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

Smartphone application versus written material for smoking reduction and cessation in individuals undergoing low-dose computed tomography (LDCT) screening for lung cancer: a phase II open-label randomised controlled trial

Background

Counseling, nicotine replacement, and other cessation medications have been proven effective in smoking cessation. The wide-scale adoption of smartphones and other mobile devices has opened new possibilities for scalable and personalized smoking cessation approaches. The study investigated whether a smartphone application would be more effective than written material for smoking cessation and reduction in smoking in individuals undergoing low-dose computed tomography (LDCT) screening for lung cancer (NCT05630950).

Methods

This randomized controlled trial enrolled 201 current smokers with marked smoking history (smoked ≥15 cigarettes/day for ≥25 years or smoked ≥10 cigarettes/day for ≥30 years). Participants were stratified by age and pack-years and randomized in 1:1 fashion to the developed smartphone application (experimental arm) or written material (standard of care). All the subjects underwent LDCT screening. Self-reported smoking cessation at three and six months were the primary endpoints of the study. The smoking-related secondary endpoints of the study were the percentage of individuals who had reduced the number of smoked cigarettes/d from the baseline.

Findings

Between Nov 18, 2022, and Apr 14, 2023, 201 patients were screened at Oulu University Hospital, Finland, of whom all were randomly assigned to smartphone application (n = 101) or written cessation material (n = 100); 200 were included in the full analysis set. Study arms were well-balanced for all the studied demographic factors. Subjects randomized to the smartphone application arm had significantly higher rates for self-reported smoking cessation at three (19.8 versus 7.1%; OR 3.175 CI 95% 1.276-7.899) and six months (18.8 versus 7.1%; OR 2.847 CI 95% 1.137-7.128). In the experimental arm, individuals with a frequent use of the application had a higher chance for smoking cessation at three (p < 0.001) and six months (p = 0.003).

Interpretation

The study showed that the developed smartphone application increases the likelihood for smoking cessation in individuals undergoing lung cancer LDCT screening.

Funding

AstraZeneca, Roche, and Cancer Foundation Finland.

The impact of chronic disease diagnoses on smoking behavior change and maintenance: Evidence from China

INTRODUCTION

Managing chronic diseases and tobacco use is a formidable challenge in low- and middle-income countries (LMICs) with limited health literacy and access to quality healthcare. This study examines the empirical evidence from China, utilizing quasi-experimental approaches to assess the causal effect of chronic disease diagnoses on smoking behavior.

METHODS

Employing the diagnosis of chronic disease in the older cohorts of the population as a natural experiment, this study utilizes recent advancements in difference-in-difference estimation methods (CS-DID) to investigate the effect of a diagnosis on smoking behavior. Self-reported new diagnoses of conditions ascertained chronic disease diagnoses. CS-DID was run using the study sample from the 2011 to 2018 waves of the China Health and Retirement Longitudinal Study, comparing results with traditional two-way fixed effects and event-study models.

RESULTS

The average treatment effect (ATT) of CS-DID is slightly greater than the effects reported using conventional difference-in-difference methods. We found that diagnoses of cancer, heart disease, and stroke reduced smoking rates by 16% (95% CI: -24 - -8), smoking intensity by 0.31 (95% CI: -0.46 - -0.15), and had lasting impacts on smoking cessation behavior (one wave after diagnosis ATT= -0.17; 95% CI: -0.34 - -0.00, two waves after diagnosis ATT= -0.17; 95% CI: -0.37-0.03). A diagnosis of a mild chronic disease, such as hypertension, diabetes, asthma, chronic lung disease, liver disease, or gastric disease, had more negligible and transient effects on smoking behavior.

CONCLUSIONS

Efforts to enhance smoking cessation in middle-aged and elderly patients with chronic diseases are crucial to improving health outcomes. The 'teachable moment' of chronic disease diagnosis should be seized to provide smoking cessation assistance to achieve the goal of healthy ageing.

Pharmacotherapy for Treatment of Tobacco Use Disorder

Tobacco use disorder (TUD), the leading cause of preventable deaths in the United States, disproportionally impacts those with psychiatric disorders. There are multiple first-line, U.S. Food and Drug Administration-approved pharmacotherapy options for the treatment of TUD. The current review focuses on these medications, underlining practical tips to improve cessation rates, while emphasizing a harm reduction and patient-centered approach to treatment. [Journal of Psychosocial Nursing and Mental Health Services, 61(11), 6-9.].

Early Assessment of Impact of Increased Value Added Tax on Smoking Behaviors and Financing among Adult Smokers in Saudi Arabia

Background

Cigarette smoking has been identified as most perilous risk factor for several health ailments. Increased price may discourage smoking habits. There is limited literature available on impact of price rise on smoking behaviors in Saudi Arabia, which is the fourth largest importer of cigarettes and this study assessed the impact of tax increase (in 2020) on smoking behaviors.

Methods

A cross-sectional survey was carried out between July 2021 and December 2021.i.e.one year after new value added tax (VAT) system came into force. Data was collected with 14-item pretested questionnaire from 721 adult smokers in Al-Jouf Region of Saudi Arabia selected through stratified cluster ransom sampling. We measured effects of tax increase on smoking behaviors, its impact on decision to quit and perceived health improvements as outcome variables.

Results

Nearly 40% of the respondents said that increased price lead them to smoke less number of cigarettes per day (P=0.000), decreased smoking improved their health in terms of breathing capacity, mood, ability to exercise and sleep in hierarchy. 67.4% of the participants are currently thinking of quitting smoking due to increased prices (P=0.001) and logistic regression models identified reduced smoking due to tax rise (Odds=5.68), improvement in health (Odds=2.94) and excess spending of above 20% (Odds=1.72) significantly associated with intentions to quit smoking.

Conclusion

Increased price of cigarettes due to VAT significantly decreased smoking behaviors and has impact on smokers' decision to quit smoking. Future studies needed to assess the long-term effect of increased tax on smoking behaviors and its relapse.

Randomised controlled trial testing effectiveness of feedback about lung age or exhaled CO combined with very brief advice for smoking cessation compared to very brief advice alone in North Macedonia: findings from the Breathe Well group

INTRODUCTION

In 2019, smoking prevalence in North Macedonia was one of the world's highest at around 46% in adults. However, access to smoking cessation treatment is limited and no co-ordinated smoking cessation programmes are provided in primary care.

METHODS

We conducted a three parallel-armed randomised controlled trial (n = 1368) to investigate effectiveness and cost-effectiveness of lung age (LA) or exhaled carbon monoxide (CO) feedback combined with very brief advice (VBA) to prompt smoking cessation compared with VBA alone, delivered by GPs in primary care in North Macedonia. All participants who decided to attempt to quit smoking were advised about accessing smoking cessation medications and were also offered behavioural support as part of the "ACT" component of VBA. Participants were aged ≥ 35 years, smoked ≥ 10 cigarettes per day, were recruited from 31 GP practices regardless of motivation to quit and were randomised (1:1:1) using a sequence generated before the start of recruitment. The primary outcome was biochemically validated 7-day point prevalence abstinence at 4 weeks (wks). Participants and GPs were not blinded to allocation after randomisation, however outcome assessors were blind to treatment allocation.

RESULTS

There was no evidence of a difference in biochemically confirmed quitting between intervention and control at 4wks (VBA + LA RR 0.90 (97.5%CI: 0.35, 2.27); VBA + CO RR 1.04 (97.5%CI: 0.44, 2.44)), however the absolute number of quitters was small (VBA + LA 1.6%, VBA + CO 1.8%, VBA 1.8%). A similar lack of effect was observed at 12 and 26wks, apart from in the VBA + LA arm where the point estimate was significant but the confidence intervals were very wide. In both treatment arms, a larger proportion reported a reduction in cigarettes smoked per day at 4wks (VBA + LA 1.30 (1.10, 1.54); VBA + CO 1.23 (1.03, 1.49)) compared with VBA. The point estimates indicated a similar direction of effect at 12wks and 26wks, but differences were not statistically significant. Quantitative process measures indicated high fidelity to the intervention delivery protocols, but low uptake of behavioural and pharmacological support. VBA was the dominant intervention in the health economic analyses.

CONCLUSION

Overall, there was no evidence that adding LA or CO to VBA increased quit rates. However, a small effect cannot be ruled out as the proportion quitting was low and therefore estimates were imprecise. There was some evidence that participants in the intervention arms were more likely to reduce the amount smoked, at least in the short term. More research is needed to find effective ways to support quitting in settings like North Macedonia where a strong smoking culture persists.

TRIAL REGISTRATION

The trial was registered at http://www.isrctn.com (ISRCTN54228638) on the 07/09/2018.

Feasibility of a Stop Smoking Program for Healthcare Workers in an Italian Hospital: Econometric Analysis in a Total Worker Health® Approach

Background

Over 20% of healthcare workers (HCWs) are active smokers. Smoking is a targeted issue for workplace health promotion (WHP) programs.

Objective

Our study aims to evaluate the effectiveness of the Stop Smoking Promotion (SSP) intervention, a 6-hour training course for HCWs, which took place from May 2018 to July 2019.

Methods

We compared HCWs who successfully quit smoking (n = 15) to those who did not (n = 25) in terms of Sickness Absence Days (SADs). Moreover, we conducted an econometric analysis by calculating the return on investment and implementing a break-even analysis.

Findings

Among the 40 enrolled workers, a success rate of 37.5% was observed after a span of over two years from the SSP intervention (with nurses and physicians showed the best success rate). Overall, participants showed a noticeable absenteeism reduction after the SSP intervention, with a reduction rate of 85.0% in a one-year period. The estimated ROI for the hospital was 1.90, and the break-even point was 7.85. In other words, the organization nearly doubled its profit from the investment, and the success of at least eight participants balanced costs and profits.

Conclusion

Our pilot study confirms that WHP programs are simple and cost-saving tools which may help improve control over the smoking pandemic in healthcare settings.

Smoking behavior change and risk of cardiovascular disease incidence and mortality in patients with type 2 diabetes mellitus

BACKGROUND

We aimed to examine the association between smoking behavior change and risk of cardiovascular disease (CVD) incidence and mortality in patients with type 2 diabetes mellitus (T2DM).

METHODS

This study used nationwide data from the Korean National Health Insurance System and included 349,137 T2DM patients who smoked. Smoking behavior changes were defined with five groups: quitters, reducers I (≥ 50% reduction), reducers II (20-50% reduction), sustainers (± 20%), and increasers (≥ 20% increase) from the number of cigarettes/day at the baseline.

RESULTS

During a median follow-up of 5.1 years, 6,514 cases of myocardial infarction (MI) (1.9%), 7,837 cases of ischemic stroke (IS) (2.2%), and 14,932 deaths (4.3%) were identified. Quitters had a significantly decreased risk of MI (adjusted hazard ratio [aHR] 0.80, 95% CI 0.75-0.86) and IS (aHR 0.80, 95% CI 0.75-0.85) compared to sustainers, whereas reducers did not have a significant association with the risk of MI (aHR 1.03, 95% CI 0.94-1.13) and IS (aHR 1.00, 95% CI 0.92-1.08) in reducer I. Quitters also had a lower all-cause and CVD mortality than sustainers.

CONCLUSIONS

Smoking cessation was associated with decreased CVD incidence, and all-cause and CVD mortality among T2DM patients. However, smoking reduction was not associated with decreased risks for these.

Long-term follow-up of tobacco cessation intervention in a dental setting: A randomized trial

Aims and Objectives

Tobacco dependence is widely prevalent and a harmful chronic disorder. Achieving long-term tobacco abstinence is an important public health goal. This study aims to assess the long-term effectiveness of moderate-intensity treatment for tobacco cessation in the dental clinic setting.

Materials and Methods

Out of 1206 subjects registered to the Tobacco cessation clinic (TCC) during this time period, only 999 of them completed the 1-year follow-up period. The mean age was 45.9 ± 9 years. Six hundred and three (60.3%) of these subjects were male and 396 (39.6%) of them were females. Five hundred and fifty-eight (55.8%) used smoking tobacco and 441 (44.1%) used smokeless tobacco. Patients received tailored behavioral counseling, educational material, and pharmacotherapy consisting of nicotine replacement therapy (NRT) and\or NON-NRT. Patients were monitored by phone or clinic visits for 11 months.

Results

Outcomes assessed were complete abstinence, harm reduction (>50% reduction), no change and lost to follow-up. At the end of 12 months the tobacco quit rate was180 (18%), tobacco reduction >50% was 342 (34.2%), no change 415 (41.5%) and relapse 62 (6.2%).

Conclusions

Our study has identified adequate quit-rates in a cohort of dental patients attending a hospital-based TCC.

Effect of quitting immediately vs progressively on smoking cessation for smokers at emergency department in Hong Kong: A posteriori analysis of a randomized controlled trial

BACKGROUND

A progressive approach to quitting smoking has been a popular strategy for motivating smokers who are reluctant to quit. However, whether this strategy can effectively achieve complete cessation or is as successful as quitting immediately remains unresolved. This study aimed to determine whether quitting immediately or progressively was more effective in achieving complete cessation among smokers in Hong Kong who presented at emergency departments.

METHODS AND FINDINGS

A posteriori analysis of a single-blinded, multicenter, randomized controlled trial was performed. The original trials was conducted at emergency departments of four major acute hospitals in different districts of Hong Kong. In total, 1571 smokers 18 years or older who presented at 4 major emergency departments between July 4, 2015 and March 17, 2017 were randomized into an intervention group (n = 787) and a control group (n = 784). The intervention group received brief advice (about 1 minute) and could choose their own quit schedules (immediate or progressive, labeled QI and QP, respectively). The control group received a smoking cessation leaflet. Follow-ups were conducted at 1, 3, 6 and 12 months. The primary outcomes, by intention-to-treat, were biochemically validated abstinence between the QI subgroup and control group; between the QP subgroup and control group, and between the QI subgroup and QP subgroup at 6 months. After the propensity sore matching, the biochemically validated abstinence was statistically significantly higher in the QI subgroup than the control group at 6 months (12.1% vs 3.4%, P = 0.003; adjusted odds ratio [aOR] 4.34, 95% CI 1.63-11.52) and higher in the QP subgroup than the control group at 6 months (9.8% vs 3.4%, P = 0.02; aORs 2.95, 95% CI: 1.04-8.39). No statistically significant differences of biochemically validated abstinence at both 6 month (12.1% vs 9.8%, P = 0.49; aORs 1.50, 95% CI: 0.71-3.19) were found in the comparison between QI and QP subgroups.

CONCLUSIONS

This study demonstrates that the strategy of quitting progressively is effective, especially for smokers who lack motivation or find it difficult to quit. If adopted routinely, such an approach can help achieve a greater level of smoking abstinence in the community.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02660957.

Tobacco Harm Reduction with Vaporised Nicotine (THRiVe): A Feasibility Trial of Nicotine Vaping Products for Smoking Cessation Among People Living with HIV

People living with HIV (PLHIV) have high rates of tobacco smoking. Nicotine vaping products (NVPs) may promote tobacco smoking cessation and/or harm reduction. This study aimed to trial the feasibility of NVPs for promoting tobacco smoking cessation among PLHIV. The Tobacco Harm Reduction with Vaporised Nicotine (THRiVe) study was a mixed-methods trial among 29 PLHIV who used tobacco daily. Participants trialled a 12-week intervention of NVPs. This study reports descriptive analyses of quantitative data on tobacco abstinence and associated adverse events. Short-term abstinence (7-day point prevalence; i.e., no tobacco use for 7 days) was achieved by 35% of participants at Week 12 and 31% reported short-term abstinence at Week 24. Sustained medium-term abstinence (8 weeks' abstinence) was achieved by 15% of participants at Week 12 and 31% at Week 24. Most adverse events were mild. NVPs may represent a feasible and potentially effective short-to-medium term tobacco smoking cessation aid and/or harm reduction strategy among PLHIV.

Outcomes of a Comprehensive Mobile Smoking Cessation Program With Nicotine Replacement Therapy in Adult Smokers: Pilot Randomized Controlled Trial

BACKGROUND

Cigarette smoking remains the leading cause of preventable illness and death, underscoring ongoing need for evidence-based solutions. Pivot, a US Clinical Practice Guideline-based mobile smoking cessation program, comprises a personal carbon monoxide breath sensor; a smartphone app; in-app, text-based human-provided coaching; nicotine replacement therapy; and a moderated web-based community. Promising Pivot cohort studies have established the foundation for comparative assessment.

OBJECTIVE

This study aimed to compare engagement, retention, attitudes toward quitting smoking, smoking behavior, and participant feedback between Pivot and QuitGuide, a US Clinical Practice Guideline-based smoking cessation smartphone app from the National Cancer Institute.

METHODS

In this remote pilot randomized controlled trial, cigarette smokers in the United States were recruited on the web and randomized to Pivot or QuitGuide. Participants were offered 12 weeks of free nicotine replacement therapy. Data were self-reported via weekly web-based questionnaires for 12 weeks and at 26 weeks. Outcomes included engagement and retention, attitudes toward quitting smoking, smoking behavior, and participant feedback. The primary outcome was self-reported app openings at 12 weeks. Cessation outcomes included self-reported 7- and 30-day point prevalence abstinence (PPA), abstinence from all tobacco products, and continuous abstinence at 12 and 26 weeks. PPA and continuous abstinence were biovalidated via breath carbon monoxide samples.

RESULTS

Participants comprised 188 smokers (94 Pivot and 94 QuitGuide): mean age 46.4 (SD 9.2) years, 104 (55.3%) women, 128 (68.1%) White individuals, and mean cigarettes per day 17.6 (SD 9.0). Engagement via mean "total app openings through 12 weeks" (primary outcome) was Pivot, 157.9 (SD 210.6) versus QuitGuide, 86.5 (SD 66.3; P<.001). Self-reported 7-day PPA at 12 and 26 weeks was Pivot, 35% (33/94) versus QuitGuide, 28% (26/94; intention to treat [ITT]: P=.28) and Pivot, 36% (34/94) versus QuitGuide, 27% (25/94; ITT: P=.12), respectively. Self-reported 30-day PPA at 12 and 26 weeks was Pivot, 29% (27/94) versus QuitGuide, 22% (21/94; ITT: P=.32) and Pivot, 32% (30/94) versus QuitGuide, 22% (21/94; ITT: P=.12), respectively. The biovalidated abstinence rate at 12 weeks was Pivot, 29% (27/94) versus QuitGuide, 13% (12/94; ITT: P=.008). Biovalidated continuous abstinence at 26 weeks was Pivot, 21% (20/94) versus QuitGuide, 10% (9/94; ITT: P=.03). Participant feedback, including ease of setup, impact on smoking, and likelihood of program recommendation were favorable for Pivot.

CONCLUSIONS

In this randomized controlled trial comparing the app-based smoking cessation programs Pivot and QuitGuide, Pivot participants had higher engagement and biovalidated cessation rates and more favorable user feedback at 12 and 26 weeks. These findings support Pivot as an effective, durable mobile smoking cessation program.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04955639; https://clinicaltrials.gov/ct2/show/NCT04955639.

Supporting pregnant women not ready to quit smoking: an economic evaluation

OBJECTIVES

Some pregnant women are not ready or do not want to quit smoking completely, and currently there is no support provided for these women in the UK. Offering help to reduce smoking could reduce the health risks associated with smoking and increase the limited reach of the NHS Stop Smoking Services (SSS) for pregnant women. This study aimed to design and evaluate a hypothetical intervention aimed at pregnant women who are not yet ready or do not want to quit smoking entirely.

METHODS

A hypothetical intervention, the Reduced Smoking During Pregnancy (RSDP) intervention, was conceptualised based on the best available evidence. The intervention was evaluated, using a decision-analytic model developed for SDP interventions. Two different scenarios, a base-case and a cautious-case were developed, and a cost-utility analysis and return on investment analysis were conducted. The uncertainty around the estimates was assessed, using deterministic and probabilistic sensitivity analyses.

RESULTS

The RSDP intervention could prevent the loss of 13 foetuses and generate 43 quitters 1 year after delivery per 1000 women. In the lifetime analysis, the intervention was cost-effective in both scenarios, with an incremental cost of £363 (95% CI £29 to £672) and 0.44 (95% CI 0.32 to 0.53) QALYs gained in the base-case.

CONCLUSIONS

The study found that the hypothetical reduction intervention would produce significant health benefits, reduce smoking and be cost-effective. Offering pregnant smokers help to reduce smoking could reduce health inequalities, widen the reach of SSS and improve health. This economic evaluation of a novel, intensive intervention could inform the piloting of such interventions.

Using mixed methods to establish tobacco treatment acceptability from the perspective of clients and clinicians of antenatal substance use services

Background

Up to 95% of pregnant women with alcohol and other drug (AOD) problems also smoke tobacco. Challenging psychosocial circumstances and a lack of targeted tobacco interventions contribute to low rates of prenatal abstinence and more effective treatment strategies are required. This study explores smoking in pregnant clients of AOD treatment services from a consumer and healthcare provider perspective to examine characteristics of behaviour change and the acceptability of evidence-based tobacco treatment strategies. Outcomes will support the design and implementation of a comprehensive tobacco intervention.

Methods

A mixed methods triangulated design was used. Thirteen women who smoked and attended antenatal AOD services in New South Wales, Australia, were interviewed and 28 clinicians from the same services were surveyed. Domains including experiences of tobacco smoking in pregnancy, motivators and barriers to cessation and evidence-based strategies to assist cessation during pregnancy were explored. Interviews were analysed using Iterative Categorization, with interpretation guided by Qualitative Description. Online surveys were analysed descriptively. A convergent-parallel mixed methods analysis was performed.

Results

Women and clinicians agreed that improving baby’s health outcomes was the primary motivation to stop smoking. Negative experiences with nicotine replacement therapy (NRT), financial constraints and maternal contraindications restricted its uptake and effectiveness during pregnancy. Both groups agreed that other AOD use, stopping multiple substances concurrently, difficulty coping with stress and the influence of partners who smoke had the biggest impacts on cessation efforts. Clinicians favoured harm-reduction rather than abstinence-based tobacco interventions and women appeared satisfied with reduction efforts. Both views may influence the attainment of prenatal abstinence-based goals. Although previous evidence suggested the contrary, clinicians were willing to encourage simultaneous cessation of tobacco and other substances. Non-judgmental treatment approaches that provide extra support, education and motivation were important for women. Women and clinicians supported use of NRT despite concerns. Financial incentives, counselling, partner support and offering tobacco treatment with antenatal AOD care were considered acceptable treatment options.

Conclusions

NRT, incentives, counselling and partner support could be utilized in a tobacco intervention for pregnant women with substance use concerns. Non-judgmental education, motivation, and provision of NRT including instruction for correct use are important considerations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00337-y.

Trends and consumption patterns in the use of e-cigarettes among adolescents and young adults in Germany (the DEBRA study)

INTRODUCTION

Considering the growing popularity and rapid evolution of e-cigarettes, we examined e-cigarette use and tobacco smoking trends, and e-cigarette consumption patterns (i.e., device type, nicotine level) among adolescents and young adults in Germany.

METHODS

Data from 26 waves of the German Study on Tobacco Use (DEBRA), a repeated cross-sectional nationwide household survey, were used to explore trends in the prevalence of ever e-cigarette use and tobacco smoking in a sample of adolescents (aged 14-17 years, N = 1,396) and young adults (aged 18-24 years, N = 4,685) between June/July 2016 and Aug/Sept 2020. Among current e-cigarette users (N = 208), consumption patterns were examined. Associations with e-cigarette use were analysed using multivariable regression.

RESULTS

Adolescent e-cigarette use increased from 9.2% in 2016 to 16.5% in 2017, decreased in 2018 to 8.3% and then gradually increased to 13.4% by 2020. Adolescent tobacco smoking followed a similar trend. Young adult e-cigarette use rates remained relatively stable at 19.1% on average, while tobacco smoking slowly declined (2016: 44.7%, 2020: 38.5%). More than half of current e-cigarette users used refillable-style e-cigarettes (59.4% adolescents; 68.4% young adults) and also smoked tobacco (62.5% adolescents; 79.4% young adults). About 41.6% of adolescents and 56.0% of young adults vaped with nicotine. Among young adults, men (OR = 1.5; 95%CI: 1.3-1.8) and former (OR = 9.6; 95%CI: 1.1-13.1) and current (OR = 10.7; 95%CI: 8.7-13.2) tobacco smokers were more likely to have vaped.

CONCLUSION

E-cigarette use continues to rise in German adolescents and young adults requiring targeted health interventions and campaigns aimed at preventing and/or reducing use in this population.

Smoking cessation, but not reduction, reduces cardiovascular disease incidence

AIMS

The aim of this study was to assess the association of smoking cessation and reduction with risk of cardiovascular disease (CVD).

METHODS AND RESULTS

A total of 897 975 current smokers aged ≥40 years who had undergone two consecutive national health examinations (in 2009 and 2011) were included. Participants were classified as quitters (20.6%), reducers I (≥50% reduction, 7.3%), reducers II (20-50% reduction, 11.6%), sustainers (45.7%), and increasers (≥20% increase, 14.5%). During 5 575 556 person-years (PY) of follow-up, 17 748 stroke (3.2/1000 PY) and 11 271 myocardial infarction (MI) (2.0/1000 PY) events were identified. Quitters had significantly decreased risk of stroke [adjusted hazard ratio (aHR) 0.77 95% confidence interval (CI) 0.74-0.81; absolute risk reduction (ARR) -0.37, 95% CI -0.43 to -0.31] and MI (aHR 0.74, 95% CI 0.70-0.78; ARR -0.27, 95% CI -0.31 to -0.22) compared to sustainers after adjustment for demographic factors, comorbidities, and smoking status. The risk of stroke and MI incidence in reducers I (aHR 1.02, 95% CI 0.97-1.08 and aHR 0.99, 95% CI 0.92-1.06, respectively) and reducers II (aHR 1.00, 95% CI 0.95-1.05 and aHR 0.97, 95% CI 0.92-1.04, respectively) was not significantly different from the risk in sustainers. Further analysis with a subgroup who underwent a third examination (in 2013) showed that those who quit at the second examination but had starting smoking again by the third examination had 42-69% increased risk of CVD compared to sustained quitters.

CONCLUSIONS

Smoking cessation, but not reduction, was associated with reduced CVD risk. Our study emphasizes the importance of sustained quitting in terms of CVD risk reduction.

Harm reduction for smokers living with HIV

Tobacco use is now a leading cause of death in people living with HIV in the USA. Increasing cessation rates in this group is a public health priority, yet the results of clinical trials aimed at optimising tobacco treatment strategies have been largely disappointing. Combinations of behavioural and pharmacological cessation therapies in people living with HIV have yielded increases in short-term quit rates, but few have shown long-term efficacy. Even with aggressive therapy combining intensive behavioural treatment with pharmacological agents, most smokers living with HIV continue to smoke. The generalised approach to tobacco treatment that prevails in guidelines and in clinical practices might do a disservice to these individuals, who represent a sizable segment of the population of people living with HIV. Harm reduction is a sensible and needed approach for smokers living with HIV who are unable or unwilling to quit. In this Viewpoint, we take an expansive view of harm reduction to include not only cutting down on cigarette intake for persistent smokers, but also reducing smoking's downstream health effects by increasing lung cancer screening and by controlling concurrent cardiovascular risk factors, especially hypertension and hyperlipidaemia.

Cigarette pack size and consumption: an adaptive randomised controlled trial

Background

Observational evidence suggests that cigarette pack size – the number of cigarettes in a single pack – is associated with consumption but experimental evidence of a causal relationship is lacking. The tobacco industry is introducing increasingly large packs, in the absence of maximum cigarette pack size regulation. In Australia, the minimum pack size is 20 but packs of up to 50 cigarettes are available. We aimed to estimate the impact on smoking of reducing cigarette pack sizes from ≥25 to 20 cigarettes per pack.

Method

A two-stage adaptive parallel group RCT in which Australian smokers who usually purchase packs containing ≥25 cigarettes were randomised to use only packs containing either 20 (intervention) or their usual packs (control) for four weeks. The primary outcome, the average number of cigarettes smoked per day, was measured through collecting all finished cigarette packs, labelled with the number of cigarettes participants smoked. An interim sample size re-estimation was used to evaluate the possibility of detecting a meaningful difference in the primary outcome.

Results

The interim analysis, conducted when 124 participants had been randomised, suggested 1122 additional participants needed to be randomised for sufficient power to detect a meaningful effect. This exceeded pre-specified criteria for feasible recruitment, and data collection was terminated accordingly. Analysis of complete data (n = 79) indicated that the mean cigarettes smoked per day was 15.9 (SD = 8.5) in the intervention arm and 16.8 (SD = 6.7) among controls (difference − 0.9: 95%CI = − 4.3, 2.6).

Conclusion

It remains unclear whether reducing cigarette pack sizes from ≥25 to 20 cigarettes reduces cigarette consumption. Importantly, the results of this study provide no evidence that capping cigarette pack sizes would be ineffective at reducing smoking. The limitations identified in this study can inform a more efficient RCT, which is urgently required to address the dearth of experimental evidence on the impact of large cigarette pack sizes on smoking.

Trial registration

10.1186/ISRCTN34202533

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11413-4.

Spatial clusters of daily tobacco consumption before and after a smoke-free policy implementation

This study assessed the spatial dependence of daily tobacco consumption and how it is spatially impacted by individual and neighborhood socioeconomic determinants, and tobacco consumption facilities before and after a smoke-free implementation. Individual data was obtained from the Bus Santé, a cross-sectional survey in Geneva. Spatial clusters of high and low tobacco consumption were assessed using Getis-Ord Gi*. Daily tobacco consumption was not randomly clustered in Geneva and may be impacted by tobacco consumption facilities independently of socioeconomic factors and a smoking ban. Spatial analysis should be considered to highlight the impact of smoke-free policies and guide public health interventions.

Systematic Review of Psychosocial Smoking Cessation Interventions for People with Serious Mental Illness

Tobacco smoking is a major driver of premature mortality in people with serious mental illness (SMI; e.g., schizophrenia, bipolar disorder). This systematic literature review described randomized control trials of psychosocial smoking cessation interventions for people with SMI, rated their methodological rigor, evaluated the inclusion of racial/ethnic and sexual/gender minorities, and examined smoking cessation outcomes. Methods: Eligible studies included peer-reviewed articles published between 2009 and 2020 that examined psychosocial smoking cessation interventions in people with SMI. We used the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines to conduct our review and the Methodological Quality Rating Scale to evaluate methodological rigor. Results: Eighteen studies were included. Ten were categorized as high methodological rigor given their study characteristics (e.g., longer follow-up) and eight as lower methodological rigor based on their characteristics (e.g., not intent-to-treat). Racial/ethnic and sexual/gender minorities were under-represented in these studies. A range of psychosocial interventions were examined including motivational enhancements, smoking cessation education, cognitive behavioral strategies, and contingency management. Most studies also provided smoking cessation medications (e.g., NRT, bupropion), although provision was not always uniform across treatment conditions. Three studies found the intervention condition achieved significantly higher abstinence from smoking compared to the comparison group. Seven studies found the intervention condition achieved significantly higher reductions in smoking compared to the comparison group. Conclusions: Studies finding significant differences between the intervention and comparison groups shared common evidenced-based components, including providing smoking cessation medications (e.g., NRT, bupropion), motivational enhancement techniques, and cessation education and skills training, but differed in intensity (e.g., number and frequency of sessions), duration, and modality (e.g., group, individual, technology). Methodological limitations and a small number of studies finding significant between-group differences prevent the identification of the most effective psychosocial smoking cessation interventions. Clinical trial designs (e.g., SMART, factorial) that control for the provision of psychosocial medications and allow for the identification of optimal psychosocial treatments are needed. Future studies should also ensure greater inclusion of racial/ethnic and sexual/gender minorities and should be culturally/linguistically adapted to improve treatment engagement and study outcomes.

Randomised pilot trial of cash incentives for reducing paediatric asthmatic tobacco smoke exposures from maternal caregivers and members of their social network

BACKGROUND

The primary aim was to evaluate the efficacy of financial incentives for reducing paediatric tobacco smoke exposures (TSEs) through motivating cigarette usage reduction among low-income maternal caregivers and members of their social network.

DESIGN

Randomised control pilot trial over a 6-month study follow-up time period. The study was undertaken from May 2017 to -May 2018. Once monthly follow-up visits occurred over the 6-month study period.

SETTING

Baltimore City, Maryland, USA.

PARTICIPANTS

We grouped 135 participants into 45 triads (asthmatic child (2-12 years of age), maternal caregiver and social network member). Triads were assigned in a 1:1 allocation ratio. The maternal caregiver and social network members were active smokers and contributed to paediatric TSE.

INTERVENTIONS

Triads were randomised to receive either usual care (TSE education and quitline referrals) or usual care plus financial incentives. Cash incentives up to $1000 were earned by caregivers and designated social network participants. Incentives for either caregivers or social network participants were provided contingent on their individual reduction of tobacco usage measured by biomarkers of tobacco usage. Study visits occurred once a month during the 6-month trial.

MAIN OUTCOME MEASURES

The main outcome measure was mean change in monthly paediatric cotinine levels over 6 months of follow-up interval and was analysed on an intention-to-treat basis.

RESULTS

The mean change in monthly child cotinine values was not significantly different in the intervention cohort over the 6-month follow-up period, compared with the control group (p=0.098, CI -0.16 to 1.89). Trends in child cotinine could not be ascribed to caregivers or social network members. Despite decreasing mean monthly cotinine values, neither the intervention cohort's caregivers (difference in slope (control-intervention)=3.30 ng/mL/month, CI -7.72 to 1.13, p=0.144) or paired social network members (difference in slope (control-intervention)=-1.59 ng/mL/month, CI -3.57 to 6.74, p=0.546) had significantly different cotinine levels than counterparts in the control group.

CONCLUSIONS

Financial incentives directed at adult contributors to paediatric TSE did not decrease child cotinine levels.

TRIAL REGISTRATION NUMBER

NCT03099811.

Healthy recovery: A stepped wedge cluster randomised controlled trial of a healthy lifestyle intervention for people attending residential alcohol and other drug treatment

BACKGROUND

Unhealthy lifestyle behaviours contribute to the poor health of people attending alcohol and other drug (AOD) treatment. Healthy Recovery is an 8-session group-based intervention that targets smoking, diet and physical inactivity as part of an integrated healthy lifestyle approach. The current study aimed to examine the effectiveness of Healthy Recovery when delivered within residential AOD treatment settings.

METHODS

The study design was a stepped-wedge cluster randomised trial. Participants were 151 current smokers attending residential AOD programs provided by the Australian Salvation Army (n = 71, Control condition; n = 80, Intervention condition). The primary outcome was number of cigarettes smoked per day. Secondary outcomes examined other smoking behaviours (7-day point prevalence, use of nicotine replacement therapy [NRT]), diet (servings and variety of fruit and vegetables), and physical activity.

RESULTS

The mean number of cigarettes smoked per day was significantly lower in the Intervention condition at 2-, 5-, and 8-month follow-up. There were also significant differences in favour of the Intervention condition for number of quit attempts, use of NRT and variety of fruit. There were no other significant differences for other dietary or physical activity variables.

CONCLUSIONS

Healthy Recovery had a positive impact on smoking behaviours. Future research should consider strategies to further promote smoking cessation (e.g. promoting longer-term use of NRT), as well as addressing physical activity and dietary behaviours. The introduction of broader organisational approaches (e.g. smoke free policies, organised group exercise and cooking activities) might help to enhance healthy lifestyle approaches within AOD treatment settings.

Linkage of Maternal Caregiver Smoking Behaviors on Environmental and Clinical Outcomes of Children with Asthma: A Post-Hoc Analysis of a Financial Incentive Trial Targeting Reduction in Pediatric Tobacco Smoke Exposures

(1) Background: Monthly variability in smoking behaviors in caregivers of pediatric asthmatics yields questions of how much and when does smoking reduction result in improved environmental and clinical outcomes. (2) Methods: Post hoc analysis of data from a 6 month pilot randomized-control trial occurring from May 2017 to May 2018 in Baltimore City (MD, USA). The initial trial's primary intervention explored the utility of financial incentives in modifying caregiver smoking behaviors. Post hoc analyses examined all dyads independent of the initial trial's randomization status. All caregivers received pediatric tobacco smoke harm reduction education, in addition to monthly encouragement to access the state tobacco quitline for individual phone-based counseling and nicotine replacement therapy. Maternal caregivers who were active cigarette smokers and their linked asthmatic child (aged 2-12 years) were grouped into two classifications ("high" versus "low") based on the child and caregiver's cotinine levels. A "low" cotinine level was designated by at least a 25% reduction in cotinine levels during 3 months of the trial period; achieving ≤2 months of low cotinine levels defaulted to the "high" category. Twenty-seven dyads (caregivers and children) (total n = 54) were assigned to the "high" category, and eighteen dyads (caregivers and children) (total n = 36) were allocated to the "low" category. The primary outcome measure was the correlation of caregiver cotinine levels with pediatric cotinine values. Secondary outcomes included asthma control, in addition to caregiver anxiety and depression. (3) Results: Caregivers with 3 months of ≥25% decrease in cotinine levels had a significantly greater mean change in child cotinine levels (p = 0.018). "Low" caregiver cotinine levels did not significantly improve pediatric asthma control (OR 2.12 (95% CI: 0.62-7.25)). Caregiver anxiety and depression outcomes, measured by Patient Health Questionnaire (PHQ)-4 scores, was not significantly different based on cotinine categorization (p = 0.079); (4) Conclusion: Reduced pediatric cotinine levels were seen in caregivers who reduced their smoking for at least 3 months, but clinical outcome measures remained unchanged.

Effect of e-Cigarettes Plus Counseling vs Counseling Alone on Smoking Cessation: A Randomized Clinical Trial

IMPORTANCE

Electronic cigarettes (e-cigarettes) for smoking cessation remain controversial.

OBJECTIVE

To evaluate e-cigarettes with individual counseling for smoking cessation.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial enrolled adults motivated to quit smoking from November 2016 to September 2019 at 17 Canadian sites (801 individuals screened; 274 ineligible and 151 declined). Manufacturing delays resulted in early termination (376/486 participants, 77% of target). Outcomes through 24 weeks (March 2020) are reported.

INTERVENTIONS

Randomization to nicotine e-cigarettes (n = 128), nonnicotine e-cigarettes (n = 127), or no e-cigarettes (n = 121) for 12 weeks. All groups received individual counseling.

MAIN OUTCOMES AND MEASURES

The primary end point was point prevalence abstinence (7-day recall, biochemically validated using expired carbon monoxide) at 12 weeks, changed from 52 weeks following early termination. Participants missing data were assumed to be smoking. The 7 secondary end points, examined at multiple follow-ups, were point prevalence abstinence at other follow-ups, continuous abstinence, daily cigarette consumption change, serious adverse events, adverse events, dropouts due to adverse effects, and treatment adherence.

RESULTS

Among 376 randomized participants (mean age, 52 years; 178 women [47%]), 299 (80%) and 278 (74%) self-reported smoking status at 12 and 24 weeks, respectively. Point prevalence abstinence was significantly greater for nicotine e-cigarettes plus counseling vs counseling alone at 12 weeks (21.9% vs 9.1%; risk difference [RD], 12.8 [95% CI, 4.0 to 21.6]) but not 24 weeks (17.2% vs 9.9%; RD, 7.3 [95% CI, -1.2 to 15.7]). Point prevalence abstinence for nonnicotine e-cigarettes plus counseling was not significantly different from counseling alone at 12 weeks (17.3% vs 9.1%; RD, 8.2 [95% CI, -0.1 to 16.6]), but was significantly greater at 24 weeks (20.5% vs 9.9%; RD, 10.6 [95% CI, 1.8 to 19.4]). Adverse events were common (nicotine e-cigarette with counseling: 120 [94%]; nonnicotine e-cigarette with counseling: 118 [93%]; counseling only: 88 [73%]), with the most common being cough (64%) and dry mouth (53%).

CONCLUSIONS AND RELEVANCE

Among adults motivated to quit smoking, nicotine e-cigarettes plus counseling vs counseling alone significantly increased point prevalence abstinence at 12 weeks. However, the difference was no longer significant at 24 weeks, and trial interpretation is limited by early termination and inconsistent findings for nicotine and nonnicotine e-cigarettes, suggesting further research is needed.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02417467.

Defining and Measuring Abstinence in Clinical Trials of Smoking Cessation Interventions: An Updated Review

BACKGROUND

Changes in tobacco products, use patterns, and assessment technology in the last 15 years led the Society for Research on Nicotine and Tobacco (SRNT) Treatment Research Network to call for an update to the 2003 SRNT recommendations for assessing abstinence in clinical trials of smoking cessation interventions.

METHODS

The SRNT Treatment Research Network convened a group of investigators with decades of experience in conducting tobacco treatment clinical trials. To arrive at the updated recommendations, the authors reviewed the recommendations of the prior SRNT Workgroup as well as current literature. Ten additional experts in the field provided feedback on this paper and these recommendations.

RESULTS

With respect to defining abstinence, the authors recommend: (1) continuing to use the definition of no use of combustible tobacco products (regardless of use of noncombustible tobacco products [e.g., snus] and alternative products [e.g., e-cigarettes]) and collecting additional data to permit alternate abstinence definitions; (2) no use of combustible or smokeless tobacco products; and (3) no use of combustible or smokeless tobacco products or alternative products, as appropriate for the research question being addressed. The authors also recommend reporting point prevalence and prolonged abstinence at multiple timepoints (end of treatment, ≥3 months after the end of treatment, and ≥6 months postquit or posttreatment initiation).

CONCLUSIONS

Defining abstinence requires specification of which products a user must abstain from using, the type of abstinence (i.e., point prevalence or continuous), and the duration of abstinence. These recommendations are intended to serve as guidelines for investigators as they collect the necessary data to accurately describe participants' abstinence during smoking cessation clinical trials.

IMPLICATIONS

This paper provides updated recommendations for defining abstinence in the context of smoking cessation treatment clinical trials.

Impact of Graphic Warning Messages on Intentions to Use Alternate Tobacco Products

Graphic cigarette warnings increase quit attempts. Perceived message effectiveness and message avoidance are predictive of later quit attempts. We sought to examine whether randomized exposure to warning messages would inadvertently increase intentions to use alternate tobacco products while enhancing attempts to quit cigarettes. An online survey of 1392 adult smokers in the US asked participants to rate six randomly selected tobacco warnings (from a set of 319) on perceived effectiveness and avoidance intentions. These two indicators of message effectiveness were calculated at the message-level and then at the individual campaign-level to facilitate causal inference. After viewing a message campaign of six warning messages, participants indicated their intentions to use alternate tobacco products. Sixty-eight percent of participants reported some intention to use e-cigarettes and intentions to use other alternate tobacco products ranged from 31% to 40%. Campaigns of messages eliciting higher avoidance increased the odds of intending to use hookah (aOR: 4.32), smokeless tobacco (aOR: 4.88), and snus (aOR: 8.06), but not the intention to use electronic cigarettes. These relationships are mediated by intentions to quit smoking (all p <.05). Viewing campaigns with higher campaign-level perceived effectiveness increased the intentions to quit, which in turn increased intentions to try alternate tobacco products. Our findings increase the tobacco control community's understanding of unintended consequences of graphic tobacco warnings.

Smoker motivations and predictors of smoking cessation: lessons from an inpatient smoking cessation programme

INTRODUCTION

Our study aimed to review the quit rates of smokers from our inpatient smoking cessation programme in relation to habits and sociodemographic factors, and also to explore the potential usefulness of electronic cigarettes (ECs) by reviewing smoking motivations.

METHODS

This was a retrospective study of patients recruited into our inpatient smoking cessation programme from June 2008 to June 2015. Sociodemographic factors and information on smoking habits were collected using a counsellor-administered questionnaire. Patients were given intensive counselling followed by a phone interview at one, three and six months to assess smoking status.

RESULTS

A total of 2,722 patients were enrolled. 27.6% of patients were abstinent at six months' follow-up. Patients who quit smoking were older, married, initiated smoking at a later age and had lower Fagerström Test for Nicotine Dependence scores. There was a trend towards successful quitting in those with higher education levels and Chinese ethnicity, but this was not statistically significant. Patients who planned to quit cold turkey and those who quit because of social pressures were more successful. Of the smoking motivations, only nicotine dependence was an independent predictor of smoking cessation.

CONCLUSION

Smoking motivations such as habitual use and psychological dependence did not influence quit rates and therefore do not support the use of ECs. Instead, a cold turkey method of quitting was shown in our study to contribute to cessation success. We recommend an increased focus on the use of pharmacologic aids as well as involvement of peer/spousal support to aid in such quit attempts.

Should cigarette pack sizes be capped?

BACKGROUND

Very few countries regulate maximum cigarette pack size. Larger, non-standard sizes are increasingly being introduced by the tobacco industry. Larger portion sizes increase food consumption; larger cigarette packs may similarly increase tobacco consumption. Here we consider the evidence for legislation to cap cigarette pack size to reduce tobacco-related harm.

AIMS AND ANALYSIS

We first describe the regulations regarding minimum and maximum pack sizes in the 12 countries that have adopted plain packaging legislation and describe the range of sizes available. We then discuss evidence for two key assumptions that would support capping pack size. First, regarding the causal nature of the relationship between pack size and tobacco consumption, observational evidence suggests that people smoke fewer cigarettes when using smaller packs. Secondly, regarding the causal nature of the relationship between reducing consumption and successful cessation, reductions in number of cigarettes smoked per day are associated with increased cessation attempts and subsequent abstinence. However, more experimental evidence is needed to infer the causal nature of these associations among general populations of smokers.

CONCLUSION

Cigarette pack size is positively associated with consumption and consumption is negatively associated with cessation. Based on limited evidence of the causal nature of these associations, we hypothesize that government regulations to cap cigarette pack sizes would positively contribute to reducing smoking prevalence.

Impact of tobacco tax increases and industry pricing on smoking behaviours and inequalities: a mixed-methods study

Background

Increasing tobacco prices through taxation is very effective for reducing smoking prevalence and inequalities. For optimum effect, understanding how the tobacco industry and smokers respond is essential. Tobacco taxation changes occurred in the UK over the study period, including annual increases, a shift in structure from ad valorem to specific taxation and relatively higher increases on roll-your-own tobacco than on factory-made cigarettes.

Objectives

Understanding tobacco industry pricing strategies in response to tax changes and the impact of tax on smokers’ behaviour, including tax evasion and avoidance, as well as the effect on smoking inequalities. Synthesising findings to inform how taxation can be improved as a public health intervention.

Design

Qualitative analysis and evidence synthesis (commercial and Nielsen data) and longitudinal and aggregate cross-sectional analyses (International Tobacco Control Policy Evaluation Project data).

Setting

The UK, from 2002 to 2016.

Data sources and participants

Data were from the tobacco industry commercial literature and retail tobacco sales data (Nielsen, New York, NY, USA). Participants were a longitudinal cohort (with replenishment) of smokers and ex-smokers from 10 surveys of the International Tobacco Control Policy Evaluation Project (around 1500 participants per survey).

Main outcome measures

(1) Tobacco industry pricing strategies, (2) sales volumes and prices by segments over time and (3) smokers’ behaviours, including products purchased, sources, brands, consumption, quit attempts, success and sociodemographic differences.

Review methods

Tobacco industry commercial literature was searched for mentions of tobacco products and price segments, with 517 articles extracted.

Results

The tobacco industry increased prices on top of tax increases (overshifting), particularly on premium products, and, recently, the tobacco industry overshifted more on cheap roll-your-own tobacco than on factory-made cigarettes. Increasingly, price rises were from industry revenue generation rather than tax. The tobacco industry raised prices gradually to soften impact; this was less possible with larger tax increases. Budget measures to reduce cheap product availability failed due to new cheap factory-made products, price marking and small packs. In 2014, smokers could buy factory-made (roll-your-own tobacco) cigarettes at real prices similar to 2002. Exclusive roll-your-own tobacco and mixed factory-made cigarettes and roll-your-own tobacco use increased, whereas exclusive factory-made cigarette use decreased, alongside increased cheap product use, rather than quitting. Quitting behaviours were associated with higher taxes. Smokers consumed fewer factory-made cigarettes and reduced roll-your-own tobacco weight over time. Apparent illicit purchasing did not increase. Disadvantaged and dependent smokers struggled with tobacco affordability and were more likely to smoke cheaper products, but disadvantage did not affect quit success.

Limitations

Different for each data set; triangulation increased confidence.

Conclusions

The tobacco industry overshifted taxes and increased revenues, even when tax increases were high. Therefore, tobacco taxes can be further increased to reduce price differentials and recoup public health costs. Government strategies on illicit tobacco appear effective. Large, sudden tax increases would reduce the industry’s ability to manipulate prices, decrease affordability and increase quitting behaviours. More disadvantaged, and dependent, smokers need more help with quitting.

Future work

Assessing the impact of tax changes made since 2014; changing how tax changes are introduced (e.g. sudden intermittent or smaller continuous); and tax changes on tobacco initiation.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

The Acute Impact of Hatha Yoga on Craving Among Smokers Attempting to Reduce or Quit

INTRODUCTION

Despite negative effects of smoking, smokers have difficulty quitting, suggesting a need for additional strategies to help them quit. A single-session hatha yoga intervention acutely reduced craving among nicotine-deprived smokers not attempting to reduce or quit, yet it is unknown if it reduces craving among those attempting to change their smoking. Thus, this study tested the efficacy of a single-session hatha yoga intervention for acutely reducing craving among smokers attempting to reduce or quit smoking.

METHODS

Data presented are part of a larger dissertation project. Participants were 55 community-recruited smokers (62% male) motivated to reduce or quit smoking randomized to one session of hatha yoga (n = 25) or wellness control (ie, reading educational materials about healthy lifestyle; n = 30) on their intervention day (ie, the day on which they began to reduce or quit smoking). Participants rated, "I have a desire for a cigarette right now," on a 7-point Likert scale immediately before and after the intervention.

RESULTS

After statistically controlling for CO in breath, participant type, age, gender, race, and ethnicity, a significant Time × Condition interaction was found, F(1, 47) = 4.72, p = .035, ηp2 = .09, suggesting craving decreased at a greater rate in the hatha yoga condition relative to the wellness condition.

CONCLUSIONS

Results from this study add to a growing body of research demonstrating the potential clinical utility of hatha yoga as an adjunctive intervention tool for smoking cessation.

IMPLICATIONS

This is the first known study to test the impact of a single-session hatha yoga intervention on craving among adult smokers attempting to reduce or quit smoking. We found that 30 minutes of hatha yoga produced a greater reduction in craving compared to a 30-minute wellness control condition. This relationship was evident even after statistically accounting for other important variables (eg, gender). Results of this study add to a growing body of literature demonstrating the potential clinical utility of hatha yoga as an adjunctive intervention strategy for smoking cessation.

An online randomised controlled trial of mental contrasting with implementation intentions as a smoking behaviour change intervention

Objective: We assessed the effectiveness of mental contrasting with implementation intentions (MCII), an established self-regulatory strategy, as a brief online smoking behaviour change intervention. We expected that MCII would enhance smoking reduction among the highly cigarette dependent because MCII is most effective for challenging pursuits. Design: Participants interested in reducing or quitting smoking were recruited online via Amazon Mechanical Turk. At Time 1, we assessed cigarette dependence using the Cigarette Dependence Scale (CDS-5), then administered one of two brief self-help interventions: MCII (n = 172) or a government-promoted control strategy (n = 174). Participants were invited to complete an online follow-up survey 4 weeks later (Time 2). Main Outcome Measure: At Time 1 and Time 2, we measured recent cigarette smoking with a retrospective, self-report questionnaire. We used these reports to compute smoking reduction scores, with an intent-to-treat approach. Results: MCII increased smoking reduction compared to the control strategy at high, but not low, levels of cigarette dependence. Conclusion: We found preliminary evidence consistent with MCII, delivered as a brief online intervention, as an effective smoking reduction strategy for highly dependent cigarette smokers. Further research is needed on MCII as a smoking behaviour change intervention.

Feasibility and Acceptability of Mindfulness-Based Group Visits for Smoking Cessation in Low-Socioeconomic Status and Minority Smokers with Cancer

Objective: Smoking cessation studies tailored for low-income and racial/ethnic minority cancer patients are limited. African American and low-socioeconomic status (SES) smokers have higher cancer mortality rates and are less likely to use evidence-based smoking cessation treatments compared with white and higher SES counterparts. Mindfulness training is a promising approach to address racial and SES disparities in smoking cessation. The authors assessed the feasibility and acceptability of a mindfulness-based smoking cessation (MBSC) medical group visit for low-income and racially diverse smokers with cancer. Design and intervention: The authors adapted the integrative medical group visit model used for chronic pain and included the You Can Quit smoking cessation curriculum used at the study site, Tobacco Treatment Center. The program was conducted in eight weekly 2-h visits. The authors then tested the feasibility and acceptability of this intervention for actively smoking cancer patients and cancer survivors in two pilot groups (N = 18) using a pre-post design. Setting/Location: This study took place at Boston Medical Center, a large urban safety net academic teaching hospital. Outcome measures: The authors used a medical group visit intake form to collect data on weekly cigarette intake and home practice. They also gathered additional qualitative data from focus groups and in-depth interviews. Results: Over 50% of participants (n = 10) self-identified as black and 56% reported an annual income of $20,000 or less. Over two-thirds of the participants attended four or more of the eight group visits. There was a significant decrease in weekly cigarette intake from 75.1 cigarettes at baseline to 44.3 at 3 months (p = 0.039). None of the participants quit smoking. Participants were satisfied with the program and reported positive lifestyle changes. Conclusion: MBSC group visits are feasible and acceptable among racially diverse and low-SES smokers with cancer and should be further studied in a larger cohort.

Self-initiated gradual smoking reduction among community correction smokers

INTRODUCTION

Smoking remains the leading cause of preventable death in the United States. Many smoking cessation guidelines advise smokers to quit precipitately; however, most quit attempts involve a more gradual cessation. Characteristics of individuals who tend to reduce prior to quitting and the effectiveness of pre-quit reduction are not well understood. This study examined individual differences and smoking cessation outcomes between individuals who self-initiated gradual reduction in cigarettes per day (CPD) and those who did not reduce prior to quit date.

METHODS

This study is a secondary analysis from a randomized clinical trial of smoking cessation with pharmacotherapy among individuals under community corrections supervision. We compared participants who self-initiated smoking reduction by at least 25% between baseline and the first treatment session (n = 128) to participants who either increased or did not reduce smoking between baseline and the first treatment session (n = 354).

RESULTS

African American race, no previous cigar smoking, no previous use of pharmacotherapy for smoking cessation, less withdrawal symptoms at baseline, and older age at first smoking were associated with being a self-initiated gradual reduction in univariate analyses. Individuals who self-initiated gradual reduction also had a had a greater likelihood of achieving at least one quit during the one-year study period as compared to those who did not reduce prior to the intervention.

CONCLUSIONS

Individuals who self-initiate gradual reduction differ from those who increase or do not change their smoking prior to a quit date. Gradual reduction also increased success in quitting.

Harm reduction treatment for smoking (HaRT-S): findings from a single-arm pilot study with smokers experiencing chronic homelessness

Background: Smoking prevalence and mortality is 5 times higher for the chronically homeless versus general population. Unfortunately, traditional smoking cessation treatment does not optimally engage this population. In a preliminary study, smokers experiencing chronic homelessness suggested providers avoid giving advice to quit and instead use a more compassionate, nonjudgmental style to discuss a broader menu of patient-driven options, including safer nicotine use. Most had negative perceptions of smoking cessation medications; however, 76% expressed interest in a switchover to electronic nicotine delivery systems (ENDS). Methods: Using a community-based participatory research approach, we codeveloped harm-reduction treatment for smoking (HaRT-S) together with people with lived experience of chronic homelessness and smoking and a community-based agency that serves them. In HaRT-S, interventionists embody a compassionate, advocacy-oriented "heart-set" and deliver manualized components: a) participant-led tracking of smoking-related outcomes, b) elicitation of harm-reduction goals and progress made toward them, c) discussion of relative risks of nicotine delivery systems, and d) distribution and instructions on use of safer nicotine products. We then conducted a single-arm, 14-week pilot of HaRT-S (N = 44). Results: Participants rated procedures "totally acceptable/effective," which was reflected in 26% overrecruitment within a 4-month period and 70% retention at the 14-week follow-up. For each week in the study, participants experienced an 18% increase in odds of reporting 7-day, biochemically verified, point-prevalence abstinence. All participants reporting abstinence used ENDS. Participants evinced reductions in cigarette dependence (-45%), frequency (-29%), and intensity (-78%; ps < .05). Participants who used ENDS experienced an additional 44% reduction in smoking intensity and a 1.2-point reduction in dependence compared to participants who did not. Conclusions: Harm-reduction counseling plus ENDS shows promise for smokers experiencing chronic homelessness. Randomized controlled trials are needed to establish the efficacy of this approach in decreasing smoking-related harm and improving health-related quality of life for this marginalized and disproportionately affected population.

Effects of time-varying changes in tobacco and alcohol use on depressive symptoms following pharmaco-behavioral treatment for smoking and heavy drinking

BACKGROUND

Complete abstinence from alcohol as well as smoking cessation have been shown to predict reductions in depressive symptoms over time. However, whether reducing alcohol use or smoking positively affect depressive symptoms has yet to be examined. The current study examined depressive symptoms as a function of time-varying changes in alcohol use and smoking status following a pharmaco-behavioral treatment addressing smoking cessation and alcohol reduction.

METHODS

Participants were heavy-drinking smokers (n = 150) followed for 26 weeks after their quit smoking date, with assessments of smoking, alcohol use, and depressive symptoms at baseline and 2, 8, 16, and 26 weeks.

RESULTS

Abstinence from smoking was associated with significantly lower depressive symptoms, as compared to little to no reduction in smoking (B = -6.1) as well as significant reductions in smoking (B = 4.01). Exploratory analyses, which excluded observations in which a participant was abstinent, revealed a significant effect of percent change in cigarettes smoked, modeled continuously, on depressive symptoms, (B = 4.39). By contrast, no differences were observed in depressive symptoms in relation to changes in alcohol use.

CONCLUSION

It appears that smoking abstinence is associated with improvements in depression as compared to any level of sustained or reduced use and that the magnitude of smoking reduction may be associated with lower depressive symptoms among those who did not quit successfully. If replicated, these findings may inform treatment for individuals for whom depression is a major barrier to cessation and who have been unable or are unwilling to be completely abstinent from smoking.

Keeping smoking affordable in higher tax environments via smoking thinner roll-your-own cigarettes: Findings from the International Tobacco Control Four Country Survey 2006-15

BACKGROUND

Roll-Your-Own tobacco (RYO) use is increasingly popular in many countries: it is generally cheaper than factory-made cigarettes (FM), and smokers can further reduce costs by adjusting the amount of tobacco in each cigarette. However, the level of risk of RYO compared with FM cigarettes is similar and does not meaningfully change with cigarette weight. We assessed the weight of tobacco in RYO cigarettes across jurisdictions with differing tobacco taxes/prices and over time.

METHOD

Six waves of the International Tobacco Control 4 Country longitudinal study of smokers and recent ex-smokers, providing 3176 observations from exclusive RYO users covering 2006-15, are used to calculate the weight of tobacco used in RYO cigarettes in the US, Canada, Australia, and the UK. Multilevel regression analyses were used to compare weights across countries, socio-demographic factors, and over time.

RESULTS

Smokers in the UK and Australia, where tobacco is relatively expensive, show higher levels of exclusive RYO use (25.8% and 13.8% respectively) and lower mean weights of tobacco per RYO cigarette (0.51 g(sd 0.32 g) and 0.53 g(0.28 g)), compared with both Canada and especially the US (6.0% and 3.5%, and 0.76 g(0.45 g) and 1.07 g(0.51 g)). Smokers in the UK and Australia also exhibited a statistically significant year-on-year decrease in the mean weight of each RYO cigarette.

CONCLUSIONS

Taxation of RYO should increase considerably in the UK and Australia so that RYO and FM cigarettes are taxed equivalently to reduce RYO attractiveness and inequalities. Other measures to reduce the price differentials, including taxing RYO solely on weight, are also discussed.

Predictors of reduced smoking quantity among recovering alcohol dependent men in a smoking cessation trial

INTRODUCTION

Adults with alcohol dependence (AD) have exceptionally high smoking rates and poor smoking cessation outcomes. Discovery of factors that predict reduced smoking among AD smokers may help improve treatment. This study examined baseline predictors of smoking quantity among AD smokers in a pharmacotherapy trial for smoking cessation.

METHODS

The sample includes male, AD smokers (N = 129) with 1-32 months of alcohol abstinence who participated in a 12-week trial of medication (topiramate vs. placebo) and adjunct counseling with 6 months of follow-up. Baseline measures of nicotine dependence, AD severity, psychopathology, motivation to quit smoking, and smoking-related cognitions were used to predict smoking quantity (cigarettes per day) at post-treatment and follow-up.

RESULTS

Overall, the sample had statistically significant reductions in smoking quantity. Greater nicotine dependence (Incidence rate ratios (IRRs) = 0.82-0.90), motivation to quit (IRRs = 0.65-0.85), and intrinsic reasons for quitting (IRRs = 0.96-0.98) predicted fewer cigarettes/day. Conversely, greater lifetime AD severity (IRR = 1.02), depression severity (IRRs = 1.05-1.07), impulsivity (IRRs = 1.01-1.03), weight-control expectancies (IRRs = 1.10-1.15), and childhood sexual abuse (IRRs = 1.03-1.07) predicted more cigarettes/day.

CONCLUSIONS

Smokers with AD can achieve large reductions in smoking quantity during treatment, and factors that predict smoking outcomes in the general population also predict greater smoking reductions in AD smokers. Treatment providers can use severity of nicotine dependence and AD, motivation to quit, smoking-related cognitions, and severity of depression to guide treatment and improve outcomes among AD smokers.

About One in Five Novice Vapers Buying Their First E-Cigarette in a Vape Shop Are Smoking Abstinent after Six Months

Background: E-cigarette use is rising with the majority of vapers purchasing their e-cigarettes in vape shops. We investigated the smoking/vaping trajectories and quit-smoking success rates of smokers deciding to start vaping for the first time and buying their e-cigarette in brick-and-mortar vape shops in Flanders. Methods: Participants filled out questionnaires assessing smoking/vaping behaviour at three moments (intake, after three and six months) and smoking status was biochemically verified using eCO measurements. Results: Participants (n = 71) were regular smokers (M_eCO-intake = 22 ppm), half of whom reported a motivation to quit smoking in the near future. Participants bought 3rd/4th generation e-cigarettes and e-liquid with a nicotine concentration averaging 7 mg/mL. A smoking reduction of 53% (17 cigarettes per day (CPD) at intake to 8 CPD after six months) was observed, whereas eCO decreased to 15 ppm. Eighteen percent of participants had quit smoking completely (eCO = 2 ppm), another 25% had at least halved CPD, whereas 57% had failed to reduce CPD by at least 50% (including 13% lost to follow-up). Quitters consumed more e-liquid than reducers and those who continued to smoke. Conclusions: Around one in five smoking customers buying their first e-cigarette in a brick-and-mortar vape shop had quit smoking completely after six months.

Prevention and Treatment of Tobacco Use: JACC Health Promotion Series

Tobacco use is the leading preventable cause of death worldwide and is a major risk factor for cardiovascular disease (CVD). Both prevention of smoking initiation among youth and smoking cessation among established smokers are key for reducing smoking prevalence and the associated negative health consequences. Proven tobacco cessation treatment includes pharmacotherapy and behavioral support, which are most effective when provided together. First-line medications (varenicline, bupropion, and nicotine replacement) are effective and safe for patients with CVD. Clinicians who care for patients with CVD should give as high a priority to treating tobacco use as to managing other CVD risk factors. Broader tobacco control efforts to raise tobacco taxes, adopt smoke-free laws, conduct mass media campaigns, and restrict tobacco marketing enhance clinicians' actions working with individual smokers.

Cost-effectiveness analysis of smoking cessation interventions using cell phones in a low-income population

BACKGROUND

The prevalence of cigarette smoking is significantly higher among those living at or below the federal poverty level. Cell phone-based interventions among such populations have the potential to reduce smoking rates and be cost-effective.

METHODS

We performed a cost-effectiveness analysis of three smoking cessation interventions: Standard Care (SC) (brief advice to quit, nicotine replacement therapy and self-help written materials), Enhanced Care (EC) (SC plus cell phone-delivered messaging) and Intensive Care (IC) (EC plus cell phone-delivered counselling). Quit rates were obtained from Project ACTION (Adult smoking Cessation Treatment through Innovative Outreach to Neighborhoods). We evaluated shorter-term outcomes of cost per quit and long-term outcomes using cost per quality-adjusted life year (QALY).

RESULTS

For men, EC cost an additional $541 per quit vs SC; however, IC cost an additional $5232 per quit vs EC. For women, EC was weakly dominated by IC-IC cost an additional $1092 per quit vs SC. Similarly, for men, EC had incremental cost-effectiveness ratio (ICER) of $426 per QALY gained vs SC; however, IC resulted in ICER of $4127 per QALY gained vs EC. For women, EC was weakly dominated; the ICER of IC vs SC was $1251 per QALY gained. The ICER was below maximum acceptable willingness-to-pay threshold of $50 000 per QALY under all alternative modelling assumptions.

DISCUSSION

Cell phone interventions for low socioeconomic groups are a cost-effective use of healthcare resources. Intensive Care was the most cost-effective strategy both for men and women.

TRIAL REGISTRATION NUMBER

NCT00948129; Results.

Effects of six weeks of electronic cigarette use on smoking rate, CO, cigarette dependence, and motivation to quit smoking: A pilot study

OBJECTIVES

Switching from combustible tobacco cigarettes to electronic cigarettes (e-cigs) may or may not help smokers to reduce cigarette consumption and toxicant exposure. This pilot study investigated the effects of asking smokers to switch to e-cigs for 6weeks on smoking, exhaled carbon monoxide (CO) concentration, dependence, and motivation to quit smoking.

METHODS

Non-treatment seeking daily smokers (n=18) were given free e-cigs and instructed to use them instead of smoking cigarettes for 6weeks. Smokers were assessed at baseline, weekly for 6weeks, and at 8 and 10weeks for cigarettes/day, e-cig use, CO, cigarette dependence, and Contemplation Ladder.

RESULTS

All participants completed 6weeks; 17 completed 10weeks. At Week 6, cigarettes/day were reduced by two-thirds and CO by 45% from baseline (p's<.001), with reductions maintained at Week 10 (p's<.005). Cigarette dependence scores were a third lower at Weeks 6 (p<.002) and 10 (p<.001) than at baseline. Contemplation Ladder scores were higher at Weeks 6 and 10 (p's<.001) than at baseline. All these statistical effect sizes were large. At Week 6, number of reasons not to use e-cigs increased (p<.011).

CONCLUSIONS

Results show preliminary evidence for beneficial effects of short-term switching to e-cigs by non-treatment seeking smokers in terms of reduced smoke toxicant exposure and cigarette dependence, and increased motivation to quit, all maintained at least 4weeks after free e-cigs were no longer provided.

Evaluation of the cognitive behavioral smoking reduction program "Smoke_less": a randomized controlled trial

The vast majority of smokers are unable or unwilling to quit, but many are open to reducing smoking. No treatment options exist for these smokers besides medication-based therapies. Thus, this study investigated the efficacy of a cognitive behavioral therapy (CBT) smoking reduction program, Smoke_less. A sample of 155 outpatient smokers aged 18-70 years was recruited at the Tobacco Dependence Outpatient Clinic of the Medical Center of the University of Munich, Germany, and randomly assigned to the experimental group (Smoke_less: four weekly CBT group sessions and two telephone calls over 5 weeks, n = 51), active comparator group (one 15-minute counseling session, n = 49), or waiting control group (no intervention during the study, n = 55). The primary endpoint was a ≥50% smoking reduction in the intention-to-treat group 1 week and 6 months after the intervention. We evaluated also abstinence rates at follow-up. Significantly more participants in the Smoke_less group had reduced smoking ≥50% compared to the waiting group at 1 week [OR 7.59 (2.59-22.19)] and 6 months [OR 5.00 (1.68-14.84)] and compared to the active comparison group at 1 week [OR 8.58 (2.67-27.31)] but not at 6 months [OR 1.73 (0.71-4.20)]. We found no significant effects on abstinence rates. The CBT smoking reduction program Smoke_less is effective for smoking reduction but is superior to brief counseling only in the short term. Further research is required to improve its efficacy in long-term smoking reduction to provide a valid, non-medication-based alternative to smokers unable or unwilling to quit.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02337400.

E-cigarette initiation and associated changes in smoking cessation and reduction: the Population Assessment of Tobacco and Health Study, 2013-2015

Background

The role of electronic cigarettes (e-cigarettes) in product transitions has been debated.

Methods

We used nationally representative data from the Population Assessment of Tobacco and Health Study waves 1 (2013–2014) and 2 (2014–2015) to investigate the associations between e-cigarette initiation and cigarette cessation/reduction in the USA. We limited the sample to current cigarette smokers aged 25+ years who were not current e-cigarette users at wave 1. We modelled 30-day cigarette cessation and substantial reduction in cigarette consumption as a function of e-cigarette initiation between surveys using multivariable logistic regression.

Results

Between waves 1 and 2, 6.9% of cigarette smokers who were not current e-cigarette users transitioned to former smokers. After adjusting for covariates, cigarette smokers who initiated e-cigarette use between waves and reported they used e-cigarettes daily at wave 2 had 7.88 (95% CI 4.45 to 13.95) times the odds of 30-day cigarette cessation compared with non-users of e-cigarettes at wave 2. Cigarette smokers who began using e-cigarettes every day and did not achieve cessation had 5.70 (95% CI 3.47 to 9.35) times the odds of reducing their average daily cigarette use by at least 50% between waves 1 and 2 compared with e-cigarette non-users.

Conclusions

Daily e-cigarette initiators were more likely to have quit smoking cigarettes or reduced use compared with non-users. However, less frequent e-cigarette use was not associated with cigarette cessation/reduction. These results suggest incorporating frequency of e-cigarette use is important for developing a more thorough understanding of the association between e-cigarette use and cigarette cessation.

Dual use of electronic nicotine delivery systems (ENDS) and smoked tobacco: a qualitative analysis

INTRODUCTION

Electronic nicotine delivery systems (ENDS) arguably pose fewer health risks than smoking, yet many smokers adopt ENDS without fully relinquishing smoking. Known as 'dual use', this practice is widespread and compromises the health benefits that ENDS may offer. To date, few studies have explored how dual use practices arise and manifest.

METHODS

We conducted in-depth, semi-structured interviews with 20 current ENDS users from New Zealand who reported smoking tobacco at least once a month. We explored participants' smoking history, their recent and current smoking, trial, uptake and patterns of ENDS use, and future smoking and vaping intentions. We managed the data using NVivo V.11 and used a thematic analysis approach to interpret the transcripts.

RESULTS

Dual use practices among participants evolved in four ways. First, as an attempt to manage the 'inauthenticity' of vaping relative to smoking and to retain meaningful rituals. Second, as complex rationalisations that framed decreased tobacco use, rather than smoking cessation, as 'success'. Third, as a means of alleviating the financial burden smoking imposed and to circumvent smoke-free policies. Lastly, dual use reflected attempts to comply with social group norms and manage stigma.

CONCLUSIONS

Dual use reflects both social and physical cues. It assisted participants to navigate smoking restrictions and allowed them to manage divergent norms. Policies that discourage smoking, particularly excise tax increases on smoked tobacco and smoke-free space restrictions, appear important in prompting ENDS use. Future research could explore whether these policies also help foster complete transition from smoking to exclusive ENDS use.

Population Modeling of Modified Risk Tobacco Products Accounting for Smoking Reduction and Gradual Transitions of Relative Risk

Introduction

As suggested by the Food and Drug Administration (FDA) Modified Risk Tobacco Product (MRTP) Applications Draft Guidance, we developed a statistical model based on public data to explore the effect on population mortality of an MRTP resulting in reduced conventional cigarette smoking. Many cigarette smokers who try an MRTP persist as dual users while smoking fewer conventional cigarettes per day (CPD). Lower-CPD smokers have lower mortality risk based on large cohort studies. However, with little data on the effect of smoking reduction on mortality, predictive modeling is needed.

Methods

We generalize prior assumptions of gradual, exponential decay of Excess Risk (ER) of death, relative to never-smokers, after quitting or reducing CPD. The same age-dependent slopes are applied to all transitions, including initiation to conventional cigarettes and to a second product (MRTP). A Monte Carlo simulation model generates random individual product use histories, including CPD, to project cumulative deaths through 2060 in a population with versus without the MRTP. Transitions are modeled to and from dual use, which affects CPD and cigarette quit rates, and to MRTP use only.

Results

Results in a hypothetical scenario showed high sensitivity of long-run mortality to CPD reduction levels and moderate sensitivity to ER transition rates.

Conclusions

Models to project population effects of an MRTP should account for possible mortality effects of reduced smoking among dual users. In addition, studies should follow dual-user CPD histories and quit rates over long time periods to clarify long-term usage patterns and thereby improve health impact projections.

Implications

We simulated mortality effects of a hypothetical MRTP accounting for cigarette smoking reduction by smokers who add MRTP use. Data on relative mortality risk versus CPD suggest that this reduction may have a substantial effect on mortality rates, unaccounted for in other models. This effect is weighed with additional hypothetical effects in an example.

Using Self-affirmation to Increase the Effects of Emotive Health Warnings on Smoking: A Randomized Exploratory Trial

Introduction

Emotive health messages are widely used tools in tobacco control. However, under some circumstances, they can be less effective than desired by eliciting defensive responses in smokers.

Aims

This study tests whether enhancing a currently used emotive graphic smoking health warning with a self-affirmation component reduces cigarette consumption and whether potential effects are stronger in heavier smokers, as suggested by previous research.

Methods

Participants (n = 265) were randomly allocated to a self-affirmation (reflecting on personal values and positive traits using a questionnaire) or matched control condition before viewing an emotive graphic health message from a current Australian government public health campaign. The primary outcome (cigarettes per day [CPD]) was assessed both before and a week following the intervention.

Results

No main effect of self-affirmation on smoking, but as hypothesized, a significant interaction between baseline smoking and self-affirmation was found that showed that heavier smokers (>21 CPD) who self-affirmed significantly reduced CPD compared to nonaffirmed smokers.

Conclusions

These findings support the use of self-affirmation to enhance smoking awareness campaigns in heavier smokers.

Implications

This study shows that enhancing emotive graphic smoking health messages with self-affirmation (the act of reflecting on positive aspects of oneself) increases their effectiveness in heavier smokers. This suggests that self-affirmation might be a particularly useful tool for health promotion targeting heavier smokers. This study adds to previous research in that it is the first to test the add-on effects of self-affirmation to current graphic health messages on smoking rather than smoking-related cognitions.

Default mode network deactivation to smoking cue relative to food cue predicts treatment outcome in nicotine use disorder

Identifying predictors of treatment outcome for nicotine use disorders (NUDs) may help improve efficacy of established treatments, like varenicline. Brain reactivity to drug stimuli predicts relapse risk in nicotine and other substance use disorders in some studies. Activity in the default mode network (DMN) is affected by drug cues and other palatable cues, but its clinical significance is unclear. In this study, 143 individuals with NUD (male n = 91, ages 18-55 years) received a functional magnetic resonance imaging scan during a visual cue task during which they were presented with a series of smoking-related or food-related video clips prior to randomization to treatment with varenicline (n = 80) or placebo. Group independent components analysis was utilized to isolate the DMN, and temporal sorting was used to calculate the difference between the DMN blood-oxygen-level dependent signal during smoke cues and that during food cues for each individual. Food cues were associated with greater deactivation compared with smoke cues in the DMN. In correcting for baseline smoking and other clinical variables, which have been shown to be related to treatment outcome in previous work, a less positive Smoke - Food difference score predicted greater smoking at 6 and 12 weeks when both treatment groups were combined (P = 0.005, β = -0.766). An exploratory analysis of executive control and salience networks demonstrated that a more positive Smoke - Food difference score for executive control network predicted a more robust response to varenicline relative to placebo. These findings provide further support to theories that brain reactivity to palatable cues, and in particular in DMN, may have a direct clinical relevance in NUD.

Discontinuous Patterns of Cigarette Smoking From Ages 18 to 50 in the United States: A Repeated-Measures Latent Class Analysis

INTRODUCTION

Effective cigarette smoking prevention and intervention programming is enhanced by accurate understanding of developmental smoking pathways across the life span. This study investigated within-person patterns of cigarette smoking from ages 18 to 50 among a US national sample of high school graduates, focusing on identifying ages of particular importance for smoking involvement change.

AIMS AND METHODS

Using data from approximately 15,000 individuals participating in the longitudinal Monitoring the Future study, trichotomous measures of past 30-day smoking obtained at 11 time points were modeled using repeated-measures latent class analyses. Sex differences in latent class structure and membership were examined.

RESULTS

Twelve latent classes were identified: three characterized by consistent smoking patterns across age (no smoking; smoking < pack per day; smoking pack + per day); three showing uptake to a higher category of smoking across age; four reflecting successful quit behavior by age 50; and two defined by discontinuous shifts between smoking categories. The same latent class structure was found for both males and females, but membership probabilities differed between sexes. Although evidence of increases or decreases in smoking behavior was observed at virtually all ages through 35, 21/22 and 29/30 appeared to be particularly key for smoking category change within class.

CONCLUSIONS

This examination of latent classes of cigarette smoking among a national US longitudinal sample of high school graduates from ages 18 to 50 identified unique patterns and critical ages of susceptibility to change in smoking category within class. Such information may be of particular use in developing effective smoking prevention and intervention programming.

IMPLICATIONS

This study examined cigarette smoking among a national longitudinal US sample of high school graduates from ages 18 to 50 and identified distinct latent classes characterized by patterns of movement between no cigarette use, light-to-moderate smoking, and the conventional definition of heavy smoking at 11 time points via repeated-measures latent class analysis. Membership probabilities for each smoking class were estimated, and critical ages of susceptibility to change in smoking behaviors were identified.

Depression Among Non-Daily Smokers Compared to Daily Smokers and Never-Smokers in the United States: An Emerging Problem

INTRODUCTION

Depression is strongly associated with daily smoking. Yet, little is known about the association between depression and non-daily smoking. The aim of this study was to investigate the prevalence of past-year depression and changes in past-year depression over time among non-daily smokers, compared to daily smokers and never-smokers, overall and stratified by age, gender, income, nicotine dependence, and cigarettes per day.

METHODS

Data were drawn from the National Household Survey on Drug Use (NSDUH), an annual cross-sectional study of persons aged 12 and over (total study population N = 496 805). The prevalence of past-year depression was examined annually among non-daily smokers, daily smokers, and never-smokers from 2005 to 2013 using linear trend analyses.

RESULTS

Past-year depression was common among 10.10% of non-daily smokers, common among 10.78% of daily smokers, and 5.51% of never-smokers in 2013. The prevalence of depression increased from 2005 to 2013 among non-daily smokers (9.06% vs. 10.10%; p = .034) while there was no significant change in depression over time among daily smokers. Increases in depression among non-daily smokers occurred for both men and women and appear most pronounced youth, those smoking fewer cigarettes, and those without nicotine dependence.

CONCLUSIONS

The prevalence of depression among non-daily smokers was equivalent to daily smokers and nearly twice that among nonsmokers. Depression appears to be increasing over time in non-daily smokers especially among youth, those who smoke less, and those without nicotine dependence. More work on the mental health of non-daily smokers is needed as this is an increasing and understudied group.

IMPLICATIONS

This is the first study to investigate changes in the prevalence of depression among non-daily smokers compared to daily smokers and never-smokers over the past decade in a nationally representative sample of the United States. The results suggest an increase in depression among non-daily smokers over time that did not similarly occur for daily smokers. Further, there were several subgroups of non-daily smokers among whom depression has increased more rapidly. This study suggests the need for more information about the relationship between depression and non-daily smoking including the impact of depression on quit attempts and outcomes.

Cigarette Smoking: An Accessory to the Development of Insulin Resistance

Insulin resistance is a condition characterized by decreased sensitivity of a skeletal or adipose cell to insulin, resulting in decreased glucose uptake by the cell. This can lead to hyperinsulinemia and further reduce insulin sensitivity. Insulin resistance is one of the primary factors contributing to metabolic syndrome (MetS), causing elevated glucose and fatty acid concentrations in the blood. Smoking is associated with insulin resistance in a dose-dependent manner. It directly increases the risk for insulin resistance, mainly via hormone activation, and may indirectly cause insulin resistance due to its effects on abdominal obesity. Nicotine may be the factor underlying these potential mechanisms. With the prevalence of prediabetes and diabetes on the rise, and considering the role of smoking and its relationship to insulin resistance, smoking reduction or cessation may be a viable option for those who are at risk or already identified as insulin resistant. Therefore, smoking cessation or reduction would serve as a beneficial component in any diabetes prevention or treatment plan.