Parental Smoking Cessation: Impacting Children's Tobacco Smoke Exposure in the Home

Smoking cessation medicines and e-cigarettes: a systematic review, network meta-analysis and cost-effectiveness analysis

BACKGROUND

Cigarette smoking is one of the leading causes of early death. Varenicline [Champix (UK), Pfizer Europe MA EEIG, Brussels, Belgium; or Chantix (USA), Pfizer Inc., Mission, KS, USA], bupropion (Zyban; GlaxoSmithKline, Brentford, UK) and nicotine replacement therapy are licensed aids for quitting smoking in the UK. Although not licensed, e-cigarettes may also be used in English smoking cessation services. Concerns have been raised about the safety of these medicines and e-cigarettes.

OBJECTIVES

To determine the clinical effectiveness, safety and cost-effectiveness of smoking cessation medicines and e-cigarettes.

DESIGN

Systematic reviews, network meta-analyses and cost-effectiveness analysis informed by the network meta-analysis results.

SETTING

Primary care practices, hospitals, clinics, universities, workplaces, nursing or residential homes.

PARTICIPANTS

Smokers aged ≥ 18 years of all ethnicities using UK-licensed smoking cessation therapies and/or e-cigarettes.

INTERVENTIONS

Varenicline, bupropion and nicotine replacement therapy as monotherapies and in combination treatments at standard, low or high dose, combination nicotine replacement therapy and e-cigarette monotherapies.

MAIN OUTCOME MEASURES

Effectiveness - continuous or sustained abstinence. Safety - serious adverse events, major adverse cardiovascular events and major adverse neuropsychiatric events.

DATA SOURCES

Ten databases, reference lists of relevant research articles and previous reviews. Searches were performed from inception until 16 March 2017 and updated on 19 February 2019.

REVIEW METHODS

Three reviewers screened the search results. Data were extracted and risk of bias was assessed by one reviewer and checked by the other reviewers. Network meta-analyses were conducted for effectiveness and safety outcomes. Cost-effectiveness was evaluated using an amended version of the Benefits of Smoking Cessation on Outcomes model.

RESULTS

Most monotherapies and combination treatments were more effective than placebo at achieving sustained abstinence. Varenicline standard plus nicotine replacement therapy standard (odds ratio 5.75, 95% credible interval 2.27 to 14.90) was ranked first for sustained abstinence, followed by e-cigarette low (odds ratio 3.22, 95% credible interval 0.97 to 12.60), although these estimates have high uncertainty. We found effect modification for counselling and dependence, with a higher proportion of smokers who received counselling achieving sustained abstinence than those who did not receive counselling, and higher odds of sustained abstinence among participants with higher average dependence scores. We found that bupropion standard increased odds of serious adverse events compared with placebo (odds ratio 1.27, 95% credible interval 1.04 to 1.58). There were no differences between interventions in terms of major adverse cardiovascular events. There was evidence of increased odds of major adverse neuropsychiatric events for smokers randomised to varenicline standard compared with those randomised to bupropion standard (odds ratio 1.43, 95% credible interval 1.02 to 2.09). There was a high level of uncertainty about the most cost-effective intervention, although all were cost-effective compared with nicotine replacement therapy low at the £20,000 per quality-adjusted life-year threshold. E-cigarette low appeared to be most cost-effective in the base case, followed by varenicline standard plus nicotine replacement therapy standard. When the impact of major adverse neuropsychiatric events was excluded, varenicline standard plus nicotine replacement therapy standard was most cost-effective, followed by varenicline low plus nicotine replacement therapy standard. When limited to licensed interventions in the UK, nicotine replacement therapy standard was most cost-effective, followed by varenicline standard.

LIMITATIONS

Comparisons between active interventions were informed almost exclusively by indirect evidence. Findings were imprecise because of the small numbers of adverse events identified.

CONCLUSIONS

Combined therapies of medicines are among the most clinically effective, safe and cost-effective treatment options for smokers. Although the combined therapy of nicotine replacement therapy and varenicline at standard doses was the most effective treatment, this is currently unlicensed for use in the UK.

FUTURE WORK

Researchers should examine the use of these treatments alongside counselling and continue investigating the long-term effectiveness and safety of e-cigarettes for smoking cessation compared with active interventions such as nicotine replacement therapy.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016041302.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 59. See the NIHR Journals Library website for further project information.

Phenomenological insight into the motivation to quit smoking

INTRODUCTION

Quitting tobacco is often viewed as a difficult experience as the dependence includes sets of behavioral, cognitive, social, and physiologic phenomena that prevent most smokers from having a successful first attempt of quitting. The aim of this qualitative study was to gain insight into and understand the motivation for attempts to quit smoking in relation to the stages of the behavior change model.

METHOD

The study team based this qualitative study on Alfred Schütz's social phenomenology framework. The study team planned for fourteen in-depth interviews with patients registered at a Quit Smoking Clinic. Each in-depth session lasted 45-60 min and we audio recorded them with consent. Following full verbatim transcription, the study team carried out detailed thematic analysis using Nvivo software.

RESULTS

Out of a total of 14 patients, 10 agreed to participate (response rate 71.4%). Seven participants (70%) had successfully quit smoking, while the remaining 30% relapsed after the first quit attempt. The study team extracted from the data three key themes with eight child nodes: barriers to quitting smoking, reasons for quit attempt, and how to quit. Unsuccessful attempts were related to tobacco addiction and successful attempts were based on the need to improve one's health and family. The study explored two intrinsic (self-realization and healthy lifestyle) and two extrinsic motivations (family's health and role model for children) for attempting to quit.

CONCLUSION

The study highlights the importance of psychological support in successful quit attempts. Treatment providers should encourage behavior change through intrinsic goals, as such goals, compared to extrinsic goals, have a long-term and positive impact because they can activate autonomous motivation.

Pediatrician intervention impacts parental smoking in cystic fibrosis, diabetes, and bronchiolitis

BACKGROUND

Child exposure to cigarette smoke is harmful. It should be reduced through parental smoking cessation interventions. The aim of our study was to determine the impact of simple advice provided by the pediatrician on the smoking habits of parents of children with cystic fibrosis (CF), diabetes mellitus (DM), and infants hospitalized for bronchiolitis.

METHODS

Parents were interviewed on their smoking habits. Smoking cessation advice was provided by the pediatrician. A new smoking habits assessment was done at 3 months by phone interviews.

RESULTS

A total of 260 parents were interviewed (91 in the CF group, 136 in the DM group, and 33 in the bronchiolitis group). A total of 70 parents were active smokers: 33% of parents of children with CF, 23.5% of parents of children with DM, and 24.2% for those with infants hospitalized for bronchiolitis (p = .42). In the CF group, smoking cessation had been significantly more frequently discussed with the medical team previously. A total of 67 smoking parents (95.7%) answered the 3-month assessment: 29.8% reported having started a smoking cessation process; 10.4% had quit smoking. The quitting rate was significantly higher in the groups of patients followed for a respiratory disorder (37.5% for bronchiolitis, 15% for CF vs. 0% for DM, p = .005).

CONCLUSION

This study shows the important role that information and simple advice from pediatricians can have in initiating smoking cessation in parents of patients followed in specialized clinics or who are hospitalized, with a greater efficiency in parents of patients suffering from lung disorders.

The Effectiveness of Smoking Cessation Interventions Tailored to Smoking Parents of Children Aged 0–18 Years: A Meta-Analysis

INTRODUCTION

A meta-analysis was conducted to examine the effectiveness of smoking cessation interventions tailored to parents of children aged 0-18 years.

METHODS

A systematic search was carried out in PsycInfo, Embase, and PubMed in March 2020. A manual search of the reference lists of the included studies and systematic reviews related to the topic was also performed. Two authors independently screened the studies based on the following inclusion criteria: (1) effect studies with control groups that examine smoking cessation interventions tailored to parents of children (0-18 years), and (2) full-text original articles written in English and published between January 1990 and February 2020. In total, 18 studies were included in the analyses. The TiDieR checklist and the Cochrane Risk of Bias Tool 2.0 were used to extract data and to assess the risk of bias. Consensus among authors was reached at each stage.

RESULTS

Random-effects meta-analyses were performed. With a total number of 8,560 parents, the pooled relative risk was 1.62 (95% CI 1.38-1.90; p < 0.00001), showing a modest effect of the interventions on smoking cessation. Overall, 13.1% of the parents in the intervention conditions reported abstinence versus 8.4% of the parents in the control conditions.

DISCUSSION/CONCLUSION

Smoking cessation interventions tailored to parents are modestly effective. To increase the effectiveness and the impact of these interventions in terms of controlling tobacco use and public health, it is crucial for further research to explore how these interventions can be improved.

Systematic Review of Behaviour Change Techniques within Interventions to Reduce Environmental Tobacco Smoke Exposure for Children

Children are particularly vulnerable to environmental tobacco smoke (ETS). There is no routine support to reduce ETS in the home. We systematically reviewed trials to reduce ETS in children in order to identify intervention characteristics and behaviour change techniques (BCTs) to inform future interventions. We searched Medline, EMBASE, CINAHL, PsycINFO, ERIC, Cochrane Central Register of Controlled Trials, and Cochrane Tobacco Addiction Group Specialised Register from January 2017 to June 2020 to update an existing systematic review. We included controlled trials to reduce parent/caregiver smoking or ETS in children <12 years that demonstrated a statistically significant benefit, in comparison to less intensive interventions or usual care. We extracted trial characteristics; and BCTs using Behaviour Change Technique Taxonomy v1. We defined "promising" BCTs as those present in at least 25% of effective interventions. Data synthesis was narrative. We included 16 trials, of which eight were at low risk of bias. All trials used counselling in combination with self-help or other supporting materials. We identified 13 "promising" BCTs centred on education, setting goals and planning, or support to reach goals. Interventions to reduce ETS in children should incorporate effective BCTs and consider counselling and self-help as mechanisms of delivery.

Tobacco use and other aspects related to smoking among school-going adolescents aged 13-15 years in Malaysia: Analysis of three cross-sectional nationally representative surveys in 2003, 2009 and 2016

INTRODUCTION

Periodic surveys on tobacco use patterns and other aspects of tobacco use among school-going adolescents in Malaysia provide information on the effectiveness of anti-smoking measures implemented. However, such information is limited in Malaysia. We investigated the prevalence of smoking and other related aspects among middle-secondary school students in Malaysia from the years 2003-2016 to fill this gap.

METHODS

We analyzed data from the Global Youth Tobacco Survey (GYTS) 2003, GYTS 2009, and the Tobacco and Electronic Cigarette Survey among Malaysia Adolescents (TECMA) 2016. The surveys employed multistage sampling to select representative samples of adolescents attending secondary school in Malaysia. Data were collected using a pre-validated self-administered anonymous questionnaire adopted from the GYTS.

RESULTS

Between 2003 and 2016, major changes occurred in which there were reductions in the prevalence of ever smoking, current smoking, and susceptibility to smoking. Reductions were also observed in exposure to SHS in public places and in the home. The proportion of school-going adolescents who support a ban on smoking in public places increased between 2013 to 2016, and there was a significant reduction in the proportion of respondents that were offered 'free' cigarettes by tobacco company representatives. However, there was no difference in the proportion of adolescents who initiated smoking before the age of 10 years and current smokers seeking advice to quit smoking across the time period.

CONCLUSIONS

Our study indicates that the smoking policies and measures have been effective in reducing smoking prevalence, secondhand smoke exposure, and access to cigarettes, among school-going adolescents in Malaysia. However, measures to reduce smoking initiation and increase smoking cessation need to be strengthened to reduce the burden of smoking-related diseases in Malaysia in the long-term.

Tobacco smoke exposure in pediatric cystic fibrosis: A qualitative study of clinician and caregiver perspectives on smoking cessation

OBJECTIVE

Tobacco smoke exposure has negative impacts on the lung health of children with cystic fibrosis (CF), yet evidence-based strategies for smoking cessation have not been tested with or tailored to CF caregivers. This qualitative study identified barriers and facilitators of smoking cessation in this population and outlined potential interventional approaches.

METHODS

We conducted semi-structured interviews with CF familial caregivers who were current or former smokers, and with members of the CF care team. We asked about experiences, practices, and prerequisites for a successful program. Interviews were recorded, transcribed verbatim, and coded by two investigators. Analysis used a thematic approach guided by the PRECEDE model, which identifies predisposing (intrapersonal), reinforcing (interpersonal), and enabling (structural) factors relevant to health behaviors and programs.

RESULTS

Seventeen interviews were conducted-eight with familial caregivers and nine with CF team members. Whereas caregivers provided greater insight into internal difficulties and motivators to quit smoking, clinicians offered more extensive input on barriers and solutions related to the clinical environment. Based on study recommendations, a successful tobacco cessation program should include (a) family education about the harms of smoke exposure for children with CF; (b) screening for exposure, ideally with biochemical verification; (c) access to trained tobacco counselors; (d) affordable pharmacotherapy; and (e) outpatient follow-up of those undergoing tobacco treatment.

CONCLUSION

This qualitative study revealed intrapersonal, interpersonal, and structural barriers to eliminating tobacco smoke exposure in children with CF, outlined opportunities to address these barriers, and made recommendations for a comprehensive tobacco cessation strategy.

Proactive Telephone Smoking Cessation Counseling Tailored to Parents: Results of a Randomized Controlled Effectiveness Trial

A recent Dutch efficacy trial showed the efficacy of a telephone smoking cessation counseling tailored to smoking parents. Currently, it is unknown whether such telephone counseling would be effective under more real-world conditions. This study aimed to examine the effectiveness of parent-tailored telephone smoking cessation counseling in a two-arm randomized controlled effectiveness trial and whether the effectiveness depended on the recruitment approaches that were used to recruit parents (mass media vs. health care). In total, 87 parents received either telephone counseling (intervention) or a self-help brochure (control). Parents were asked to complete questionnaires at baseline and three months post-intervention. Results showed that the odds of reporting 7-day point-prevalence abstinence at three months post-intervention was 7.54 higher for parents who received telephone counseling than for parents in the control condition (53.3% vs. 13.2%, 95% CI = 2.49–22.84). Because inclusion was lower than anticipated, interaction-effects of condition and recruitment approach could not be interpreted. The present study demonstrates that the parent-tailored smoking cessation telephone counseling is effective in helping parents to quit smoking. Yet, before large-scale implementation, future research should focus on how recruitment of parents via the recruitment approaches could be improved.