Effectiveness of a nurse-managed, lay-led tobacco cessation intervention among ohio appalachian women

Efficacy of a Gender-Relevant Smoking Cessation Intervention Among Women in Brazil: Findings from a Group Randomized Controlled Trial

Background: There is scarcity of smoking cessation programs that take gender into account during its development, implementation, and evaluation. We evaluated the efficacy of a theory-based, culturally, and gender-relevant smoking cessation intervention delivered by Community Health Workers (CHWs) among Brazilian women that augments the smoking cessation program offered through the public health system (PHS). Materials and Methods: A total of 328 women current smokers (100% cigarette smokers) were recruited across 8 towns in a tobacco producing state in Brazil between 2014 and 2017. Four towns were randomly assigned to the intervention (12 home visits by a CHW and a scheduled appointment to attend the smoking cessation program at the PHS) and four towns to the control condition (scheduled appointment to attend the cessation program at the PHS). The primary outcome was self-reported 7-day smoked tobacco abstinence at 7-month follow-up with biochemical verification. Results: Retention at 7-month follow-up was 80.7% (intervention) and 85.1% (control). Using intention-to-treat analysis, abstinence at 7-month-follow-up was 20% in the intervention arm versus 11% in the control arm. Multivariable modeling showed that participants in the intervention arm had 1.88 times the odds of self-reported smoking cessation than control participants after adjustment for depressive symptomatology, self-efficacy, and having someone in the house who smokes. Besides the intervention, only self-efficacy remained significant in the full model as a predictor of cessation. Replication of these analyses using the objective measure of carbon monoxide at a cutoff score of 8 ppm yielded similar results. Conclusions: A theory-based, culturally, and gender-relevant intervention, delivered by CHWs, can successfully promote smoking cessation among women. Clinical Trial Registration No. NCT03845413.

A cluster randomized controlled trial for a multi-level, clinic-based smoking cessation program with women in Appalachian communities: study protocol for the "Break Free" program

BACKGROUND

The cervical cancer burden is high among women living in Appalachia. Cigarette smoking, a cervical cancer risk factor, is also highly prevalent in this population. This project aims to increase smoking cessation among women living in Appalachia by embedding a smoking cessation program within a larger, integrated cervical cancer prevention program.

METHODS

The broader program, the Take CARE study, is a multi-site research collaborative designed to address three risk factors for cervical cancer incidence and mortality: tobacco use, human papillomavirus (HPV) infection, and cervical cancer screening. Break Free is a primary care clinic-based implementation program that aims to promote smoking cessation among female smokers in Appalachia by standardizing clinical practice protocols. Break Free includes: (1) implementation of a tobacco user identification system in the Electronic Health Record, (2) clinic staff and provider training on the Ask, Advise and Refer (AAR) model, (3) provider implementation of AAR to identify and treat women who want to quit smoking within the next 6 months, (4) facilitated access to cessation phone counseling plus pharmacotherapy, and (5) the bundling of Break Free tobacco cessation with HPV vaccination and cervical cancer screening interventions in an integrated approach to cervical cancer prevention. The study spans 35 Appalachian health clinics across 10 healthcare systems. We aim to enroll 51 adult female smokers per health system (total N = 510). Baseline and follow-up data will be obtained from participant (provider and patient) surveys. The primary outcome is self-reported 12-month point prevalence abstinence among enrolled patients. All randomized patients are asked to complete follow-up surveys, regardless of whether they participated in tobacco treatment. Data analysis of the primary aims will follow intent-to-treat methodology. Secondary outcomes will assess program implementation and cost effectiveness.

DISCUSSION

Addressing high tobacco use rates is critical for reducing cervical cancer morbidity and mortality among women living in Appalachia. This study evaluates the implementation and effectiveness of a smoking cessation program in increasing smoking cessation among female smokers. If results demonstrate effectiveness and sustainability, implementation of this program into other health care clinics could reduce both rates of smoking and cervical cancer. Trial registration NCT04340531 (April 9, 2020).

Ongoing tobacco use in women who experience homelessness and unstable housing: A prospective study to inform tobacco cessation interventions and policies

BACKGROUND

Tobacco use is common in people who experience homelessness. However, despite biological differences in use by sex and lower quit rates in women, research in homeless and unstably housed (HUH) women is sparse. We identified correlates of use specific to this population, with the goal of informing tobacco cessation programs tailored for HUH women.

METHODS

We conducted a prospective study among HUH women recruited from San Francisco homeless shelters, street encampments, free meal programs and low-income hotels. Between June 2016 and January 2019, study participants completed six monthly interviews to examine factors associated with tobacco use, defined as urinary cotinine >10 pg/mL or self-reported prior 30-day use.

RESULTS

Among 245 participants, 40% were Black, the median age was 53, 75% currently used tobacco and 89% had ≥one 24-hour quit attempt in the prior year. Tobacco use was more common in women with PTSD (66% vs. 48%) and depression (54% vs. 35%) compared to women without these conditions. Adjusted odds of tobacco use decreased significantly with increasing age (OR_{/5 yrs}: 0.81; 95% CI:0.68, 0.96) and increased with an increasing number of additional substances used (OR: 2.52; 95% CI: 1.88, 3.39).

CONCLUSION

Outside of a treatment setting and within a community-recruited sample population composed of HUH women, the number of additional substances used is a primary correlate of ongoing tobacco use. Tailored cessation interventions that prioritize the issue of multiple substance use, and public health policies that allocate funding to address it, may increase tobacco cessation in this population.

Peer-Delivery of a Gender-Specific Smoking Cessation Intervention for Women Living in Disadvantaged Communities in Ireland We Can Quit2 (WCQ2)-A Pilot Cluster Randomized Controlled Trial

Introduction

We Can Quit” (WCQ) is community-based stop-smoking program delivered by trained community facilitators, based on the socio-ecological framework and developed using a Community-based Participatory Research approach, targeting women living in socioeconomically disadvantaged (SED) areas of Ireland.

Aims and Methods

The We Can Quit2 (WCQ2) pilot trial assessed the feasibility of WCQ. A pragmatic cluster randomized controlled trial with a process evaluation WCQ2, was conducted in four matched pairs of SED districts (8–10 000 women per district). Districts were independently randomized to WCQ (group support + nicotine replacement therapy), or to individual support delivered by health professionals. Participants were adult women smokers interested in quitting, who were living or working in trial districts. Recruitment of districts and 194 women in four waves (49 women per wave); retention at 12 weeks and 6 months; fidelity to intervention delivery and acceptability of trial-related processes were assessed. Validated smoking abstinence at 12-week and 6-month post-intervention was recorded, missing data assumed as continued smoking.

Results

Eight districts were recruited. 125/188 (66.5%) eligible women consented. The 49 women target was reached in wave4. Retention at 12 weeks was (Intervention [I]: 55.4%; Control [C]: 51.7%), at 6 months (I: 47.7%; C: 46.7%). Smoking abstinence at 12 weeks was (I: 23.1%, [95% CI: 14.5 to 34.7]; C: 13%, [95% CI: 6.9 to 24.1]). 83.8% of session activities were delivered. Trial-related processes were acceptable to facilitators. Low literacy was highlighted as a barrier for participants’ acceptability.

Conclusions

WCQ was feasible to deliver by trained facilitators and indicated a positive direction in abstinence rates. Low literacy will need to be addressed in a future trial design.

Implications

This pilot trial showed that a stop-smoking intervention tailored to a group of women smokers living in SED areas which was delivered by trained local women within their local communities was feasible. Furthermore, although not formally compared, more WCQ women were abstinent from smoking at the end of treatment. The results are relevant to enhance the design of a fully powered effectiveness trial, and provide important evidence on the barriers to deliver a tailored smoking cessation service to SED women smokers in Ireland.

Changes in colorectal cancer knowledge and screening intention among Ohio African American and Appalachian participants: The screen to save initiative

African Americans and Appalachians experience greater incidence and mortality rates of colorectal cancer due to factors, such as reduced prevalence of screening. An educational session (the Screen to Save Initiative) was conducted to increase intent to screen for colorectal cancer among African Americans and Appalachians in Ohio. Using a community-based approach, from April to September 2017, 85 eligible participants were recruited in Franklin County and Appalachia Ohio. Participants completed a knowledge assessment on colorectal cancer before and after participating in either an educational PowerPoint session or a guided tour through an Inflatable Colon. Logistic regression models were used to determine what factors were associated with changes in colorectal cancer knowledge and intent to screen for colorectal cancer. The majority (71.79%) of participants gained knowledge about colorectal cancer after the intervention. Multivariate results showed that race (OR = 0.30; 95% CI: 0.11–0.80 for African Americans versus White participants) and intervention type (OR = 5.97; 95% CI: 1.94–18.43 for PowerPoint versus Inflatable Colon) were associated with a change in knowledge. The association between education and intent to screen was marginally statistically significant (OR = 0.42; 95% CI: 0.16–1.13 for college graduate versus not a college graduate). A change in colorectal cancer knowledge was not associated with intent to screen. Future educational interventions should be modified to increase intent to screen and screening for colorectal cancer. Further research with these modified interventions should aim to reduce disparities in CRC among underserved populations while listening to the voices of the communities.

A Multi-level Model to Understand Cervical Cancer Disparities in Appalachia

The Appalachian region experiences higher incidence and mortality due to cervical cancer compared with other regions of the United States. The goal of the Ohio State University Center for Population Health and Health Disparities (CPHHD), called the Community Awareness Resources and Education (CARE) project, was to understand reasons for this disparity. The first wave (2003-2008) of funding included three projects focusing on the known risk factors for cervical cancer, lack of screening, smoking, and infection with human papillomavirus (HPV). On the basis of the results of these projects, the second wave (2011-2017) included four projects, designed to address a multi-level model of factors contributing to cervical disparities in Appalachia. The results of these projects were then used to refine a multi-level model that explains cervical cancer disparities in Appalachia. Future funded projects will take these multi-level explanations for cervical disparities and focus on implementation science strategies to reduce the burden of cervical cancer morbidity and mortality in Appalachia.See all articles in this Special Collection Honoring Paul F. Engstrom, MD, Champion of Cancer Prevention.

Smoking-Cessation Interventions in Appalachia: A Systematic Review and Meta-Analysis

CONTEXT

Appalachia, a socioeconomically disadvantaged rural region in the eastern U.S., has one of the nation's highest prevalence rates of smoking and some of the poorest health outcomes. Effective interventions that lower smoking rates in Appalachia have great potential to reduce health disparities and preventable illness; however, a better understanding of effective interventions is needed.

EVIDENCE ACQUISITION

This review included trials that evaluated the impact of smoking-cessation programs among populations living in Appalachia. The search was carried out on October 9, 2018 and comprised the Cochrane Central Register of Controlled Trials, Medline, Embase, and Scopus for academic journal articles published in English, with no date restrictions. After preliminary screening, potentially relevant full-text articles were independently reviewed by the authors with a Cohen's κ of 0.72, leading to the final inclusion of 9 articles.

EVIDENCE SYNTHESIS

Eligible studies were assessed qualitatively for heterogeneity and risk of bias. Six of the 9 included studies had extractable data related to dichotomous smoking status and reported a measure of association suitable for inclusion in a meta-analysis. For those 6 studies, the pooled RR and pooled OR were estimated using random effects models, with an I² index demonstrating substantial heterogeneity. A funnel plot of the 6 trials appeared relatively symmetric.

CONCLUSIONS

Participation in smoking-cessation interventions increased the probability of smoking abstinence among Appalachian smokers by an estimated 2.33 times (pooled RR=2.33, 95% CI=1.03, 5.25, p=0.04). Given the low number of studies, their substantial heterogeneity, and high risk of bias, the evidence of the effectiveness of smoking-cessation interventions in Appalachia must be interpreted with caution.

Development of a gender-relevant tobacco cessation intervention for women in Brazil-an intervention mapping approach to planning

The purpose of this article is to describe the development of a theory-based, culturally and gender-relevant Community Health Worker (CWH)-led tobacco cessation intervention for low-income Brazilian women who augments the tobacco cessation program offered through the public health system using Intervention Mapping (IM). We began with the establishment of a network of representatives from different segments of society followed by comprehensive needs assessments. We then established a logical planning process that was guided by a theoretical framework (Social Cognitive Theory) and existing evidence-based tobacco cessation programs, taking into account socio-political context of a universal health care system. Given the gender-relevance of our intervention and the importance of social support in tobacco cessation among women, we chose an intervention that would be delivered within the public health system but augmented by CHWs that would be trained in behavior change by researchers. One of major advantages of utilizing IM was that decisions were made in a transparent and supportive manner with involvement of all stakeholders throughout the process. Despite the fact that this process is very taxing on researchers and the health care system as it takes time, resources and negotiation skills, it builds trust and promotes ownership which can assure sustainability.

Smoking reduction interventions for smoking cessation

BACKGROUND

The standard way most people are advised to stop smoking is by quitting abruptly on a designated quit day. However, many people who smoke have tried to quit many times and may like to try an alternative method. Reducing smoking behaviour before quitting could be an alternative approach to cessation. However, before this method can be recommended it is important to ensure that abrupt quitting is not more effective than reducing to quit, and to determine whether there are ways to optimise reduction methods to increase the chances of cessation.

OBJECTIVES

To assess the effect of reduction-to-quit interventions on long-term smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, Embase and PsycINFO for studies, using the terms: cold turkey, schedul*, cut* down, cut-down, gradual*, abrupt*, fading, reduc*, taper*, controlled smoking and smoking reduction. We also searched trial registries to identify unpublished studies. Date of the most recent search: 29 October 2018.

SELECTION CRITERIA

Randomised controlled trials in which people who smoked were advised to reduce their smoking consumption before quitting smoking altogether in at least one trial arm. This advice could be delivered using self-help materials or behavioural support, and provided alongside smoking cessation pharmacotherapies or not. We excluded trials that did not assess cessation as an outcome, with follow-up of less than six months, where participants spontaneously reduced without being advised to do so, where the goal of reduction was not to quit altogether, or where participants were advised to switch to cigarettes with lower nicotine levels without reducing the amount of cigarettes smoked or the length of time spent smoking. We also excluded trials carried out in pregnant women.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison (no smoking cessation treatment, abrupt quitting interventions, and other reduction-to-quit interventions) and carried out meta-analyses where appropriate, using a Mantel-Haenszel random-effects model. We also extracted data on quit attempts, pre-quit smoking reduction, adverse events (AEs), serious adverse events (SAEs) and nicotine withdrawal symptoms, and meta-analysed these where sufficient data were available.

MAIN RESULTS

We identified 51 trials with 22,509 participants. Most recruited adults from the community using media or local advertising. People enrolled in the studies typically smoked an average of 23 cigarettes a day. We judged 18 of the studies to be at high risk of bias, but restricting the analysis only to the five studies at low or to the 28 studies at unclear risk of bias did not significantly alter results.We identified very low-certainty evidence, limited by risk of bias, inconsistency and imprecision, comparing the effect of reduction-to-quit interventions with no treatment on cessation rates (RR 1.74, 95% CI 0.90 to 3.38; I2 = 45%; 6 studies, 1599 participants). However, when comparing reduction-to-quit interventions with abrupt quitting (standard care) we found evidence that neither approach resulted in superior quit rates (RR 1. 01, 95% CI 0.87 to 1.17; I2 = 29%; 22 studies, 9219 participants). We judged this estimate to be of moderate certainty, due to imprecision. Subgroup analysis provided some evidence (P = 0.01, I2 = 77%) that reduction-to-quit interventions may result in more favourable quit rates than abrupt quitting if varenicline is used as a reduction aid. Our analysis comparing reduction using pharmacotherapy with reduction alone found low-certainty evidence, limited by inconsistency and imprecision, that reduction aided by pharmacotherapy resulted in higher quit rates (RR 1. 68, 95% CI 1.09 to 2.58; I2 = 78%; 11 studies, 8636 participants). However, a significant subgroup analysis (P < 0.001, I2 = 80% for subgroup differences) suggests that this may only be true when fast-acting NRT or varenicline are used (both moderate-certainty evidence) and not when nicotine patch, combination NRT or bupropion are used as an aid (all low- or very low-quality evidence). More evidence is likely to change the interpretation of the latter effects.Although there was some evidence from within-study comparisons that behavioural support for reduction to quit resulted in higher quit rates than self-help resources alone, the relative efficacy of various other characteristics of reduction-to-quit interventions investigated through within- and between-study comparisons did not provide any evidence that they enhanced the success of reduction-to-quit interventions. Pre-quit AEs, SAEs and nicotine withdrawal symptoms were measured variably and infrequently across studies. There was some evidence that AEs occurred more frequently in studies that compared reduction using pharmacotherapy versus no pharmacotherapy; however, the AEs reported were mild and usual symptoms associated with NRT use. There was no clear evidence that the number of people reporting SAEs, or changes in withdrawal symptoms, differed between trial arms.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that neither reduction-to-quit nor abrupt quitting interventions result in superior long-term quit rates when compared with one another. Evidence comparing the efficacy of reduction-to-quit interventions with no treatment was inconclusive and of low certainty. There is also low-certainty evidence to suggest that reduction-to-quit interventions may be more effective when pharmacotherapy is used as an aid, particularly fast-acting NRT or varenicline (moderate-certainty evidence). Evidence for any adverse effects of reduction-to-quit interventions was sparse, but available data suggested no excess of pre-quit SAEs or withdrawal symptoms. We downgraded the evidence across comparisons due to risk of bias, inconsistency and imprecision. Future research should aim to match any additional components of multicomponent reduction-to-quit interventions across study arms, so that the effect of reduction can be isolated. In particular, well-conducted, adequately-powered studies should focus on investigating the most effective features of reduction-to-quit interventions to maximise cessation rates.

Adaptação transcultural para o Brasil e confiabilidade da Smoking Cessation Counseling

Resumo Objetivo Realizar a tradução e adaptação transcultural da escala “Smoking Cessation Counseling” para a língua portuguesa e o contexto brasileiro e avaliar a confiabilidade da versão adaptada. Métodos Pesquisa metodológica de adaptação transcultural que empregou as seguintes fases: tradução, síntese das traduções, retrotradução, comitê de experts e pré-teste. No pré-teste, foi verificado a confiabilidade da escala por meio da análise da consistência interna (Alfa de Cronbach). Resultados Na tradução e retrotradução, as discordâncias relacionaram-se ao uso de sinônimos e nenhum dos itens foi modificado em relação ao seu entendimento e sim na adequação para a realidade brasileira. A avaliação do comitê de experts demonstrou que a retrotradução manteve as equivalências semântica e idiomática. A consistência interna da SCC mostrou-se excelente (0,916). Conclusão A escala adaptada tem equivalência cultural com o instrumento original e evidências de alta confiabilidade. Demais propriedades psicométricas estão sendo investigadas.

Testing the feasibility of a system-based approach to deliver a smoking cessation and food nudging intervention at food pantry sites

Food-insecure adults disproportionately experience high cardiovascular risk. Guided by the Feeding America recommendations, we tested the feasibly of a system-based approach to address the cardiovascular risk behaviors of current smoking and dietary choice at food distribution sites. Food pantries affiliated with the Food Bank of Delaware organization (N = 14) were invited to take part. Pantries who agreed solicited personnel within the pantry (i.e., staff, active volunteers) to become trained as quit-smoking coaches and/or food environment "nudging" interventionists. After training, trained personnel implemented the evidence-based treatments. Across a 6-month observation period, quit coaches reported each month on the number of (a) enrolled food pantry clients, (b) total quit-smoking sessions scheduled and attended, and (c) the smoking status of clients who attended the final, third session. Trained evaluators visited participating pantries once per month across the observation period to assess adherence to nudging guidelines. One in five (21%; 3/14) invited pantries participated in the study, and five personnel were trained to deliver intervention components. Across the observation period, quit coaches reported that 86 new smoking cessation clients were enrolled, 228 quit coaching sessions were scheduled, and 187 attended (82% attendance rate). Smoking cessation rates were estimated at 19%-36%. A 100% adherence to the food nudging approach was observed. These data demonstrate the feasibility of a system-based approach to build the capacity of food distribution sites and personnel to deliver smoking cessation quit-coaching and food nudging interventions on-site.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions in adults. To establish whether nursing-delivered smoking cessation interventions are more effective than no intervention; are more effective if the intervention is more intensive; differ in effectiveness with health state and setting of the participants; are more effective if they include follow-ups; are more effective if they include aids that demonstrate the pathophysiological effect of smoking.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register and CINAHL in January 2017.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Fifty-eight studies met the inclusion criteria, nine of which are new for this update. Pooling 44 studies (over 20,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention increased the likelihood of quitting (RR 1.29, 95% CI 1.21 to 1.38); however, statistical heterogeneity was moderate (I² = 50%) and not explained by subgroup analysis. Because of this, we judged the quality of evidence to be moderate. Despite most studies being at unclear risk of bias in at least one domain, we did not downgrade the quality of evidence further, as restricting the main analysis to only those studies at low risk of bias did not significantly alter the effect estimate. Subgroup analyses found no evidence that high-intensity interventions, interventions with additional follow-up or interventions including aids that demonstrate the pathophysiological effect of smoking are more effective than lower intensity interventions, or interventions without additional follow-up or aids. There was no evidence that the effect of support differed by patient group or across healthcare settings.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that behavioural support to motivate and sustain smoking cessation delivered by nurses can lead to a modest increase in the number of people who achieve prolonged abstinence. There is insufficient evidence to assess whether more intensive interventions, those incorporating additional follow-up, or those incorporating pathophysiological feedback are more effective than one-off support. There was no evidence that the effect of support differed by patient group or across healthcare settings.

Effectiveness of Two Community Health Worker Models of Tobacco Dependence Treatment Among Community Residents of Ohio Appalachia

INTRODUCTION

Community health workers (CHW) may be effective in the delivery of tobacco dependence treatment with underserved groups. This study evaluated two evidence-based CHW models of treatment. It was hypothesized that smokers assigned to a CHW face-to-face condition would have higher abstinence at 12-month posttreatment than smokers enrolled in CHW referral to a state-sponsored quitline condition. Intrapersonal and treatment-related factors associated with abstinence at 12 months were determined.

METHODS

A group-randomized trial was conducted with residents of 12 Ohio Appalachian counties with counties (n = 6) randomized to either a CHW face-to-face (F2F) or CHW quitline (QL) condition. Both conditions included behavioral counseling and free nicotine replacement therapy for 8 weeks. Follow-up data were collected at 3-, 6-, and 12-month posttreatment. Biochemically validated abstinence at 12 months served as the primary outcome.

RESULTS

Seven hundred and seven participants were enrolled (n = 353 CHWF2F; n = 354 CHWQL). Baseline sample characteristics did not differ by condition. Using an intent-to-treat analysis (85.4% retention at 12 months), 13.3% of CHWF2F participants were abstinent at 12 months, compared to 10.7% of CHWQL members (OR = 1.28; 95% confidence interval [CI] = 0.810, 2.014; p = .292). No differences in abstinence were noted at 3 or 6 months by condition. Age, marital status, and baseline levels of cigarette consumption, depressive symptoms, and self-efficacy for quitting in positive settings were associated with abstinence, as was counseling dose during treatment.

CONCLUSIONS

This research adds to the body of science evaluating the effectiveness of CHW models of tobacco dependence treatment. Both approaches may offer promise in low-resource settings and underserved regions.

IMPLICATIONS

This 12-county community-based group-randomized trial in Ohio Appalachia adds to the body of science evaluating the effectiveness of CHW models of tobacco dependence treatment. Both CHW approaches may offer promise in low-resource settings and underserved regions. These findings are useful to national, state, and local tobacco control agencies, as they expand delivery of preventive health care services postadoption of the Affordable Care Act in the United States.

Combined pharmacotherapy and behavioural interventions for smoking cessation

BACKGROUND

Both behavioural support (including brief advice and counselling) and pharmacotherapies (including nicotine replacement therapy (NRT), varenicline and bupropion) are effective in helping people to stop smoking. Combining both treatment approaches is recommended where possible, but the size of the treatment effect with different combinations and in different settings and populations is unclear.

OBJECTIVES

To assess the effect of combining behavioural support and medication to aid smoking cessation, compared to a minimal intervention or usual care, and to identify whether there are different effects depending on characteristics of the treatment setting, intervention, population treated, or take-up of treatment.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register in July 2015 for records with any mention of pharmacotherapy, including any type of NRT, bupropion, nortriptyline or varenicline.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials evaluating combinations of pharmacotherapy and behavioural support for smoking cessation, compared to a control receiving usual care or brief advice or less intensive behavioural support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

Search results were prescreened by one author and inclusion or exclusion of potentially relevant trials was agreed by two authors. Data was extracted by one author and checked by another.The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Fifty-three studies with a total of more than 25,000 participants met the inclusion criteria. A large proportion of studies recruited people in healthcare settings or with specific health needs. Most studies provided NRT. Behavioural support was typically provided by specialists in cessation counselling, who offered between four and eight contact sessions. The planned maximum duration of contact was typically more than 30 minutes but less than 300 minutes. Overall, studies were at low or unclear risk of bias, and findings were not sensitive to the exclusion of any of the six studies rated at high risk of bias in one domain. One large study (the Lung Health Study) contributed heterogeneity due to a substantially larger treatment effect than seen in other studies (RR 3.88, 95% CI 3.35 to 4.50). Since this study used a particularly intensive intervention which included extended availability of nicotine gum, multiple group sessions and long term maintenance and recycling contacts, the results may not be comparable with the interventions used in other studies, and hence it was not pooled in other analyses. Based on the remaining 52 studies (19,488 participants) there was high quality evidence (using GRADE) for a benefit of combined pharmacotherapy and behavioural treatment compared to usual care, brief advice or less intensive behavioural support (RR 1.83, 95% CI 1.68 to 1.98) with moderate statistical heterogeneity (I² = 36%).The pooled estimate for 43 trials that recruited participants in healthcare settings (RR 1.97, 95% CI 1.79 to 2.18) was higher than for eight trials with community-based recruitment (RR 1.53, 95% CI 1.33 to 1.76). Compared to the first version of the review, previous weak evidence of differences in other subgroup analyses has disappeared. We did not detect differences between subgroups defined by motivation to quit, treatment provider, number or duration of support sessions, or take-up of treatment.

AUTHORS' CONCLUSIONS

Interventions that combine pharmacotherapy and behavioural support increase smoking cessation success compared to a minimal intervention or usual care. Updating this review with an additional 12 studies (5,000 participants) did not materially change the effect estimate. Although trials differed in the details of their populations and interventions, we did not detect any factors that modified treatment effects apart from the recruitment setting. We did not find evidence from indirect comparisons that offering more intensive behavioural support was associated with larger treatment effects.

Adherence to Tobacco Dependence Treatment Among HIV-Infected Smokers

High prevalence of tobacco use and low success in quitting remain significant problems for reducing disease burden among HIV-infected persons. This study's purpose was to examine participant responsiveness and tobacco dependence treatment adherence and their influences on tobacco abstinence among HIV-infected patients. This non-randomized study included HIV-infected smokers 18 years of age or older, who smoked at least 5 cigarettes per day, and had an interest in quitting smoking in the next 30 days. HIV-infected smokers (n = 247) received a 12-week tobacco dependence treatment intervention that included pharmacotherapy and telephone counseling. Younger age and non-White race were associated with lower adherence to pharmacotherapy. Younger age, non-White race, and increased monthly binge drinking were associated with lower adherence to telephone counseling. High participant responsiveness was associated with adherence to pharmacotherapy, counseling, and abstinence. Development and testing of interventions to improve adherence to evidence-based tobacco dependence treatment is warranted.

Smoking cessation interventions for smokers with current or past depression

BACKGROUND

Individuals with current or past depression are often smokers who are more nicotine dependent, more likely to suffer from negative mood changes after nicotine withdrawal, and more likely to relapse to smoking after quitting than the general population, which contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit smoking.

OBJECTIVES

To evaluate the effectiveness of smoking cessation interventions, with and without specific mood management components, in smokers with current or past depression.

SEARCH METHODS

In April 2013, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, other reviews, and asked experts for information on trials.

SELECTION CRITERIA

Criteria for including studies in this review were that they had to be randomised controlled trials (RCTs) comparing smoking cessation interventions in adult smokers with current or past depression. Depression was defined as major depression or depressive symptoms. We included studies where subgroups of participants with depression were identified, either pre-stated or post hoc. The outcome was abstinence from smoking after six months or longer follow-up. We preferred prolonged or continuous abstinence and biochemically validated abstinence where available.

DATA COLLECTION AND ANALYSIS

When possible, we estimated pooled risk ratios (RRs) with the Mantel-Haenszel method (fixed-effect model). We also performed subgroup analyses, by length of follow-up, depression measurement, depression group in study, antidepressant use, published or unpublished data, format of intervention, level of behavioural support, additional pharmacotherapy, type of antidepressant medication, and additional nicotine replacement therapy (NRT).

MAIN RESULTS

Forty-nine RCTs were included of which 33 trials investigated smoking cessation interventions with specific mood management components for depression. In smokers with current depression, meta-analysis showed a significant positive effect for adding psychosocial mood management to a standard smoking cessation intervention when compared with standard smoking cessation intervention alone (11 trials, N = 1844, RR 1.47, 95% CI 1.13 to 1.92). In smokers with past depression we found a similar effect (13 trials, N = 1496, RR 1.41, 95% CI 1.13 to 1.77). Meta-analysis resulted in a positive effect, although not significant, for adding bupropion compared with placebo in smokers with current depression (5 trials, N = 410, RR 1.37, 95% CI 0.83 to 2.27). There were not enough trial data to evaluate the effectiveness of fluoxetine and paroxetine for smokers with current depression. Bupropion (4 trials, N = 404, RR 2.04, 95% CI 1.31 to 3.18) might significantly increase long-term cessation among smokers with past depression when compared with placebo, but the evidence for bupropion is relatively weak due to the small number of studies and the post hoc subgroups for all the studies. There were not enough trial data to evaluate the effectiveness of fluoxetine, nortriptyline, paroxetine, selegiline, and sertraline in smokers with past depression.Twenty-three of the 49 trials investigated smoking cessation interventions without specific components for depression. There was heterogeneity between the trials which compared psychosocial interventions with standard smoking cessation counselling for both smokers with current and past depression. Therefore, we did not estimate a pooled effect. One trial compared nicotine replacement therapy (NRT) versus placebo in smokers with current depression and found a positive, although not significant, effect (N = 196, RR 2.64, 95% CI 0.93 to 7.45). Meta-analysis also found a positive, although not significant, effect for NRT versus placebo in smokers with past depression (3 trials, N = 432, RR 1.17, 95% CI 0.85 to 1.60). Three trials compared other pharmacotherapy versus placebo and six trials compared other interventions in smokers with current or past depression. Due to heterogeneity between the interventions of the included trials we did not estimate pooled effects.

AUTHORS' CONCLUSIONS

Evidence suggests that adding a psychosocial mood management component to a standard smoking cessation intervention increases long-term cessation rates in smokers with both current and past depression when compared with the standard intervention alone. Pooled results from four trials suggest that use of bupropion may increase long-term cessation in smokers with past depression. There was no evidence found for the use of bupropion in smokers with current depression. There was not enough evidence to evaluate the effectiveness of the other antidepressants in smokers with current or past depression. There was also not enough evidence to evaluate the group of trials that investigated interventions without specific mood management components for depression, including NRT and psychosocial interventions.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise people to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group specialized Register and CINAHL in June 2013.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed-effect model and reported the outcome as a risk ratio (RR) with a 95% confidence interval (CI).

MAIN RESULTS

Forty-nine studies met the inclusion criteria. Pooling 35 studies (over 17,000 participants) comparing a nursing intervention to a control or to usual care, we found the intervention to increase the likelihood of quitting (RR 1.29; 95% CI 1.20 to 1.39). In a subgroup analysis the estimated effect size was similar for the group of seven studies using a particularly low intensity intervention but the confidence interval was wider. There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized adults also showed evidence of benefit. Eleven studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Six studies of nurse counselling on smoking cessation during a screening health check or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.

AUTHORS' CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses, with reasonable evidence that intervention is effective. The evidence for an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow-up.

Treatment adherence in a lay health adviser intervention to treat tobacco dependence

Lay health advisers (LHAs) are increasingly used to deliver tobacco dependence treatment, especially with low-socioeconomic status (SES) populations. More information is needed about treatment adherence to help interpret mixed evidence of LHA intervention effectiveness. This study examined adherence to behavioral counseling and nicotine patches in an LHA intervention with 147 Ohio Appalachian female daily smokers. Participants were randomly selected from clinics and randomized to the intervention condition of a randomized controlled trial. Overall, 75.5% of participants received all seven planned LHA visits, 29.3% used patches for >7 weeks and approximately half received high average ratings on participant responsiveness. Depressive symptoms and low nicotine dependence were associated with lower patch adherence while high poverty-to-income ratio was associated with high responsiveness. Compared with those with fewer visits, participants who received all visits were more likely to be abstinent (22.5 versus 2.8%, P=0.026) or have attempted quitting (85.0 versus 47.4%, P=0.009) at 3 months. High participant responsiveness was associated with 12-month abstinence. LHA interventions should focus on improving adherence to nicotine patches and managing depression because it is an independent risk factor for low adherence.

Perceived risk of cervical cancer in Appalachian women

OBJECTIVE

To examine perceptions of cervical cancer risk in elevated-risk Appalachians.

METHODS

Appalachian women (n=571) completed interviews examining self-regulation model factors relevant to perceived risk of cervical cancer.

RESULTS

Women with good/very good knowledge of cervical cancer, greater worry, and history of sexually transmitted infection had higher odds of rating their perceived risk as somewhat/much higher than did other women. Former smokers, compared to never smokers, had lower risk perceptions.

CONCLUSIONS

Self-regulation model factors are important to understanding perceptions of cervical cancer risk in underserved women. The relationship of smoking and worry to perceived risk may be a target for intervention.

Combined pharmacotherapy and behavioural interventions for smoking cessation

BACKGROUND

Both behavioural support (including brief advice and counselling) and pharmacotherapies (including nicotine replacement therapy (NRT), varenicline and bupropion) are effective in helping people to stop smoking. Combining both treatment approaches is recommended where possible, but the size of the treatment effect with different combinations and in different settings and populations is unclear.

OBJECTIVES

To assess the effect of combining behavioural support and medication to aid smoking cessation, compared to a minimal intervention or usual care, and to identify whether there are different effects depending on characteristics of the treatment setting, intervention, population treated, or take-up of treatment.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register in July 2012 for records with any mention of pharmacotherapy, including any type of NRT, bupropion, nortriptyline or varenicline.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials evaluating combinations of pharmacotherapy and behavioural support for smoking cessation, compared to a control receiving usual care or brief advice or less intensive behavioural support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

Search results were prescreened by one author and inclusion or exclusion of potentially relevant trials was agreed by both authors. Data was extracted by one author and checked by the other.The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model.

MAIN RESULTS

Forty-one studies with a total of more than 20,000 participants met the inclusion criteria. A large proportion of studies recruited people in healthcare settings or with specific health needs. Most studies provided NRT. Behavioural support was typically provided by specialists in cessation counselling, who offered between four and eight contact sessions. The planned maximum duration of contact was typically more than 30 minutes but less than 300 minutes. Overall, studies were at low or unclear risk of bias, and findings were not sensitive to the exclusion of any of the three studies rated at high risk of bias in one domain. One large study (the Lung Health Study) contributed heterogeneity due to a substantially larger treatment effect than seen in other studies (RR 3.88, 95% CI 3.35 to 4.50). Since this study used a particularly intensive intervention which included extended availability of nicotine gum, multiple group sessions and long term maintenance and recycling contacts, the results may not be comparable with the interventions used in other studies, and hence it was not pooled in other analyses. Based on the remaining 40 studies (15,021 participants) there was good evidence for a benefit of combination pharmacotherapy and behavioural treatment compared to usual care or brief advice or less intensive behavioural support (RR 1.82, 95% CI 1.66 to 2.00) with moderate statistical heterogeneity (I² = 40%). The pooled estimate for 31 trials that recruited participants in healthcare settings (RR 2.06, 95% CI 1.81 to 2.34) was higher than for eight trials with community-based recruitment (RR 1.53, 95% CI 1.33 to 1.76). Pooled estimates were lower in a subgroup of trials where the behavioural intervention was provided by specialist counsellors versus trials where counselling was linked to usual care (specialist: RR 1.73, 95% CI 1.55 to 1.93, 28 trials; usual provider: RR 2.41, 95% CI 1.91 to 3.02, 8 trials) but this was largely attributable to the small effect size in two trials using specialist counsellors where the take-up of the planned intervention was low, and one usual provider trial with alarge effect. There was little indirect evidence that the relative effect of an intervention differed according to whether participants in a trial were required to be motivated to make a quit attempt or not. There was only weak evidence that studies offering more sessions had larger effects and there was not clear evidence that increasing the duration of contact increased the effect, but there was more evidence of a dose-response relationship when analyses were limited to trials where the take-up of treatment was high.

AUTHORS' CONCLUSIONS

Interventions that combine pharmacotherapy and behavioural support increase smoking cessation success compared to a minimal intervention or usual care. Further trials would be unlikely to change this conclusion. We did not find strong evidence from indirect comparisons that offering more intensive behavioural support was associated with larger treatment effects but this could be because intensive interventions are less likely to be delivered in full.

Does the use of ingredients added to tobacco increase cigarette addictiveness?: a detailed analysis

The possibility that ingredients added to tobacco contribute to the addictiveness of cigarette smoking was evaluated by comparing cessation rates of smokers of traditional blended cigarettes to those of smokers of flue-cured cigarettes. Such a comparison is a valid means of assessing cigarette ingredients as traditional blended cigarettes contain ingredients (>20), whereas flue-cured cigarettes contain no or very few ingredients. Separate analysis of 108 treatment groups and 108 control groups from randomized clinical trials of nicotine replacement therapy (NRT) were performed by multiple logistic regressions. The results of these analyses demonstrated slightly higher quit rates for smokers of blended cigarettes (OR = 1.90, 95% CI 1.70-2.13 and OR = 1.32, 95% CI 1.14-1.53 for treatment and control groups, respectively). The control groups were also investigated using classification tree analysis from which no difference in quit rates were observed for smokers of either type of cigarette. Further analyses showed that studies that utilized a high level of psychological support in conjunction with NRT produced at least a two-fold increase in quit rates compared to studies that utilized a low level of psychological support. It was also demonstrated that there is a large difference when results were reported by sustained abstinence compared to point prevalence. Additional meta-analyses found the pooled OR for NRT treatment to be in exact agreement with a recent review that assessed the effectiveness of NRT. Overall these results strongly suggest that ingredients used in the manufacture of traditional blended cigarettes do not increase the inherent addictiveness of cigarettes.

Perceptions of smoking cessation programs in rural Appalachia

OBJECTIVES

To identify perspectives on smoking cessation programs in Appalachian Kentucky, a region with particularly high smoking rates and poor health outcomes.

METHODS

Insufficient existing research led us to conduct 12 focus groups (smokers and nonsmokers) and 23 key informant interviews.

RESULTS

Several findings previously not described in this high-risk population include (1) transition from pro-tobacco culture toward advocacy for tobacco cessation approaches, (2) region-specific challenges to program access, and (3) strong and diverse social influences on cessation.

CONCLUSIONS

To capitalize on changes from resistance to support for smoking cessation, leaders should incorporate culturally appropriate programs and characteristics identified here.

A pilot test of a combined tobacco dependence treatment and lung cancer screening program

Lung cancer screening with computed tomography has demonstrated a significant reduction in mortality. While these findings are important for the lung cancer research field, the most important risk factor for lung cancer, i.e. smoking, should not be ignored. We performed a pilot study to examine the feasibility of delivering a program that included both tobacco dependence treatment and lung cancer screening. The objectives of this study were to: (1) estimate the proportion of smokers who complied with a 12-week treatment protocol that included both tobacco dependence treatment and lung cancer screening, (2) obtain preliminary estimates of abstinence and quit attempts at 4 and 6 months, and (3) obtain preliminary estimates of the cognitive social health information processing (C-SHIP) constructs and how they change following the intervention. In this randomized pilot study, 18 volunteers completed a 12-week protocol: half received the tobacco dependence treatment program before a CT scan (BCT) and the other received the CT scan first, followed by the treatment program (ACT). The treatment protocol included both nurse-delivered telephone counseling and either nicotine replacement therapy or varenicline. Only one person did not complete all follow-up evaluations. At 4 months post enrollment, the carbon monoxide confirmed quit rates were 33.3% in the BCT arm and 22.2% in the ACT arm (27.8% overall), and all but one had made a 24-h attempt to quit. At 6 months the confirmed abstinence decreased to 22.1% in the BCT arm and 11.1% in the ACT arm (16.7% overall), and 72.2% of participants had made a 24-h quit attempt. These preliminary results suggest that it might be better to deliver treatment before the screening test. Future randomized trials with a larger sample size are needed to confirm these findings.

Enabling distributed electronic research data collection for a rural Appalachian tobacco cessation study

Tobacco use is increasingly prevalent among vulnerable populations, such as people living in rural Appalachian communities. Owing to limited access to a reliable internet service in such settings, there is no widespread adoption of electronic data capture tools for conducting community-based research. By integrating the REDCap data collection application with a custom synchronization tool, the authors have enabled a workflow in which field research staff located throughout the Ohio Appalachian region can electronically collect and share research data. In addition to allowing the study data to be exchanged in near-real-time among the geographically distributed study staff and centralized study coordinator, the system architecture also ensures that the data are stored securely on encrypted laptops in the field and centrally behind the Ohio State University Medical Center enterprise firewall. The authors believe that this approach can be easily applied to other analogous study designs and settings.

Characteristics of rural Appalachian women who enroll in a tobacco dependence treatment clinical trial

INTRODUCTION

Clinical trials are needed to inform evidence-based smoking cessation approaches in rural and Appalachian women, but trial enrollment in these groups is sparse. Little is known about factors associated with enrollment of Appalachian women in tobacco dependence treatment randomized clinical trials (RCT). We report a comparison of Appalachian women enrolling in a tobacco dependence treatment RCT to those declining and identify correlates to enrollment.

METHODS

Smokers identified during a cervical health-related survey among Ohio Appalachian women were invited to enroll in a tobacco dependence treatment RCT incorporating behavioral counseling and nicotine replacement. Women who agreed to enroll were compared to women who declined in terms of sociodemographic, health- and smoking-related measures.

RESULTS

The mean age of women sampled was 35.1 years. Women reported daily consumption of 1-10 (39%), 11-20 (46%), or >20 (16%) cigarettes. In a multivariable logistic regression model adjusting for age and nicotine dependence, pros of smoking most outweighing cons (odds ratio [OR] = 0.11, 95% confidence intervals [CI] = 0.03, 0.39), ≥3 prior quit attempts versus 1 attempt (OR = 0.18, 95% CI = 0.06, 0.59), and not having health insurance (OR = 0.29, 95% CI = 0.12, 0.77) were associated with decreased odds of RCT enrollment.

CONCLUSIONS

Rural Appalachian women who enrolled in a tobacco dependence treatment RCT differed significantly in motivational and cognitive attitudes toward smoking, insurance status, and number of prior quit attempts, as compared to those who did not enroll. Techniques that foster motivation to quit smoking as a means of boosting RCT enrollment are discussed.

Development of a Web-based tobacco cessation educational program for pediatric nurses and respiratory therapists

BACKGROUND

Nurses can be effective in providing advice and counseling to tobacco-using parents of hospitalized pediatric patients. However, lack of training in effective interventions is a barrier to the incorporation of tobacco cessation interventions into routine practice. This article describes the development and evaluation of a web-based tobacco cessation educational program aimed at pediatric nurses and respiratory therapists.

METHOD

The program was developed with input from four focus groups of nurses, respiratory therapists, and educators. The interactive training program was evaluated by 33 nurses and 17 respiratory therapists employed at a children's hospital.

RESULTS

After completing the program, participants reported a significant change in their knowledge, attitudes, perceived barriers, and self-efficacy toward providing tobacco cessation interventions to their patients' parents.

CONCLUSION

The results of the evaluation of the program were extremely promising, and further investigation is warranted.