Empowering smokers with a web-assisted tobacco intervention to use prescription smoking cessation medications: a feasibility trial

Development and validation of a nomogram to predict medication risk based on a knowledge, attitude and practice (KAP) survey of residents in Shanxi Province, China

Objective

Unsafe medication practices and medication errors are a major cause of harm in healthcare systems around the world. This study aimed to explore the factors that influence the risk of medication and provide medication risk evaluation model for adults in Shanxi province, China.

Methods

The data was obtained from the provincial questionnaire from May to December 2022, relying on the random distribution of questionnaires and online questionnaires by four hospitals in Shanxi Province. Multiple linear regression analysis was used to explore the factors affecting the KAP score of residents. Univariate and multivariate logistic regression was used to determine the independent risk factors, and the nomogram was verified by receiver operating characteristic curve, calibration and decision curve analysis.

Results

A total of 3,388 questionnaires were collected, including 3,272 valid questionnaires. The average scores of drugs KAP were 63.2 ± 23.04, 33.05 ± 9.60, 23.67 ± 6.75 and 33.16 ± 10.87, respectively. On the evaluation criteria of the questionnaire, knowledge was scored "fair", attitude and practice were scored "good". Sex, monthly income, place of residence, insurance status, education level, and employment were regarded as independent risk factors for medication and a nomogram was established by them.

Conclusion

Males, low-income, and low-educated people are important factors affecting the risk of medication. The application of the model can help residents understand the risk of their own medication behavior and reduce the harm of medication.

Barriers to smoking interventions in community healthcare settings: a scoping review

Smoking is one of the major causes of preventable death and is considered the greatest threat to global public health. While the prevalence of smoking has decreased, population growth has led to an increase in the absolute number of smokers. There are many proven smoking cessation interventions available to support smokers in their quit attempts. Most people who smoke, however, underutilize the treatments available to them. This scoping review aimed to identify the current barriers experienced by all stakeholders (smokers, service providers and policymakers) to existing evidence-based smoking cessation interventions in community healthcare settings. Five electronic databases (CINAHL, Ovid MEDLINE, PsycINFO, Scopus and Web of Science) were searched for relevant literature. A total of 40 eligible articles from different countries published between 2015 and 2022 were included in the review and content analysis carried out to identify the key barriers to smoking cessation interventions. Seven key themes were found to be common to all stakeholders: (i) literacy, (ii) competing demands and priorities, (iii) time, (iv) access to product, (v) access to service, (vi) workforce and (vii) motivation/readiness. These themes were mapped to the Capability, Opportunity, Motivation-Behaviour (COM-B) model. This study presents the effect the barriers within these themes have on current smoking cessation services and highlights priorities for future interventions.

Treatment use patterns in a large extended-treatment tobacco cessation program: predictors and cost implications

BACKGROUND

Tobacco dependence follows a chronic and relapsing course, but most treatment programmes are short. Extended care has been shown to improve outcomes. Examining use patterns for longer term programmes can quantify resource requirements and identify opportunities for improving retention.

METHODS

We analyse 38 094 primary care treatment episodes from a multisite smoking cessation programme in Ontario, Canada that provides free nicotine replacement therapy (NRT) and counselling. We calculate distributional measures of weeks of NRT used, clinical visits attended and total length of care. We then divide treatment courses into four exclusive categories and fit a multinomial logistic regression model to measure associations with participant characteristics, using multiple imputation to address missing data.

RESULTS

Time in treatment (median=50 days), visits (median=3) and weeks NRT used (median=8) were well below the maximum available. Of all programme enrolments, 28.8% (95% CI=28.3% to 29.3%) were single contacts, 31.3% (30.8% to 31.8%) lasted <12 weeks, 19.2% (18.8% to 19.6%) were ≥12 weeks with an 8-week interruption and 20.7% (20.3%-21.1%) were ≥12 weeks without interruptions. Care use was most strongly associated with participant age and whether the nicotine patch was dispensed at the first visit.

CONCLUSION

Treatment use results imply that the marginal costs of extending treatment programmes are relatively low. The prevalence of single contacts supports additional engagement efforts at the initial visit, while interruptions in care highlight the ability of longer term care to address relapse. Results show that use of the nicotine patch is associated with retention in care, and that improving engagement of younger patients should be a priority.

Evaluating the effectiveness of bupropion and varenicline for smoking cessation using an internet-based delivery system: A pragmatic randomized controlled trial (MATCH study)

BACKGROUND

Traditional randomized controlled trials have demonstrated the efficacy of pharmacotherapy for smoking cessation. However, accessibility to treatments remains a barrier, necessitating the remote delivery of evidence-based cessation interventions. The aim of this study was to evaluate the effectiveness of an online treatment that included first-line prescription medications using a pragmatic randomized controlled trial design.

METHODS

This study was a two-group, parallel block randomized, open label, controlled trial, and conducted exclusively online. Participants were randomised (1:1) to either bupropion (150 mg) or varenicline (1 mg) for twelve weeks. Medication was couriered to participants. The primary outcome was 7-day point prevalence abstinence (PPA; defined as 0 cigarette puffs in the last 7 days) at 12 weeks. Secondary outcomes were 7-day PPA at 4-, 8-, 26-, and 52-weeks follow-up. Adverse events were evaluated at each follow-up session during treatment.

RESULTS

The varenicline group (n = 499) had significantly higher 7-day PPA (30.3%) compared to the bupropion group (n = 465; 19.6%) at end of treatment (OR=2.08, 95% CI: 1.49-2.90, p < 0.001). Seven-day PPA was also higher for the varenicline group at 4-weeks (OR=1.71, 95% CI: 1.23-2.40 p = 0.0001), and 8-weeks follow-up (OR=1.95, 95% CI: 1.43-2.67 p < 0.0001), but not at post-treatment follow-up. More adverse events were reported in the varenicline group, compared to bupropion.

CONCLUSIONS

This internet-based pharmacotherapy intervention was a feasible and effective method of treatment delivery for smoking cessation. This method can be used to increase the accessibility and availability of cessation interventions, decreasing the burden of smoking-related diseases.

TRIAL REGISTRATION

This trial was registered with clinical trials.gov under NCT02146911. Registered 26 May 2014, https://clinicaltrials.gov/ct2/show/NCT02146911.

A digital solution to streamline access to smoking cessation interventions in England; findings from a primary care pilot (STOPNOW study)

Objectives

Despite the proven efficacy of several smoking cessation medications that have been shown to improve long-term abstinence rates, approximately two-thirds of smokers report not having used medication in their most recent quit attempt. A main barrier could be delayed access to pharmacological interventions. This study investigated the utility of a primary care linked online portal to streamline timely access to pharmacological support to patients who want to quit smoking by making an asynchronous request for treatment to their general practitioner.

Study design

Prospective cohort study.

Methods

An online portal with added functionality was developed, which allowed patients with a unique link to make an asynchronous request for treatment. Two GP practices identified a total of 4337 eligible patients who received an SMS or email invite to engage with an online portal including an electronic survey to capture information about smoking behaviours and to request treatment. Portal informatics and patient level data were analysed to measure the efficacy of the online system in reducing the time between making a formal request to treatment and access to pharmacological support. The primary outcome measure was the time between making a formal request for treatment and access to pharmacological support from a designated community pharmacy.

Results

323 patients (7.4%) initiated the survey, but only 56 patients completed the survey and made a formal request for treatment. 94% of participants did not return to use the portal to make a second or follow-up request for treatment. Only 3 participants completed the 12-week pathway. A total of 75 medication items were prescribed and collected by 56 patients. The time difference between the formal request to treatment and GP review ranged between 20 h and 1 week. The time difference between approval of prescription by the GP and access to medication was 5 days ± 2.1 days (range = 1.9–7.0 days).

Conclusion

The widespread adoption and diffusion of an IT enabled and asynchronous primary care led remote consultation pathway can streamline timely access to smoking cessation support without the need for the patient to see a GP or an independent prescriber in the first instance.

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Traditional face-to-face smoking cessation interventions may result in significant delays between the patient's decision to quit and access to effective pharmacological support or behavioural therapies.

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This was the first attempt in the UK where a GP-led online portal with added functionality was used to streamline timely access to pharmacotherapy for smoking cessation using an asynchronous formal request for treatment.

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We evaluated the findings of a primary care pilot from two general practices in West London where 4337 patients who are registered as smokers were contacted with unique link to access the portal.

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The pervasive use of a primary care-led online portal could enablie patients to make an asynchronous request for treatment without the need to visit the general practice.

A Pilot Randomized Clinical Trial of Remote Varenicline Sampling to Promote Treatment Engagement and Smoking Cessation

INTRODUCTION

Medication sampling is a clinically useful tool to engage smokers in the quitting process. Whether varenicline is suitable for sampling purposes is unclear. The purpose of this study was to examine the feasibility, uptake, and preliminary outcomes of varenicline sampling.

METHODS

Smokers (N = 99), both motivated to quit and not, were recruited and randomized to varenicline sampling versus not, with 12 week follow-up. The intervention consisted of mailing one-time samples of varenicline (lasting 2-4 wks), with minimally suggestive guidance on use.

RESULTS

Uptake of varenicline was strong, at 2 weeks (54% any use, 66% daily use) and 4 weeks (38%, 46%), with 58% of medication users seeking additional medication. Most users followed conventional titration patterns, self-titrating from 0.5 mg to 2 mg. Relative to control, varenicline sampling increased motivation (p = 0.006) and confidence to quit (p = 0.02), and decreased cigarette smoking (p = 0.02). Smokers receiving varenicline samples were significantly more likely to achieve 50% reduction in cigarettes per day (CPD), both immediately following the sampling exercise (Adjusted Odds Ratio [AOR] = 4.12; 95% CI: 1.39 to 12.17) and at final follow-up (AOR = 4.50; 95% CI: 1.56 to 13.01). Though cessation outcomes were not statistically significant, there was a 1.5 to 3-fold increase in quit attempts and abstinence from varenicline sampling throughout follow-up. These outcomes were comparable among smokers motivated to quit and not.

CONCLUSIONS

Unguided, user-driven sampling of varenicline sampling is a concrete behavioral exercise that is feasible to do and seems to suggest clinical utility. Sampling is a pragmatic clinical approach to engage more smokers in quitting.

IMPLICATIONS

Use of evidence-based pharmacotherapies for smoking cessation is low. Medication sampling is a pragmatic behavioral exercise that allows smokers to experience the benefits of using them, while promoting positive downstream effects towards quitting. While previous studies have shown that nicotine replacement therapy (NRT) sampling is viable and effective, whether this extends to varenicline is unclear. Results from this trial demonstrate that varenicline sampling is feasible, safe, and suggestive of clinically important steps toward quitting, deserving of a larger trial.

CLINICAL TRIAL REGISTRATION

NCT #03742154.

An empowerment-psycho-behavioral program on neuropsychiatric symptoms in persons with mild cognitive impairment: Study protocol of a randomized controlled trial

AIMS

Neuropsychiatric symptoms (NPS) are highly prevalent among persons with mild cognitive impairment (PwMCI). However, the mainstay of treatments only focuses on cognitive training. This study develops an empowerment-psycho-behavioural programme to improve the NPS and other health outcomes of this preclinical cohort. The empirical effects and the participants' perception and experience of the programme will be explored.

DESIGN

This sequential mixed-method study comprises a single-blind randomized controlled trial and a qualitative study.

METHODS

This study will recruit 250 PwMCI from the community and randomize them to either the intervention group to receive a 13-week empowerment-psycho-behavioural programme which focuses on promoting cognitive coping and stress adaptation, or the control group to receive a health education programme which serves as an attention placebo with content unrelated to dementia. The primary outcome is NPS, and the secondary outcomes include cognitive function, subjective memory complaints and health-related quality of life. These outcomes will be measured at baseline, upon completing the programme and 4 weeks thereafter. A purposive sample of 30 participants from the intervention group will be interviewed for their engagement experience in the programme. This study received funding support in July 2020.

DISCUSSION

Given the high prevalence and detrimental effects of NPS on disease progression, effective management is yet to be determined. Underpinned by the Progressively Lowered Stress Threshold (PLST) Model, the empowerment-psycho-behavioural programme is designed. Results on the outcome-based evaluation and the patients' experience can advance the science in this under-addressed area.

IMPACT

This study enhances our understanding of the PLST Model in explaining the manifestations of NPS by the stress-coping disequilibrium at the early disease stage. It will shed important insight into the care management of MCI to attend both cognition function and psychological well-being in research and clinical context.

TRIAL REGISTRATION

This study is registered in the ClinicalTrials.gov (NCT04723667) and the HKU Clinical Trials Registry (HKUCTR-2915).

Feasibility, Efficacy, and Cost Analysis of Promoting Smoking Cessation at Outdoor Smoking "Hotspots": A Pre-Post Study

Introduction

To motivate smokers to quit, there is a need for enhanced smoking cessation (SC) recruitment and for innovative and proactive approaches to SC. This study evaluated the feasibility, efficacy, and cost of promoting SC in public outdoor areas where smokers gather to smoke (smoking hotspots).

Methods

We selected 14 smoking hotspots in Hong Kong for SC promotion in 2015. University students were trained as SC ambassadors to deliver brief SC intervention, and to recruit smokers for telephone follow-up. The proportion of smokers accepting the intervention components was recorded. Self-reported abstinence in the past 7 days and knowledge of smoking and health were assessed at the 6-month follow-up. The average costs of each smoker receiving our intervention and quitting were also compared.

Results

Of 3,080 smokers approached, 1,278 (41.5%) accepted the souvenir and 920 (29.9%) received brief advice. Of the 210 (6.8%) who consented to the follow-up, 24.5% were aged 15-29 and 46.4% were aged 30-49. Of the 151 smokers successfully contacted within 1 month after recruitment, 16 (10.6%; 1.3% of the 1,278 who received any form of intervention) reported abstinence, and their overall knowledge improved. The average costs for a smoker to receive brief advice, consent to follow up by telephone, attempt to quit, and quit successfully at the 6-month follow-up were US$30, US$132, US$601, and US$1,626, respectively.

Conclusions

Promoting SC at smoking hotspots could be a feasible way to achieve satisfactory quitting outcomes at low cost and is useful in the absence of the strengthening of tobacco policies.

Implications

Our study indicates that outdoor smoking hotspots are feasible platforms for promoting SC and recruiting smokers for cessation services; satisfactory outcomes can be achieved at a reasonable cost. Our promotion was particularly useful for recruiting young smokers and those who want to quit. It is feasible and efficacious to raise smokers' awareness of SC when other tobacco control policies not feasible. Indoor smoking bans or other substantial tobacco control policies could enhance the efficiency with which SC is promoted.

Varenicline and Bupropion for Long-Term Smoking Cessation (the MATCH Study): Protocol for a Real-World, Pragmatic, Randomized Controlled Trial

Background

Varenicline and bupropion are efficacious, prescription-only pharmacotherapies for smoking cessation; however, their real-world impact is limited by prescriber knowledge, affordability, and accessibility.

Objective

The primary objective of the MATCH (Medication Aids for Tobacco Cessation Health) study was to evaluate the real-world, long-term effectiveness of mailed bupropion and varenicline in a sample of interested smokers with the utilization of Web-based recruitment and follow-up. In addition, the study aims to investigate the genotypic and phenotypic predictors of cessation.

Methods

This is a two-group, parallel block, randomized (1:1) open-label clinical trial. This study will be conducted online with the baseline enrollment through the study’s website and follow-up by emails. In addition, medication prescriptions will be filled by the study contract pharmacy and couriered to participants. Individuals who smoke ≥10 cigarettes per day and intend to quit within the next 30 days will be recruited through Public Health Units and Tobacco Control Area Networks throughout Ontario by word-of-mouth and the internet. Eligible participants will receive an email with a prescription for 12-week assigned medication and a letter to take to their physician. The recruitment and randomization will continue until 500 participants per arm have received medication. All participants will receive weekly motivational emails during the treatment phase. The primary outcome measure is the smoking status after 6 months, biochemically confirmed by mailed-in salivary cotinine. Follow-ups will be conducted through emails after 4, 8, 12, 26, and 52 weeks of starting the treatment to assess the smoking prevalence and continuous smoking abstinence. In addition, mailed-in saliva samples will be used for genetic and nicotine metabolism analyses. Furthermore, personality characteristics will be assessed using the Big Five Aspect Scales.

Results

The project was funded in 2014 and enrollment was completed in January 2017. Data analysis is currently underway.

Conclusions

To the best of our knowledge, this is the first randomized controlled trial to mass distribute prescription medications for smoking cessation. We expect this method to be logistically feasible and cost effective with quit outcomes that are comparable to published clinical trials.

Trial Registration

ClinicalTrials.gov NCT02146911; https://clinicaltrials.gov/ct2/show/NCT02146911 (Archived by WebCite at http://www.webcitation.org/72CZ6AvXZ)

Registered Report Identifier

RR1-10.2196/10826