.4 ng control, P<0.05), and more by PF (100.7+/-3.4 ng, P<0.05 compared to both groups), suggesting disinhibition due to reduced adipose derived leptin. In contrast to equivalent food restriction, cigarette smoke exposure reduced body weight and total hypothalamic NPY, and increased thermogenesis and markers of inflammation. The suppressed hypothalamic NPY and increased UCPs may contribute to the spontaneous hypophagia and extra weight loss in SE animals. These findings contribute to our understanding of weight loss in smoking-related lung disease, suggesting a greater impact than that due to anorexia alone.

Cost-effectiveness of pharmacogenetic testing to tailor smoking-cessation treatment

We evaluated the cost-effectiveness of a range of smoking cessation drug treatments, including varenicline, transdermal nicotine (TN), bupropion and the use of a genetic test to choose between TN and bupropion. We performed Monte Carlo simulation with sensitivity analysis, informing analyses with published estimates of model parameters and current prices for genetic testing and smoking-cessation therapy. The primary outcomes were discounted life-years (LY) and lifetime tobacco-cessation treatment costs. In the base case, varenicline treatment was optimal with an ICER, compared to bupropion, of $2985/LY saved. In sensitivity analyses, varenicline was in all cases (and bupropion in most cases) admissible; only under favorable assumptions was the genetically tailored approach competitive. Our data suggest that an untailored approach of treatment with either bupropion or varenicline is a cost-effective form of tobacco dependence treatment, but a tailored approach for selecting between TN and bupropion can be cost-effective under plausible assumptions.