Nicotine Replacement Therapy Use Among a Cohort of Smokers

Smokers' utilization of quitting methods and vaping during pregnancy: an empirical cluster analysis of 2016-2018 Pregnancy Risk Assessment Monitoring System (PRAMS) data in seven US states

BACKGROUND

Patterns of utilization of numerous smoking cessation methods among pregnant women amidst the increasing popularity of vaping (use of e-cigarettes) remains unknown.

METHODS

This study included 3,154 mothers who self-reported smoking around the time of conception and delivered live births in 2016-2018 in seven US states. Latent class analysis was used to identify subgroups of smoking women based on their utilization of 10 surveyed quitting methods and vaping during pregnancy.

RESULTS

We identified four subgroups of smoking mothers with different utilization patterns of quitting methods during pregnancy: 22.0% reported "not trying to quit"; 61.4% tried to "quit on my own" without any behavioral or pharmacological assistance; 3.7% belonged to the "vaping" subgroup; and 12.9% utilized "wide-ranging methods" with higher use rate of multiple approaches, such as quit line and nicotine patch. Compared to mothers "not trying to quit," the subgroup trying to "quit on my own" were more likely to be abstinent (adjusted OR 4.95, 95% CI 2.82-8.35) or to reduce the number of cigarettes smoked daily (adjusted OR 2.46, 95% CI 1.31-4.60) in late pregnancy, and these improvements lasted into early postpartum. We did not observe a measurable reduction in smoking among the "vaping" subgroup or women trying to quit with "wide-ranging methods".

CONCLUSIONS

We identified four subgroups of smoking mothers with different utilization patterns of eleven quitting methods during pregnancy. Pre-pregnancy smokers who tried to "quit on my own" were most likely to be abstinent or to reduce smoking amount.

Evaluating level of adherence to nicotine replacement therapy and its impact on smoking cessation: a protocol for systematic review and meta-analysis

INTRODUCTION

Nicotine replacement therapy (NRT) has proven effective for smoking cessation in clinical trials, however it was found less effective in population-based studies, potentially due to inconsistent or incorrect use of NRT. The aim of this paper is to describe a systematic review protocol to evaluate level of adherence to NRT; the discrepancy of adherence to NRT in clinical and population-based studies and degree of association between level of adherence and success of smoking cessation.

METHODS AND ANALYSIS

Literature search will use five databases (Medline, Scopus, Embase, CINAHL and PsycINFO). Studies will be appraised for methodological quality using National Institutes of Health Quality Assessment Tool. To reduce heterogeneity, we will analyse clinical trials and population-based studies separately; pooled analyses will be done among studies that used similar measurements. Heterogeneity of studies will be assessed by Higgins' I² statistical test. When studies are adequately homogeneous, results will be pooled using random-effects model with proportion and ORs with 95% CIs and p values for each outcome. We will explain sources of heterogeneity by subgroup analysis or sensitivity analysis. Funnel plots and Egger's regression asymmetry test with p<0.05 will be used as a cut-off point to affirm presence of statistically significant publication bias. Statistical analyses will be carried out using Stata V.16 software. Only studies reporting a valid strategy to control for reverse causality will be included.

DISCUSSION

This review will provide evidence to support the importance of adherence on rate of smoking cessation and level of adherence to NRT. The findings will be used to inform smoking cessation interventions, researchers and policymakers.

ETHICS AND DISSEMINATION

As a systematic literature review, this protocol does not require ethics approval. Research outcomes will be presented at relevant conferences and findings will be published in a relevant peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020176749.

Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: a systematic review and synthesis of best available evidence

BACKGROUND

While some experts have emphasised the potential for e-cigarettes to facilitate cessation among smokers with low socioeconomic status (SES), there is limited evidence of their likely equity impact. We assessed the potential for electronic cigarettes and other non-combustible nicotine-containing products (NCNPs) to reduce inequalities in smoking by systematically reviewing evidence on their use by SES in countries at stage IV of the cigarette epidemic.

METHODS

Ten electronic databases were searched in February 2017 using terms relating to e-cigarettes, smokeless tobacco and nicotine replacement therapy (NRT); and SES. We included studies published since 1980 that were available in English and examined product use by SES indicators such as income and education. Data synthesis was based on those studies judged to be of medium- to high-quality using guidelines adapted from the Critical Appraisal Skills Programme.

RESULTS

We identified 54 studies describing NCNP use by SES across 12 countries, of which 27 were judged of sufficient quality to include in data synthesis. We found mixed patterns of e-cigarette current use by SES, with evidence of higher use among low-income adults but unclear or mixed findings by education and occupation. In contrast, smokeless tobacco current use was consistently higher among low SES adults. There was very limited evidence on the SES distribution of NRT in adults and of all NCNPs in young people.

CONCLUSIONS

The only NCNP for which there are clear patterns of use by SES is smokeless tobacco, where prevalence is higher among low SES groups. While this suggests a potentially positive impact on inequalities in smoking (if NCNP use displaces smoked tobacco use), this has not been seen in practice. These findings do not support the suggestion that e-cigarettes have the potential to reduce social inequalities in smoking, since i) current evidence does not show a clear trend of higher e-cigarette use in population groups with higher tobacco consumption, and ii) the experience of smokeless tobacco suggests that - even where NCNP use is higher among low SES groups - this does not necessarily replace smoked tobacco use in these groups.

Cost-effectiveness of real-world administration of tobacco pharmacotherapy in the United States Veterans Health Administration

BACKGROUND AND AIMS

Cost-effectiveness studies in randomized clinical trials have shown that tobacco cessation pharmacotherapy is among the most cost-effective of health-care interventions. Clinical trial eligibility criteria and treatment protocols may not be followed in actual practice. This study aimed to determine whether tobacco cessation pharmacotherapy is cost-effective in real-world settings.

DESIGN

A retrospective analysis of costs and outcomes.

SETTING

Hospitals and clinics of the US Veterans Health Administration, USA.

PARTICIPANTS

A total of 589 862 US veterans who screened positive for tobacco use in 2011.

INTERVENTION AND COMPARATOR

Tobacco users who initiated smoking cessation pharmacotherapy in the 6 months after screening were compared with those who did not use pharmacotherapy in this period. Pharmacotherapy included nicotine replacement therapy, bupropion (if prescribed at 300 mg per day or specifically for tobacco cessation) or varenicline.

MEASURES

Effectiveness was determined from responses to a subsequent tobacco screening conducted between 7 and 18 months after the treatment observation period. Cost of medications and prescribing health-care encounters was determined for the period between initial and follow-up tobacco use screening. Multivariate fixed-effects regression was used to assess the effect of initial treatment status on cost and outcome while controlling for differences in case-mix with propensity weighting to adjust for confounding by indication.

FINDINGS

Thirteen per cent of participants received tobacco cessation pharmacotherapy within 6 months of initial screening. After an average of an additional 218.1 days' follow-up, those who initially received pharmacotherapy incurred $143.79 in additional treatment cost and had a 3.1% absolute increase in tobacco quit rates compared with those who were not initially treated. This represents an incremental cost-effectiveness ratio of $4705 per quit. The upper limit of the 99.9% confidence region was $5600 per quit. Without propensity adjustment, the cost-effectiveness ratio was $7144 per quit, with the upper limit of the 99.9% confidence region $9500/quit.

CONCLUSIONS

Tobacco cessation pharmacotherapy provided by the US Veterans Health Administration in 2011/12 was cost-effective in this real-world setting, with an incremental cost-effectiveness ratio of $4705 per quit.

Effectiveness of Pharmaceutical Smoking Cessation Aids in a Nationally Representative Cohort of American Smokers

Background

Despite strong efficacy in randomized trials, the population effectiveness of pharmaceutical aids in long-term smoking cessation is lacking, possibly because of confounding (factors that are associated with both pharmaceutical aid use and difficulty quitting). Matching techniques in longitudinal studies can remove this confounding bias.

Methods

Using the nationally representative Tobacco Use Supplement to the Current Population Survey (TUS-CPS), we assessed the effectiveness of medications to aid quitting among baseline adult smokers who attempted to quit prior to one year of follow-up in two longitudinal studies: 2002-2003 and 2010-2011. Pharmaceutical aid users and nonusers with complete data (n = 2129) were matched using propensity score models with 12 potential confounders (age, sex, race-ethnicity, education, smoking intensity, nicotine dependence, previous quit history, self-efficacy to quit, smoke-free homes, survey year, and cessation aid use). Using matched data sets, logistic regression models were fit to assess whether use of any individual pharmaceutical aid increased the proportion of patients who were abstinent for 30 days or more at follow-up.

Results

Propensity score matching markedly improved balance on the potential confounders between the pharmaceutical aid use groups. Using matched samples to provide a balanced comparison, there was no evidence that use of varenicline (adjusted risk difference [aRD] = 0.01, 95% confidence interval [CI] = -0.07 to 0.11), bupropion (aRD = 0.02, 95% CI = -0.04 to 0.09), or nicotine replacement (aRD = 0.01, 95% CI = -0.03 to 0.06) increased the probability of 30 days or more smoking abstinence at one-year follow-up.

Conclusions

The lack of effectiveness of pharmaceutical aids in increasing long-term cessation in population samples is not an artifact caused by confounded analyses. A possible explanation is that counseling and support interventions provided in efficacy trials are rarely delivered in the general population.

How do we determine the impact of e-cigarettes on cigarette smoking cessation or reduction? Review and recommendations for answering the research question with scientific rigor

AIMS

To propose a hierarchy of methodological criteria to consider when determining whether a study provides sufficient information to answer the question of whether e-cigarettes can facilitate cigarette smoking cessation or reduction.

DESIGN

A PubMed search to 1 February 2017 was conducted of all studies related to e-cigarettes and smoking cessation or reduction.

SETTINGS

Australia, Europe, Iran, Korea, New Zealand and the United States.

PARTICIPANTS AND STUDIES

91 articles.

MEASUREMENTS

Coders organized studies according to six proposed methodological criteria: (1) examines outcome of interest (cigarette abstinence or reduction), (2) assesses e-cigarette use for cessation as exposure of interest, (3) employs appropriate control/comparison groups, (4) ensures that measurement of exposure precedes the outcome, (5) evaluates dose and duration of the exposure and (6) evaluates the type and quality of the e-cigarette used.

FINDINGS

Twenty-four papers did not examine the outcomes of interest. Forty did not assess the specific reason for e-cigarette use as an exposure of interest. Twenty papers did not employ prospective study designs with appropriate comparison groups. The few observational studies meeting some of the criteria (duration, type, use for cessation) triangulated with findings from three randomized trials to suggest that e-cigarettes can help adult smokers quit or reduce cigarette smoking.

CONCLUSIONS

Only a small proportion of studies seeking to address the effect of e-cigarettes on smoking cessation or reduction meet a set of proposed quality standards. Those that do are consistent with randomized controlled trial evidence in suggesting that e-cigarettes can help with smoking cessation or reduction.

Mailed distribution of free nicotine patches without behavioral support: Predictors of use and cessation

INTRODUCTION

There is growing evidence that the mailed distribution of free nicotine replacement therapy (NRT), usually as part of smokers' helplines, can been effective in increasing the odds of cessation on a population level. However, limited information is available on the utilization of NRT when it is provided for free, and factors associated with regimen adherence have remained largely unexplored.

METHODS

In the context of a randomized controlled trial, 500 adult smokers across Canada hypothetically interested in free NRT were mailed a 5week supply of nicotine patches, but no other support was offered. Analyses evaluated which a priori-defined demographic and smoking characteristics predicted nicotine patch use at 8week follow-up of 421 patch recipients, as well as examined the association between patch use and smoking cessation at 6months.

RESULTS

At 8weeks, 10.9% had used all, 47.5% had used some but not all, and 41.6% had not used any of the provided nicotine patches. Lower age, unemployment, past NRT use and intent to quit in the next 30days at baseline (preparation stage of change) were all identified as independent predictors of some nicotine patch use. Only use of all patches was associated with greater odds of smoking cessation, compared to non-users (Adj. OR=2.96; 95%CI=1.06-8.27).

CONCLUSIONS

The mailed distribution of free nicotine patches to smokers at large can be effective at promoting cessation, particularly among financially disadvantaged groups, those with previous NRT experience and among individuals with already advanced intent to quit.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

Impact of self-reported lifetime depression or anxiety on effectiveness of mass distribution of nicotine patches

BACKGROUND

Large-scale public health initiatives providing free nicotine replacement therapy have been shown to increase smoking cessation rates; however, their effectiveness among the highly prevalent population of smokers with depression and anxiety disorders has not been explored. The aim of this study was to investigate the influence of lifetime history of depression or anxiety on smoking cessation success following the free distribution of nicotine patches.

METHOD

In the context of a randomised controlled trial, a secondary analysis was conducted on 1000 adult regular smokers randomised to be mailed a 5-week supply of nicotine patches or to a no intervention control group. Participants were divided into subgroups based on the presence of self-reported lifetime diagnosis of depression and anxiety.

RESULTS

Irrespective of self-reported lifetime history of depression or anxiety, odds of self-reported cessation at 6 months were significantly greater among groups receiving nicotine patches compared to no intervention control (no history of depression or anxiety: OR 2.20; 95% CI 1.05 to 4.63; history of depression or anxiety present: OR 3.90; 95% CI 1.28 to 11.88). Among nicotine patch recipients only, quit outcomes did not differ between those with and without self-reported lifetime depression or anxiety in models unadjusted and adjusted for differences in demographic and smoking characteristics.

CONCLUSIONS

The mass distribution of free nicotine patches (without behavioural support) is effective among smokers with or without lifetime history of depression or anxiety alike, providing further support for the adoption of similar initiatives as a means of promoting tobacco cessation on a population level.

TRIAL REGISTRATION NUMBER

NCT01429129, Post-results.

Telephone Smoking-Cessation Counseling for Smokers in Mental Health Clinics: A Patient-Randomized Controlled Trial

INTRODUCTION

People with a mental health diagnosis have high rates of tobacco use and encounter limited availability of tobacco treatment targeted to their needs. This study compared the effectiveness of a specialized telephone smoking-cessation intervention developed for mental health patients with standard state quit-line counseling.

DESIGN

RCT.

SETTING/PARTICIPANTS

The study was conducted at six Veterans Health Administration facilities in the Northeast U.S. Participants were 577 mental health clinic patients referred by their providers for smoking-cessation treatment.

INTERVENTION

From 2010 to 2012, the study implemented a telephone program that included patient referral from a mental health provider, mailed cessation medications, and telephone counseling. Participants were randomized to receive a specialized multisession telephone counseling protocol (n=270) or transfer to their state's quit-line for counseling (n=307).

MAIN OUTCOME MEASURES

Participants completed telephone surveys at baseline, 2 months, and 6 months. The study's primary outcome was self-reported 30-day abstinence at 6 months. Secondary outcomes were self-reported 30-day abstinence, counseling satisfaction and counseling content at 2 months, and self-reported use of cessation treatment and quit attempts at 6 months. Logistic regression was used to compare treatment groups on outcomes, controlling for baseline cigarettes per day and site. Inverse probability weighting and multiple imputation were used to handle missing abstinence outcomes. Data were analyzed in 2014-2015.

RESULTS

At 6 months, participants in the specialized counseling arm were more likely to report 30-day abstinence (26% vs 18%, OR=1.62, 95% CI=1.24, 2.11). There was no significant group difference in abstinence at 2 months (18% vs 14%, OR=1.31, 95% CI=0.49, 3.49). Participants in the specialized arm were more likely to be assisted with developing a quit plan; receive follow-up calls after quitting; and receive counseling on several domains, including motivation, confidence, smoking triggers, coping with urges, and mental health symptoms (all p<0.05). Specialized counseling participants were more satisfied with treatment and more likely to find the counseling useful (p<0.05).

CONCLUSIONS

The specialized counseling intervention was more effective at helping patients quit than transfer to a state quit-line. Patients were more satisfied with the specialized counseling program.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT00724308.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nicotine replacement therapy in pregnancy and major congenital anomalies in offspring

BACKGROUND AND OBJECTIVES

Nicotine replacement therapy (NRT) is now being used as a smoking cessation aid during pregnancy, although little is known about fetal safety. We assessed the relationship between early pregnancy exposure to NRT or smoking with major congenital anomalies (MCA) in offspring.

METHODS

We studied 192,498 children born in the United Kingdom between 2001 and 2012 with linked mother-child primary care records. The absolute risks of MCAs in the NRT group (women prescribed NRT during the first trimester or 1 month before conception [and therefore likely consumed during the first trimester]) and odds ratios (ORs) and 99% confidence intervals (CIs) were compared with those of women who smoked during pregnancy and with a control group (women who neither smoked nor were prescribed NRT); logistic regression models adjusted for maternal morbidities that increase MCA risk were used for analysis.

RESULTS

MCA prevalence was 288 per 10,000 live births (5535 children with ≥ 1 MCA). Maternal morbidities were most common in the NRT group (35%) followed by smokers (27%) and the control group (20%). Compared with the control group, adjusted ORs for MCAs in the NRT group and smokers were 1.12 (99% CI: 0.84-1.48) and 1.05 (99% CI: 0.89-1.23), respectively. The OR comparing the NRT group directly with smokers was 1.07 (99% CI: 0.78-1.47). There were no statistically significant associations between maternal NRT and system-specific anomalies except for respiratory anomalies (OR: 4.65 [99% CI: 1.76-12.25]; absolute risk difference: 3 per 1000 births), which was based on 10 exposed cases.

CONCLUSIONS

For most system-specific MCAs, we found no statistically significant increased risks associated with maternal NRT prescribed during pregnancy, except for respiratory anomalies. Although this study is the largest published to date, NRT use in pregnancy remains rare; thus, the statistical power was limited. Higher morbidities in those women prescribed NRT may also be an explanatory factor. Nevertheless, absolute MCA risks were similar between women who smoked and those prescribed NRT during pregnancy.

Duration of nicotine replacement therapy use and smoking cessation: a population-based longitudinal study

In the present study, we examined the association between duration of nicotine replacement therapy (NRT) use and smoking cessation using data from the Ontario Tobacco Survey longitudinal study (3 waves of data collected between July 2005 and December 2009). We used logistic regression with generalized estimating equations to examine the association between NRT use (any use and <4 weeks, 4.0–7.9 weeks, 8.0–11.9 weeks, and ≥12 weeks of use compared with nonuse) and quitting smoking (≥1 month). Using NRT was not associated with quitting when use duration was not taken into account (adjusted odds ratio (OR) = 1.08, 95% confidence interval (CI): 0.86, 1.35). Compared with abstaining from NRT when attempting to quit smoking, using NRT for less than 4 weeks was associated with a lower likelihood of quitting (adjusted OR = 0.51, 95% CI: 0.38, 0.67); however, using NRT for 4 weeks or longer was associated with a higher likelihood of cessation (for 4.0–7.9 weeks of NRT use, adjusted OR = 2.26, 95% CI: 1.58, 3.22; for 8.0–11.9 weeks of NRT use, adjusted OR = 3.84, 95% CI: 2.24, 6.58; and for ≥12 weeks of NRT use, adjusted OR = 2.80, 95% CI: 1.70, 4.61). Thus, use of NRT for less than 4 weeks was associated with reduced likelihood of cessation, whereas NRT use for longer periods of time was associated with a higher likelihood of cessation.

Association between duration of use of pharmacotherapy and smoking cessation: findings from a national survey

OBJECTIVE

To investigate the association of the duration of use of prescription medications and nicotine replacement therapy (NRT) with smoking cessation using a national sample of the general population in the USA, controlling for nicotine dependence and sociodemographic variables.

SETTING USA PARTICIPANTS

We used data from the 2010-2011 Tobacco Use Supplement to the US Current Population Survey. We limited the analysis to current daily smokers who made a quit attempt in the past year and former smokers who were a daily smoker 1 year prior to the survey (n=8263). Respondents were asked about duration of use of prescription medication (varenicline, bupropion, other) and NRT (nicotine patch, gum/lozenges, nasal spray and inhaler) for smoking cessation.

PRIMARY OUTCOME MEASURE

Successful smoking cessation. Individuals who reported to have smoked at least 100 cigarettes in their lifetime but were not smoking at all at the time of the interview and were a daily smoker 1 year prior to the interview were considered to have successfully quit smoking.

RESULTS

After adjusting for daily cigarette consumption and sociodemographic covariates, we found evidence for an association between duration of pharmacotherapy use and smoking cessation (p<0.001). Adjusted cessation rates for those who used prescription medication or NRT for 5+ weeks were 28.8% and 27.8%, respectively. Adjusted cessation rates for those who used prescription medication or NRT for less than 5 weeks varied from 6.2% to 14.5%. Adjusted cessation rates for those who used only behavioural counselling and those who attempted to quit smoking unassisted were 16.1% and 16.4%, respectively.

CONCLUSIONS

Use of pharmacotherapy for at least 5 weeks is associated with increased likelihood of successful smoking cessation. Results suggest that encouraging smokers who intend to quit to use pharmacotherapy and to adhere to treatment duration can help improve chances of successful cessation.

Effectiveness of proactive and reactive services at the Swedish National Tobacco Quitline in a randomized trial

BACKGROUND

The Swedish National Tobacco Quitline (SNTQ), which has both a proactive and a reactive service, has successfully provided tobacco cessation support since 1998. As there is a demand for an increase in national cessation support, and because the quitline works under funding constraints, it is crucial to identify the most clinically effective and cost-effective service. A randomized controlled trial was performed to compare the effectiveness of the high-intensity proactive service with the low-intensity reactive service at the SNTQ.

METHODS

Those who called the SNTQ for smoking or tobacco cessation from February 2009 to September 2010 were randomized to proactive service (even dates) and reactive service (odd dates). Data were collected through postal questionnaires at baseline and after 12 months. Those who replied to the baseline questionnaire constituted the study base. Outcome measures were self-reported point prevalence and 6-month continuous abstinence at the 12-month follow-up. Intention-to-treat (ITT) and responder-only analyses were performed.

RESULTS

The study base consisted of 586 persons, and 59% completed the 12-month follow-up. Neither ITT- nor responder-only analyses showed any differences in outcome between proactive and reactive service. Point prevalence was 27% and continuous abstinence was 21% in analyses treating non-responders as smokers, and 47% and 35%, respectively, in responder-only analyses.

CONCLUSION

Reactive service may be used as the standard procedure to optimize resource utilization at the SNTQ. However, further research is needed to assess effectiveness in different subgroups of clients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02085616.

A systematic review of studies assessing the association between adherence to smoking cessation medication and treatment success

AIMS

Lack of adherence to smoking cessation medication regimens is assumed to play a significant role in limiting their effectiveness. This study aimed to assess evidence for this assumption.

METHODS

A systematic search was conducted, supplemented by expert consultation, of papers reporting on randomized trials and observational studies examining the association between adherence to cessation medication and the success of quit attempts. To rule out reverse causality, only studies where adherence was assessed prior to relapse were included. Five studies met the inclusion criteria and results were extracted independently by two researchers. Heterogeneity between studies precluded a pooled analysis of the data.

RESULTS

Studies varied widely with regard to both the definition of adherence and outcome measures. The included studies only addressed adherence to nicotine replacement therapy. One study of lozenge use found that the amount of medication used between 1 and 2 weeks after the quit date predicted abstinence at 6 weeks [adjusted odds ratio (OR) for 'high' versus 'low' lozenge use 1.25; 95% confidence interval (CI) = 1.05-1.50; P < 0.02]. Similarly, one study found a significant impact of oral nicotine consumption during the first week on abstinence at 4 weeks (adjusted OR per additional mg/day = 1.05; CI = 1.01-1.10). Another study found that participants using nicotine replacement therapy for at least 5 weeks were significantly more likely to self-report continuous abstinence at 6 months. The remaining two studies failed to find a significant effect of treatment duration on outcome at 1 and 2 years but had very low power to detect such an effect.

CONCLUSIONS

There is modest evidence to support the assumption that lack of adherence to nicotine replacement therapy regimens undermines effectiveness in clinical studies.

Mind-body practices: an alternative, drug-free treatment for smoking cessation? A systematic review of the literature

OBJECTIVE

The limited success of current smoking cessation therapies encourages research into new treatment strategies. Mind-body practices such as yoga and meditation have the potential to aid smoking cessation and become an alternative drug-free treatment option. The aim of this article is to assess the efficacy of yoga and other meditation-based interventions for smoking cessation, to identify the challenges of clinical trials applying mind-body treatments, and to outline directions for future research on these types of therapies to assist in smoking cessation.

METHODS

A systematic review of the scientific literature.

RESULTS

Fourteen clinical trials met the inclusion criteria defined for this review. Each article was reviewed thoroughly, and evaluated for quality, design, and methodology. Although primary outcomes differed between studies, the fourteen articles, most with limitations, reported promising effects supporting further investigation of the use of these practices to improve smoking cessation.

CONCLUSIONS

The literature supports yoga and meditation-based therapies as candidates to assist smoking cessation. However, the small number of studies available and associated methodological problems require more clinical trials with larger sample sizes and carefully monitored interventions to determine rigorously if yoga and meditation are effective treatments.

Long-term follow-up of a high- and a low-intensity smoking cessation intervention in a dental setting--a randomized trial

Background

Achieving lifelong tobacco abstinence is an important public health goal. Most studies use 1-year follow-ups, but little is known about how good these are as proxies for long-term and life-long abstinence. Also, intervention intensity is an important issue for development of efficient and cost-effective cessation treatment protocols.

The study aims were to assess the long-term effectiveness of a high- and a low-intensity treatment (HIT and LIT) for smoking cessation and to analyze to what extent 12-month abstinence predicted long-term abstinence.

Methods

300 smokers attending dental or general health care were randomly assigned to HIT or LIT at the public dental clinic. Main outcome measures were self-reported point prevalence, continuous abstinence (≥6 months), and sustained abstinence. The study was a follow-up after 5–8 years of a previously performed 12-month follow-up, both by postal questionnaires.

Results

Response rate was 85% (n=241) of those still alive and living in Sweden. Abstinence rates were 8% higher in both programs at the long-term than at the 12-month follow-up. The difference of 7% between HIT and LIT had not change, being 31% vs. 24% for point prevalence and 26% vs. 19% for 6-month continuous abstinence, respectively. Significantly more participants in HIT (12%) than in LIT (5%) had been sustained abstinent (p=0.03). Logistic regression analyses showed that abstinence at 12-month follow-up was a strong predictor for abstinence at long-term follow-up.

Conclusions

Abstinence at 12-month follow-up is a good predictor for long-term abstinence. The difference in outcome between HIT and LIT for smoking cessation remains at least 5–8 years after the intervention.

Trial registration number

NCT00670514

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

AIM

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

DESIGN

Prospective cohort survey.

SETTING

United Kingdom, Canada, Australia and the United States.

PARTICIPANTS

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

MEASUREMENTS

Continuous abstinence from smoking for 1 month/6 months.

FINDINGS

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

CONCLUSIONS

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

Interplay of genetic risk factors (CHRNA5-CHRNA3-CHRNB4) and cessation treatments in smoking cessation success

OBJECTIVE

Smoking is highly intractable, and the genetic influences on cessation are unclear. Identifying the genetic factors affecting smoking cessation could elucidate the nature of tobacco dependence, enhance risk assessment, and support development of treatment algorithms. This study tested whether variants in the nicotinic receptor gene cluster CHRNA5-CHRNA3-CHRNB4 predict age at smoking cessation and relapse after an attempt to quit smoking.

METHOD

In a community-based, crosssectional study (N=5,216) and a randomized comparative effectiveness smoking cessation trial (N=1,073), the authors used Cox proportional hazard models and logistic regression to model the relationships of smoking cessation (self-reported quit age in the community study and point-prevalence abstinence at the end of treatment in the clinical trial) to three common haplotypes in the CHRNA5-CHRNA3-CHRNB4 region defined by rs16969968 and rs680244.

RESULTS

The genetic variants in the CHRNA5-CHRNA3-CHRNB4 region that predict nicotine dependence also predicted a later age at smoking cessation in the community sample. In the smoking cessation trial, haplotype predicted abstinence at end of treatment in individuals receiving placebo but not among individuals receiving active medication. Haplotype interacted with treatment in affecting cessation success.

CONCLUSIONS

Smokers with the high-risk haplotype were three times as likely to respond to pharmacologic cessation treatments as were smokers with the low-risk haplotype. The high-risk haplotype increased the risk of cessation failure, and this increased risk was ameliorated by cessation pharmacotherapy. By identifying a high-risk genetic group with heightened response to smoking cessation pharmacotherapy, this work may support the development of personalized cessation treatments.

Use and perceived helpfulness of smoking cessation methods: results from a population survey of recent quitters

BACKGROUND

Increasing rates of smoking cessation is one of the most effective measures available to improve population health. To advance the goal of increasing successful cessation at the population level, it is imperative that we understand more about smokers' use of cessation methods, as well as the helpfulness of those methods in real-world experiences of quitting. In this survey of recent quitters, we simultaneously examined rates of use and perceived helpfulness of various cessation methods.

METHODS

Recent quitters (within 12 months; n = 1097) completed a telephone survey including questions relating to 13 cessation methods. Indices of use and perceived helpfulness for each method were plotted in a quadrant analysis. Socio-demographic differences were explored using bivariate and multivariate analyses.

RESULTS

From the quadrant analysis, cold turkey, NRT and gradual reduction before quitting had high use and helpfulness; GP advice had high use and lower helpfulness. Prescribed medication and online programs had low use but high helpfulness. Remaining methods had low use and helpfulness. Younger quitters were more likely to use unassisted methods such as cold turkey; older or less educated quitters were more likely to use assisted methods such as prescribed medication or advice from a general practitioner.

CONCLUSIONS

The majority of recent quitters quit cold turkey or cut down before quitting, and reported that these methods were helpful. Efforts to influence population smoking prevalence should attempt to provide support and motivation for smokers choosing these methods, in addition to assessing the effectiveness and accessibility of other methods for smokers who need or choose them.

Support for smoke-free policy, and awareness of tobacco health effects and use of smoking cessation therapy in a developing country

Background

Preventing an epidemic increase in smoking prevalence is a major challenge for developing countries. Ghana, has maintained a low smoking prevalence despite the presence of cigarette manufacturing for many decades. Some of this success may have been contributed by cultural factors and attitudes. We have studied public awareness of health risks, attitudes to smoke-free policy, tobacco advertising/promotion and other factors in a Ghanaian population sample.

Methods

We used two-stage cluster randomized sampling to study household members aged 14 and over in a representative household sample in the Ashanti Region of Ghana.

Results

6258 people, 88% of those eligible, took part in the study. Knowledge of health risks of smoking and passive smoking was high; radio was the main source of such information. Most people work and/or spend time in places where smoking is permitted. There was very strong support (97%) for comprehensive smoke-free legislation, particularly among Christians and Muslims. Despite the advertising ban, a third of respondents (35%), particularly in urban areas, had noticed advertising of tobacco or tobacco products, on the radio (72%) and television (28%). Among smokers, 76% had attempted to quit in the last 6 months, with the main sources of advice being friends and spouses. Use of nicotine replacement therapy was very rare. Low levels of health awareness were seen in females compared with males (Adjusted Odds Ratio (AOR); 0.51, 95% CI 0.39-0.69, p < 0.001). High levels of health awareness was seen among Traditionalists compared with Christians AOR; 2.16 95% CI 0.79-5.94, p < 0.05) and the relatively well educated (AOR; 1.70 95% CI 1.12-2.58, p < 0.05) and those living in rural areas (AOR 1.46 95% CI 1.14-1.87, p = 0.004).

Conclusion

Awareness of health risks and support for smoke-free policy are high in Ghana. Exposure to tobacco advertising or promotion is limited and most smokers have tried to quit. Whether these findings are cause or effect of current low smoking prevalence is uncertain.

Tobacco dependence and withdrawal: science base, challenges and opportunities for pharmacotherapy

Several pharmacotherapies for tobacco dependence and withdrawal have been approved by the Food and Drug Administration to aid smoking cessation. These medicines double to triple the odds of cessation compared to placebo, with the diversity in chemical entity (e.g., nicotine, varenicline, bupropion) and route (e.g., nicotine gum and transdermal patch) providing options for people who find a given medication unacceptable or ineffective. Treatments in development include vaccines, combinations of existing products, and new indications, such as reduced tobacco use and exposure. These therapies have been developed on the foundation of research on the neuropharmacology of tobacco dependence and withdrawal. Ongoing research is expected to contribute to more efficacious use of existing therapies and the development of new approaches. This article addresses these developments as well as the challenges to medication development. Challenges include understanding the population-based and individual differences in the vulnerability to dependence and responsiveness to various treatment options, which could contribute to effective treatment to patient matching. Research on the CNS effects of administration and withdrawal of nicotine and other tobacco product constituents is expanding, providing the basis for more effective therapeutic approaches and new medications development. Additionally, whereas medications are approved on the basis of standardized assessments of efficacy and safety in clinical trials, the public health impact of medications depends also on their appeal to smokers and their effectiveness in actual use settings. Research on more effective medication use along with policies that support improved access and utilization are vital to conquering the tobacco epidemic.

Interest in treatments to stop smoking

We surveyed 884 Vermont (VT) tobacco smokers by random digit dialing to determine past and future use of treatment. Among those who had recently attempted to quit, 61% had ever used a treatment, 21% had ever used a psychosocial treatment, and 57% had used a medication. Among those who planned to quit in the next month, 68% stated they would use a treatment, 35% would use a psychosocial treatment, and 62% would use a medication. The major predictors of past or future use of treatment were greater cigarettes per day, older age, being a woman, and seeing a health professional. Although this survey suggests many smokers have used or plan to use a smoking cessation treatment, program data indicate less than 10% of VT smokers who try to quit use the state quitline, counseling, or free medication provision. Why smokers do not use these treatments needs to be determined.

Over-the-counter nicotine replacement therapy: a methodological review of the evidence supporting its effectiveness

Despite optimistic predictions when nicotine replacement therapy (NRT) was switched to over-the-counter (OTC) availability, population surveys have failed to demonstrate a positive impact on long-term smoking cessation. This review examined the strength of the evidence from randomised trials and comparison group studies supporting the effectiveness of OTCNRT. Twelve eligible studies were identified: OTCNRT was compared with placebo in four studies and with health professional-delivered NRT in four studies, and four studies involved community-based minimal intervention NRT. These studies were assessed systematically to determine their methodological quality and generalisibility to 'real-world' conditions of NRT use. The review found a number of issues, including provision of free NRT, heavy cigarette intakes (average 25 daily), high levels of personal interactions (7.6 per subject), lack of blindness assessment and failure of most studies to actively follow-up all subjects seriously limit the degree to which studies' results can be applied to non-research OTCNRT users. In addition, several important limitations affecting the meta-analyses of OTCNRT by Hughes et al. were highlighted. The review concluded that the superiority of OTCNRT over unaided smoking cessation has not been demonstrated convincingly. Future directions for research involve more innovative, rigorous controlled trials and prospective cohort studies where nicotine dependence is assessed adequately.

Racial/Ethnic disparities in the use of nicotine replacement therapy and quit ratios in lifetime smokers ages 25 to 44 years

We examined racial/ethnic variations in the use of nicotine replacement therapy (NRT) and quit ratios among Caucasian, African American, Asian, and Latino lifetime smokers ages 25 to 44 years. We conducted cross-sectional analyses using data from individuals (n = 27,031) screened for enrollment in the Collaborative Study of the Genetics of Nicotine Dependence. Participants were randomly sampled from three Midwestern metropolitan areas using Health Maintenance Organization membership lists in Detroit, MI and Minneapolis, MN and a driver's license registry in St. Louis, MO from March 2003 to August 2005. A telephone survey collected information on smoking history, previous quit attempts, and sociodemographic characteristics. Among lifetime smokers (n = 9,216), univariate analysis indicated that African Americans (22%) and Latinos (22%) were significantly less likely to report having ever used NRT for smoking cessation than Caucasians (31%). Asians (22%) also reported lower rates of using NRT than Caucasians, but this difference was marginally significant (P = 0.06). These disparities persisted in multivariate analysis for African Americans [adjusted odds ratio (OR), 0.76; 95% confidence interval (95% CI), 0.63-0.91; P < 0.01] but not for Latinos (adjusted OR, 0.76; 95% CI, 0.54-1.06; P = 0.11) or Asians (adjusted OR, 0.98; 95% CI, 0.60-1.60; P = 0.95). As measured by the quit ratio, African Americans (35%) were less likely to have quit smoking than Caucasians (52%). This disparity persisted in multivariate logistic regression (adjusted OR, 0.66; 95% CI, 0.56-0.78; P < 0.001). Asian and Latino smokers were as likely as Caucasians to report smoking cessation. Future prospective studies are needed to assess whether lower utilization of cessation treatments such as NRT contribute to the observed disparity in quit ratios for African Americans.

New insights into the sympathetic, endothelial and coronary effects of nicotine

1. Nicotine is a well studied pleiotropic agent which occurs naturally in tobacco smoke and has been largely accused for many of the adverse effects of smoking on the cardiovascular system, including autonomic imbalance, endothelial dysfunction and coronary blood flow dysregulation. 2. The acute sympathoexcitatory effects of smoking on the cardiovascular system are partially mediated by catecholamine release, muscle sympathetic nerve excitation and peripheral chemoreceptor sensitivity increase, consecutive to nicotinic receptor stimulation in the autonomic nervous system. 3. Recent animal data suggest that nicotine promotes the oxidative and inflammatory stress to the endothelium and induces pathological angiogenesis, leading to the progression of the atherosclerotic lesions. 4. Nicotine increases myocardial work without impairing the physiological coronary vasodilatation. Consequently, nicotine per se cannot explain the sudden reduction in coronary flow reserve after exposure to both active and passive smoking. 5. Nicotine's biological effects are characterized by a rapid onset of tolerance, which can explain why nicotine administration does not elicit acute coronary and chemoreflex side-effect in smokers.

Use of smoking-cessation treatments in the United States

BACKGROUND

Health promotion efforts encourage smokers to quit and to use effective cessation treatments. Randomized controlled trials demonstrate that medications and behavioral treatments improve cessation rates, but retrospective surveys have been inconsistent. This study assessed frequency of quit attempts, use of treatments for cessation, and abstinence rates among treatment users and non-users.

METHODS

Data were analyzed from the 2003 Tobacco Use Special Cessation Supplement to the Current Population Survey. Participants included 29,537 U.S. smokers aged > or =18 years who smoked daily 12 months before the survey. Outcome measures included past-year quit attempts; use of behavioral, pharmacologic, and alternative treatments; receipt of social support; and abstinence for > or =4 weeks at time of survey.

RESULTS

Approximately 43.5% of smokers reported a quit attempt in the preceding year: 64.2% of attempters used no cessation treatments; 8.8% used behavioral treatment; 32.2% used medication; and 14.1% used more than one treatment. Social support was reported to have been received by 24.1%. More nicotine-dependent smokers were more likely to use medications (OR=3.58; 95% CI=3.04-4.20). At the time of the survey, 19.3% of attempters were abstinent > or =4 weeks. Smokers who sought treatment were less likely to be abstinent (OR=0.75; 95% CI=0.67-0.84), and those who sought multiple treatments were even less likely to be abstinent.

CONCLUSIONS

Many U.S. smokers make quit attempts, but most do not use behavioral or pharmacologic treatments. More nicotine-dependent smokers were more likely to seek treatment. Smokers who sought treatment were less likely to report abstinence, probably due to biased self-selection and recall. Retrospective survey data are not well-suited to assess the effectiveness of treatment.

Pharmacological approaches to smoking cessation

Smoking, the most prominent nongenetic factor contributing to mortality, remains the major public health problem throughout the world. There are nearly 1.1 billion users of nicotine and tobacco products worldwide while approximately one third to half of them will die from smoking-related disease. The habit of smoking is mainly propelled by nicotine, a strongly addictive substance, to which the vast majority of smokers fall victim. Except for the general and specific support and counseling strategies there are now effective treatments for nicotine addiction. Two types of pharmacological therapies have been approved and are now licensed for smoking cessation. The first therapy consists of nicotine replacement, substituting the nicotine from cigarettes with safer nicotine formulations. The second therapy is bupropion, an antidepressant of the aminoketone class, which has been demonstrated to be effective in smoking cessation. However, although some cigarette smokers are able to quit, many are not, and standard medications to assist smoking cessation are ineffective. Several agents used for other indications (e.g. neurological diseases, depression, alcoholism) might be used to treat this subgroup. In conclusion, new more effective drugs are needed in order to fight the panepidemic of smoking globally.

Complementary treatments for tobacco cessation: A survey

Little information is available regarding the prevalence of use and interest in future use of complementary and alternative medicine (CAM) for tobacco cessation among tobacco users. We conducted a self-administered anonymous survey among 1,175 patients seen at a midwestern outpatient tobacco treatment specialty clinic between November 2003 and July 2005. Patient use of CAM for tobacco cessation, perceived efficacy of these treatments, and interest in future use of CAM were ascertained. Data were summarized using descriptive statistics, and logistic regression models were used to determine the characteristics associated with past CAM use or interest in future use of CAM for tobacco cessation. All of the patients who received the survey completed it. A total of 27% of patients reported previous use of CAM for tobacco cessation. The interventions most commonly used were hypnosis, relaxation, acupuncture, and meditation. CAM treatments most commonly perceived to be efficacious were yoga, relaxation, meditation, and massage therapy. A total of 67% of the patients reported interest in future use of CAM for tobacco cessation. The treatments of greatest interest for use in the future were hypnosis, herbal products, acupuncture, relaxation, and massage therapy. Female gender, previous use of conventional tobacco cessation products, previous use of CAM treatments, and a higher level of education were significantly associated with interest in future CAM use. The high level of interest in CAM among tobacco users underscores the need to conduct further research in this field.