Treating tobacco dependence in a medical setting

Factors Associated With Tobacco Cessation Advice Recall and Quit Rates in Vascular Surgery Patients. A Single Center Study

OBJECTIVES

Smoking is an important modifiable risk factor in all vascular diseases and verbal advice from providers has been shown to increase rates of tobacco cessation. We sought to identify factors that will improve tobacco cessation and recall of receiving verbal cessation advice in vascular surgery patients at a single institution.

METHODS

The study is a retrospective cohort study. Patients seen in outpatient vascular surgery clinic who triggered a tobacco Best Practice Advisory (BPA) during their office visits over a 10-month period were contacted post-clinic and administered surveys detailing smoking status, cessation advice recall, and validated scales for nicotine dependence and willingness to quit smoking. This BPA is a "hard stop" that requires providers to document actions taken. Charts were reviewed for tobacco cessation documentation. Nine-digit zip-codes identified the area deprivation index, a measure of socioeconomic status. Univariate analysis was used to identify factors associated with cessation and advice recall.

RESULTS

One hundred out of 318 (31.4%) patients responded to the survey. Epic Slicer Dicer found 97 BPA responses. To dismiss the BPA, 89 providers (91.8%) selected "advised tobacco cessation" and "Unable to Advise" otherwise. Of the 318 patients, 115 (36.1%) had cessation intervention documented in their provider notes and 151 (47.5%) received written tobacco cessation advice. Of survey respondents, 70 recalled receiving verbal advice, 27 recalled receiving written advice, 28 reported receiving offers of medication/therapy for cessation. 55 patients reported having tobacco cessation plans, and among those 17 reported having quit tobacco. Recall of receiving written advice (P < .001) and recall of receiving medication/therapy (P = .008) were associated with recall of receiving verbal cessation advice.

CONCLUSIONS

Providing patients with tobacco cessation medication/therapy and written tobacco cessation education during office visits is associated with increased patients' recall of tobacco cessation advice. Vascular surgeons should continue to provide directed tobacco cessation advice.

Adapting and Evaluating a Brief Advice Tobacco Cessation Intervention in High-reach, Low-resource Settings in India: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

About 1.35 million deaths annually are attributed to tobacco use in India. The main challenge, given the magnitude of tobacco use and limited resources, is delivering cessation support at scale, low cost, and through a coordinated cross-system effort; one such example being brief advice interventions. However, highly credentialed staff to identify and counsel tobacco users are scarce. Task-shifting is an important opportunity for scaling these interventions.

OBJECTIVE

The LifeFirst SWASTH (Supporting Wellbeing among Adults by Stopping Tobacco Habit) program-adapted from the LifeFirst program (developed by the Narotam Sekhsaria Foundation, Mumbai, India)-is a tobacco cessation program focusing on lower-socioeconomic status patients in Mumbai receiving private health care. This parallel-arm, cluster randomized controlled trial investigates whether the LifeFirst SWASTH program increases tobacco cessation rates in low-resource, high-reach health care settings in Mumbai.

METHODS

This study will target tuberculosis-specific nongovernmental organizations (NGOs), dental clinics, and NGOs implementing general health programs serving lower-socioeconomic status patients. Intervention arm patients will receive a pamphlet explaining tobacco's harmful effects. Practitioners will be trained to deliver brief cessation advice, and interested patients will be referred to a Narotam Sekhsaria Foundation counselor for free telephone counseling for 6 months. Control arm patients will receive the same pamphlet but not brief advice or counseling. Practitioners will have a customized mobile app to facilitate intervention delivery. Practitioners will also have access to a peer network through WhatsApp. The primary outcome is a 30-day point prevalence abstinence from tobacco. Secondary outcomes for patients and practitioners relate to intervention implementation.

RESULTS

The study was funded in June 2020. Due to the COVID-19 pandemic, the study experienced some delays, and practitioner recruitment commenced in November 2023. As of July 2024, all practitioners have been recruited, and practitioner recruitment and training are complete. Furthermore, 36% (1687/4688) of patients have been recruited.

CONCLUSIONS

It is hypothesized that those patients who participated in the LifeFirst SWASTH program will be more likely to have been abstinent from tobacco for 30 consecutive days by the end of 6 months or at least decreased their tobacco use. LifeFirst SWASTH, if found to be effective in terms of cessation outcomes and implementation, has the potential to be scaled to other settings in India and other low- and middle-income countries. The study will be conducted in low-resource settings and will reach many patients, which will increase the impact if scaled. It will use task-shifting and an app that can be tailored to different settings, also enabling scalability. Findings will build the literature for translating evidence-based interventions from high-income countries to low- and middle-income countries and from high- to low-resource settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05234983; https://clinicaltrials.gov/study/NCT05234983.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57236.

Smoking Cessation After Initial Treatment Failure With Varenicline or Nicotine Replacement: A Randomized Clinical Trial

Importance

Most people who smoke do not quit on their initial attempt.

Objective

To determine the best subsequent strategy for nonabstinence following initial treatment with varenicline or combined nicotine replacement therapy (CNRT).

Design, Setting, and Participants

Using a double-blind, placebo-controlled, sequential multiple assignment randomized trial, 490 volunteers were randomized to receive 6 weeks of varenicline or CNRT. After 6 weeks, nonabstainers were rerandomized to continue, switch, or increase medication dosage for 6 additional weeks. The study was conducted from June 2015 through October 2019 in a Texas tobacco treatment clinic.

Interventions

The initial treatment was 2 mg/d of varenicline or the combined replacement therapy of a 21-mg patch plus 2-mg lozenge. The rerandomized participants either continued with their initial therapies, switched between varenicline and CNRT, or increased dosages either to 3-mg or more of varenicline or to a 42-mg patch and lozenges. All received weekly brief counseling.

Main Outcomes and Measures

Biochemically verified 7-day point prevalence abstinence at the end of treatment at 12 weeks.

Results

The 490 randomized participants (210 female [43%], 287 non-Hispanic White [58%], mean age, 48.1 years) smoked an average of 20 cigarettes per day. After the first phase, 54 participants in the CNRT group were abstinent and continued their therapy; of the 191 who were not abstinent, 151 were rerandomized, and the 40 who did not return for rerandomization were assigned to continue their initial CNRT condition in phase 2. The end-of-treatment abstinence rate for the 191 phase 1 nonabstainers was 8% (95% credible interval [CrI], 6% to 10%) for the 90 (47%) who continued at the dosage condition, 14% (CrI, 10% to 18%) for the 50 (33%) who increased their dosage, and 14% (95% CrI, 10% to 18%) for the 51 (34%) who switched to varenicline (absolute risk difference [RD], 6%; 95% CrI, 6% to 11%) with more than 99% posterior probability that either strategy conferred benefit over continuing the initial dosage. After the first phase, 88 participants in the varenicline group were abstinent and continued their therapy; of the 157 who were not abstinent, 122 were rerandomized and 35 who did not return for rerandomization were assigned to continue with the varenicline condition. The end-of-treatment abstinence rate for the 157 phase 1 nonabstainers was 20% (95% CrI, 16% to 26%) for the 39 (32%) who increased their varenicline dosage, 0 (95% CrI, 0 to 0) for the 41 (34%) who switched CNRT, and 3% (95% CrI, 1% to 4%) for the 77 (49%) who were assigned to the continued varenicline condition (absolute RD, -3%; 95% CrI, -4% to -1%) with more than 99% posterior probability that continuing varenicline at the initial dosage was worse than switching to a higher dosage. Furthermore, increasing the varenicline dosage had an absolute RD of 18% (95% CrI, 13% to 24%) and a more than 99% posterior probability of conferring benefit. The secondary outcome of continuous abstinence at 6 months indicated that only increased dosages of the CNRT and varenicline provided benefit over continuation of the initial treatment dosages.

Conclusions and Relevance

For individuals who smoked but did not achieve abstinence after treatment with varenicline, increasing the dosage enhanced abstinence vs continuing, whereas for nonabstainers initially treated with CNRT, a dosage increase or switch to varenicline enhanced abstinence and may be viable rescue strategies.

Trial Registration

ClinicalTrials.gov Identifier: NCT02271919.

Smoking cessation through nicotine replacement therapy for patients visiting the Dental College, Pune - A quasi-experimental study

Background and Aim

Smoking leads to a very unhealthy lifestyle and has many deleterious effects on the body and surroundings. Studies have indicated that aiding contemplating smokers using behavior counseling and nicotine replacement therapy has shown positive results for abstaining from the habit. We aimed to assess and carry out smoking cessation for smokers using behavioral counseling, motivational interviewing, and nicotine replacement therapy (NRT) and assess their carbon monoxide (CO) cutoff level, Fagerstrom nicotine dependence test (FTND) scoring, and transtheoretical model (TTM) of change at baseline and 6 months, along with abstinence from the habit.

Materials and Methods

CO cutoff, FTND scoring, and TTM of change were assessed at baseline and 6 months for smokers. Behavioral counseling with motivational interviewing was provided to the participants on the day of recruitment, and baseline data were recorded. All smokers included in the study were in the precontemplation and contemplation stages to quit smoking. Based on the frequency of smoking, NRT was prescribed to them in the form of a patch (21, 14, or 7 mg), only gums (2 mg), or a combination of both. Counseling was provided telephonically every month for 6 months. Urine cotinine assessment was carried out to verify the self-reported smoking status of the participants at the sixth month.

Results

The CO cutoff, FTND scoring, and TTM of change showed statistically significant difference from baseline to the sixth month. Also, 20% (confidence interval [CI] 0.10-0.33) of participants who abstained from the habit were in the action and maintenance stages of change. Among 20% of participants, 16% (CI 0.10-0.36) of participants self-reported quitting within 6 months using combination therapy. Two percent (CI 0.00-0.40) each abstained by using nicotine gums and combination therapy of patch and gums, which was validated through urine cotinine.

Conclusion

The cotinine test provided negative results, confirming the self-reported abstinence of 20% of participants, who were mostly male students and professionals in the age group of 20-40 years and those who used NRT. Nicotine patches provided the highest point prevalence of abstinence compared to gums and combination therapy.

The Bucket Approach: Developing and Implementing an On-line Training Program in Tobacco Dependence Interventions Tailored for Behavioral Health Clinicians

People coping with a mental illness and/or addictive disorders have a very high prevalence of smoking cigarettes. The Bucket Approach, a free online training, tailors evidence-based tobacco dependence interventions for behavioral health clinicians to increase the likelihood that they will also address the tobacco use of their patients. From October 2019 through August 2021, 999 people enrolled in and 447 people completed the training. Individuals who completed the training evaluated it highly with an overall mean score of 8.4 (scale = 1 for very poor to 10 for very good). 3- and 6-month follow-up surveys documented continued impact. The training resulted in substantial changes in beliefs about treating tobacco dependence. For example, before training, 18.3% of trainees strongly agreed with the statement, "The skills currently possessed by behavioral health clinicians can be easily applied to the treatment of tobacco dependence." This increased to 40.7% at the end of training.

Tobacco Profile and Evaluation of the DS14 Scale in Patients with Coronary Syndrome

Background: the prevalence of current smokers in patients with coronary syndrome is high. This risk behaviour significantly increases the risk of cardiovascular complications. In the recommendations for the management of cardiovascular diseases, psychosocial and psychological factors are still neglected in practice. The aim of study was to verify the prevalence of tobacco use in hospitalized patients with coronary syndrome, notably to verify the type-D personality and tobacco use in the groups obtained from the evaluation of the DS14 scale. Methods: in this cross-sectional study, we addressed 100 hospitalized patients with coronary syndrome. Results: in the cohort, 48% patient were current smokers, 21% were never smokers, 24% were former smokers, 4% were occasional smokers, and 3% were quitters. Based on the evaluation of DS14, 21% of patients were classified as type-D personality and 38% as non-type-D; we identified two subtypes: the NA group at 23% and the SI group at 18%. In the group of the current smokers, 81% declared that they wanted to quit smoking, 15% of the patients were undecided, and 4% of current smokers did not want to quit. Conclusions: cardiac patients are aware that their disease is related to smoking; despite the severity of their disease, patients’ motivation to change their risky behaviour is low.

Barriers to Tobacco Cessation for Caregivers of Hospitalized Children: Perspectives of Pediatric Hospitalists

OBJECTIVES

Secondhand smoke exposure is associated with adverse health outcomes in children, yet tobacco cessation efforts for caregivers of hospitalized children are lacking. We sought to explore pediatric hospitalists' attitudes and barriers to providing tobacco cessation for caregivers of hospitalized children.

METHODS

We conducted a cross-sectional survey of pediatric hospitalists and fellows at 7 hospitals from November 1, 2018, to November 30, 2019. A 70-question anonymous survey was used to assess participants' perceptions of current practices, attitudes, and barriers to providing tobacco cessation support for caregivers of hospitalized children. We used descriptive statistics to summarize the data.

RESULTS

Of 207 eligible participants, 100 responded (48%). A majority (79%) agreed that offering tobacco cessation counseling for caregivers is an important part of their role in caring for hospitalized children, but 79% never received tobacco cessation training. Only half of the participants were comfortable providing brief advice and few were comfortable prescribing nicotine replacement therapy. Identified barriers included lack of time (74%), perceived lack of interest from patients' caregivers (71%), and other medical conditions of the patient taking priority (70%). The majority of participants were interested in further training in tobacco cessation support.

CONCLUSIONS

In this survey of 100 pediatric hospitalists, we found overall agreement that tobacco cessation support for caregivers of hospitalized children is important. However, most participants did not feel comfortable with provision of evidence-based counseling or pharmacotherapy because of identified barriers. Future work should target actionable barriers to improve provision of tobacco cessation support in this clinical setting.

Interventions to prevent periodontal disease in tobacco-, alcohol-, and drug-dependent individuals

Substance abuse affects more than one sixth of the world's population. More importantly, the nature of the abuse and the type of addictive substances available to individuals is increasing exponentially. All substances with abusive potential impact both the human immuno-inflammatory system and oral microbial communities, and therefore play a critical role in the etiopathogenesis of periodontal diseases. Evidence strongly supports the efficacy of professionally delivered cessation counseling. Dentists, dental therapists, and hygienists are ideally placed to deliver this therapy, and to spearhead efforts to provide behavioral and pharmacologic support for cessation. The purpose of this review is to examine the biologic mechanisms underlying their role in disease causation, to understand the pharmacologic and behavioral basis for their habituation, and to investigate the efficacy of population-based and personalized interventions in prevention of periodontal disease.

Racial disparities and factors associated with prescription for smoking cessation medications among smokers receiving routine clinical care for HIV

Factors associated with prescription of smoking cessation medication (SCM), including the impact of race, have not been well described among a large population of people living with HIV (PLWH) engaged in routine clinical care. Our study investigated whether there are racial differences between African-American and White PLWH regarding SCM prescription and sought to identify other factors associated with these prescriptions at a large HIV clinic in the Southeastern United States. Among 1899 smokers, 38.8% of those prescribed SCMs were African-American and 61.2% were White. Factors associated with lower odds of SCM prescription included African-American race (AOR, 0.63 [95% CI: 0.47, 0.84]) or transferring care from another HIV provider during the study period (AOR, 0.63 [95% CI: 0.43, 0.91]). Whereas major depression (AOR, 1.54 [95% CI: 1.10, 2.15]), anxiety symptoms (AOR, 1.43 [95% CI: 1.05, 1.94]), and heavy smoking (>20 cigarettes/day) (OR, 3.50 [95% CI: 2.11, 5.98]) were associated with increased likelihood of SCM prescription. There were racial disparities in the prescription of SCM in African Americans with HIV. These findings underscore the need to increase pharmacotherapy use among African Americans to improve smoking cessation outcomes across racial groups among PLWH.

Truck Drivers' Cigarette Smoking and Preferred Smoking Cessation Methods

Introduction:

Some studies show that truck drivers use tobacco and other stimulants to stay awake as they drive. Despite their increased risks for many of tobacco-related health disparities, there is limited engagement of truck drivers in smoking cessation programs. The objective of this study was to describe smoking characteristics and identify their preferred smoking cessation methods among truck drivers.

Methods:

This was a cross-sectional mixed methods study. Participants were truck drivers recruited at trucking companies in Utah in 2019. Participants were either individually interviewed (n = 4), or filled out a survey (n = 33). We conducted qualitative data analysis of the interviews followed by descriptive statistics of smoking and cessation characteristics from the survey.

Results:

Reasons for smoking included, staying awake, stress reduction, or something to do while driving. Of the drivers surveyed, 68.8% were daily smokers while 97% had smoked at least 100 cigarettes in their life time. The mean number of cigarettes per day (cpd) was 15.7, and 25 among those who had 10 or more cpd. Sixty-one percent had made at least a quit attempt. In addition to counseling or brief advice, 68% reported interest in using Nicotine Replacement Therapy (NRT) either as gum or patch to help them quit. 21% reported interest in telephone text messaging to engage them in treatment.

Conclusion:

Cigarette smoking is a public health problem among truck drivers. Our findings suggest that truck drivers are interested in quitting smoking. Evidence based interventions tailored to this population are needed to help them quit and reduce their smoking-related morbidity.

Smoking-Cessation Interventions After Lung Cancer Screening Guideline Change

INTRODUCTION

Recent guideline changes for lung cancer screening with low-dose computed tomography recommend smoking-cessation interventions be done in parallel with screening. The purpose of this study is to determine the post-guideline rates of smoking-cessation interventions among patients eligible and ineligible for lung cancer screening.

METHODS

Using electronic health records collected from a large ambulatory care system in northern California between 2010 and 2017, authors identified new patients who were current smokers aged 55-80 years visiting a primary care provider, and grouped patients into lung cancer screening-eligible heavy smokers, screening-ineligible moderate smokers, and screening-ineligible light smokers. Screening-eligible smokers versus screening-ineligible smokers were compared in receipt of smoking-cessation interventions before (2010-2013) and after (2014-2017) the guideline change, overall and by intervention type (formal counseling, informal counseling, pharmacotherapy) using hierarchical generalized linear models. Analyses were conducted in 2018-2019.

RESULTS

After the guideline change, the likelihood of receiving any smoking-cessation intervention (OR=1.44, 95% CI=1.28, 1.61, p<0.05), informal counseling (OR=1.29, 95% CI=1.15, 1.46, p<0.05), and pharmacotherapy (OR=1.24, 95% CI=1.02, 1.50, p<0.05) during a new patient visit significantly increased, with the increase not varying by level of smoking. For formal counseling, the post-guideline increase was greater for screening-eligible heavy smokers (OR=3.15, 95% CI=1.18, 8.36, p<0.05) and moderate smokers (OR=3.58, 95% CI=1.29, 9.95, p<0.05) relative to light smokers.

CONCLUSIONS

Smoking-cessation interventions increased after new lung cancer screening guidelines. Given the sizable adverse impacts of smoking on morbidity and mortality, small increases in the implementation of smoking-cessation interventions could have substantial public health benefits.

Smoking cessation in inpatient psychiatry treatment facilities: A review

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Smoking rates are high among people with psychiatric illness.

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Smoking cessation interventions are rarely available in inpatient psychiatry settings.

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Smokers with psychiatric illness are just as interested in quitting smoking.

Background

Tobacco-related diseases are a leading cause of death among individuals with severe mental illness (SMI), yet interventions to address tobacco cessation are rare in inpatient settings where persons with SMI are hospitalized. While cigarette smoking rates have declined in the general population, they remain high in persons with SMI. Inpatient settings would be a prime location to intervene on tobacco consumption among persons with SMI. The objective of this review was to examine evidence of smoking cessation interventions in psychiatric inpatient facilities.

Method

Using narrative overview guidelines, we searched PubMed, PsycINFO, and CINAHL for smoking cessation RCT studies published between 1950 and 2018. Studies included had to have at least started in inpatient psychiatry settings. Examples of search terms included: smoking cessation in inpatient psychiatry, smoking cessation in inpatient mental health treatment facilities, and smoking cessation and mental health.

Results

Following the inclusion criteria, eight RCT studies were reviewed. One study was among adolescent psychiatric inpatient smokers ages 13–17, and 7 were among adult psychiatric inpatients with mean age 41 years. Treatment periods lasting 8 to 12 weeks started in inpatient settings and continued post discharge. A combination of behavioral and pharmacological interventions were used. Pharmacological interventions were nicotine replacement therapies, and at least one study used varenicline. At baseline, participants smoked an average of 18.1 cigarettes per day.

Conclusion

Smoking cessation in inpatient psychiatry settings is rare or delayed. There is a need for more tailored treatments among this population to help them quit smoking.

A randomized clinical trial of counseling and nicotine replacement therapy for treatment of African American non-daily smokers: Design, accrual, and baseline characteristics

BACKGROUND

Non-daily smokers (NDS) who smoke on some but not all days are a growing subset of United States (US) tobacco users. Racial/ethnic minorities are more likely to be NDS. African American NDS have strikingly high levels of nicotine and carcinogen exposure, making treatment of this high risk group a priority.

METHODS

The current study is one of three ongoing federally-funded clinical trials of NDS and, to our knowledge the only RCT focused on racial/ethnic minority NDS. The design has been guided by input from Patient and Stakeholder Advisory Panels who helped develop the research questions, design the intervention, and select the outcomes. The objective is to compare the effectiveness of smoking cessation counseling alone (C) or smoking cessation counseling plus participant's choice of nicotine replacement therapy (NRT; C + NRT) for African American NDS. Two-hundred seventy-eight African American NDS will be randomized in a 2:1 fashion to C + NRT or C. All participants receive five sessions of smoking cessation counseling; those randomized to C + NRT receive their choice of nicotine gum, patch, and/or lozenge. Treatment in both groups lasts for 12 weeks. We hypothesize that C + NRT will be more effective than C on the primary outcome of biochemically-confirmed abstinence from smoking at week 12. Secondary aims will compare C + NRT and C on patient- and provider-desired outcomes including abstinence from smoking at week 26, change in biochemically-verified nicotine and carcinogen exposure, days abstinent, and treatment process measures (e.g., NRT use and side effects). Predictors of abstinence will also be explored.

DISCUSSION

Findings will illuminate effective treatment options for African American NDS and contribute to development of evidence-based guidelines for treating the 8.9 million US adult NDS for whom no guidelines currently exist.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT02244918.

The association between nicotine dependence and physical health among people receiving injectable diacetylmorphine or hydromorphone for the treatment of chronic opioid use disorder

INTRODUCTION

People with chronic opioid use disorder often present to treatment with individual and structural vulnerabilities and remain at risk of reporting adverse health outcomes. This risk is greatly compounded by tobacco smoking, which is highly prevalent among people with chronic opioid use disorder. Despite the known burden of tobacco smoking on health, the relationship between nicotine dependence and health has not been studied among those receiving injectable opioid agonist treatment. As such, the present study aims to explore the association between nicotine dependence and physical health among participants of the Study to Assess Longer-Term Opioid Medication Effectiveness (SALOME) at baseline and six-months.

METHODS

SALOME was a double-blind phase III clinical trial testing the non-inferiority of injectable hydromorphone to injectable diacetylmorphine for chronic opioid use disorder. Participants reporting tobacco smoking were included in a linear regression analysis of physical health at baseline (before receiving treatment) and at six-months.

RESULTS

At baseline, nicotine dependence score, lifetime history of emotional, physical, or sexual abuse and prior month safe injection site access were independently and significantly associated with physical health. At six-months nicotine dependence score was the only variable that maintained this significant and independent association with physical health.

CONCLUSIONS

Findings indicate that after six-months, the injectable treatment effectively brought equity to patients' physical health status, yet the association with nicotine dependence remained. Findings could inform whether the provision of treatment for nicotine dependence should be made a priority in settings where injectable opioid agonist treatment is delivered to achieve improvements in overall physical health in this population.

The Effect of Tobacco Control Policies on US Smokeless Tobacco Use: A Structured Review

INTRODUCTION

Tobacco use has shifted increasingly from cigarettes to other products. While the focus has been mostly on cigarette-oriented policies, it is important to gauge the effects of policies targeting other products. We review and critique the literature on how policies affect smokeless tobacco (ST).

METHODS

We conducted a search of the literature on tobacco control policies as they relate to ST use, focusing on tobacco taxes, smoke-free air laws, media campaigns, advertising restrictions, health warnings, cessation treatment policies, and youth access policies. Findings from 78 total studies are summarized.

RESULTS

ST taxes, media campaigns, health warnings, and cessation treatment policies were found to be effective tools in reducing ST use. Evidence on the effects of current youth access policies is less strong. Studies have not yet been conducted on marketing or product content restrictions, but the literature indicates that product marketing, through advertising, packaging, flavorings, and extension of cigarette brands, plays an important role in ST use.

CONCLUSIONS

Although the evidence base is less established for ST policies than for cigarette policies, the existing literature indicates ST use responds to tobacco control policies. Policies should be structured in a way that aims to reduce all tobacco use while at the same time increasing the likelihood that continuing tobacco users use the least risky products.

IMPLICATIONS

Studies find that policies targeting smoking and policies targeting smokeless products affect smokeless use, but studies are needed to examine the effect of policies on the transitions between cigarette and smokeless use.

An integrated digital/clinical approach to smoking cessation in lung cancer screening: study protocol for a randomized controlled trial

Background

Delivering effective tobacco dependence treatment that is feasible within lung cancer screening (LCS) programs is crucial for realizing the health benefits and cost savings of screening. Large-scale trials and systematic reviews have demonstrated that digital cessation interventions (i.e. web-based and text message) are effective, sustainable over the long-term, scalable, and cost-efficient. Use of digital technologies is commonplace among older adults, making this a feasible approach within LCS programs. Use of cessation treatment has been improved with models that proactively connect smokers to treatment rather than passive referrals. Proactive referral to cessation treatment has been advanced through healthcare systems changes such as modifying the electronic health record to automatically link smokers to treatment.

Methods

This study evaluates the impact of a proactive enrollment strategy that links LCS-eligible smokers with an evidence-based intervention comprised of a web-based (WEB) program and integrated text messaging (TXT) in a three-arm randomized trial with repeated measures at one, three, six, and 12 months post randomization. The primary outcome is biochemically confirmed abstinence at 12 months post randomization. We will randomize 1650 smokers who present for a clinical LCS to: (1) a usual care control condition (UC) which consists of Ask–Advise–Refer; (2) a digital (WEB + TXT) cessation intervention; or (3) a digital cessation intervention combined with tobacco treatment specialist (TTS) counseling (WEB + TXT + TTS).

Discussion

The scalability and sustainability of a digital intervention may represent the most cost-effective and feasible approach for LCS programs to proactively engage large numbers of smokers in effective cessation treatment. We will also evaluate the impact and cost-effectiveness of adding proven clinical intervention provided by a TTS. We expect that a combined digital/clinical intervention will yield higher quit rates than digital alone, but that it may not be as cost-effective or feasible for LCS programs to implement. This study is innovative in its use of interoperable, digital technologies to deliver a sustainable, scalable, high-impact cessation intervention and to facilitate its integration within clinical practice. It will add to the growing knowledge base about the overall effectiveness of digital interventions and their role in the healthcare delivery system.

Trial registration

ClinicalTrials.gov, NCT03084835. Registered on 9 March 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2312-x) contains supplementary material, which is available to authorized users.

A Pilot Trial Examining African American and White Responses to Algorithm-Guided Smoking Cessation Medication Selection in Persons Living with HIV

Algorithm-based treatments (AT) may be an effective clinical tool to aid HIV clinicians in prescribing pharmacotherapy to increase smoking cessation among people living with HIV (PLWH). Initial results from AT indicated significant increases in abstinence self-efficacy and medication utilization and declines in cigarettes smoked per day across time. Given historical racial disparities, it is unclear if both African Americans and White smokers would benefit equally from this type of intervention. Thus, the aim of this study was to examine racial differences in response to AT guided smoking cessation for African American and White smokers living with HIV. One hundred PLWH smokers (n = 100) were randomized to receive either AT guided smoking cessation or Treatment as Usual (TAU) which consisted of instructing participants to talk to a provider about smoking cessation assistance when ready to make a quit attempt. Participants were African American (75%) and White (25%) and majority men (71%) who had never been married (56%). African Americans smoked fewer cigarettes and were more likely to smoke mentholated cigarettes compared to White smokers at baseline. African Americans increased their use of other tobacco products (cigars/cigarillos) over time relative to White smokers. A significant interaction between race and quit goal was observed, with White smokers who reported complete abstinence as their goal having higher quit rates, while African Americans who reported a goal other than complete abstinence demonstrating higher quit rates. The increased use of cigars/cigarillos during quit attempts as well as having a goal other than complete abstinence should be considered when applying algorithm based interventions for PLWH African American smokers.

Treatment of Tobacco Dependence, a Critical Gap in Czech Clinical Practice Guidelines

OBJECTIVE

Tobacco related comorbidities and treatment of dependence are relevant to clinicians of all disciplines. Clinicians should provide a brief intervention about tobacco use with smokers at each clinical contact (success rate of 5-10 %). Intensive treatment (success rate >30%) should be available to those who need it. Brief intervention is not yet standard clinical practice. Our aim was to assess clinical practice guidelines (CPG) of selected medical professional societies to determine whether or not tobacco dependence treatment recommendations were included.

METHODS

Between October and December 2013, we conducted a keyword search of CPG for 20 medical professional societies in the Czech Republic. We searched for the keywords "smoking", "tobacco" and "nicotine addiction" in 91 CPG documents, which were freely available on the websites of selected professional societies. We focused specifically on CPG relating to cardiovascular and respiratory diseases as well as cancer. We excluded any CPG focused on acute conditions, diagnostics only, laboratory methods, or administration.

RESULTS

There was no mention of smoking in 27.7% (26/94) of CPG documents. Only 16% (15/94) of CPG documents listed smoking as a risk factor. 42.5% (40/94) mentioned smoking related phrases (e.g. "smoking ban"). Only 13.8% (13/94) of CPG included a section on tobacco dependence, referenced tobacco dependence treatment guidelines or mentioned specialized treatment centres where smokers can be referred.

CONCLUSION

Nearly one third of CPG related to cardiovascular and respiratory diseases as well as cancer made no mention of smoking. Despite the clinical significance of smoking, the majority of CPG did not adequately address tobacco dependence and its treatment.

Nicotine Dependence and Willingness to Quit Smoking in Vascular Surgery Patients

BACKGROUND

Smoking rates have declined; however, it remains the primary modifiable risk factor for vascular disease. While vascular surgeons often advise patients to quit, few provide assistance. We sought to understand patients' interest in quitting and determine factors that influence this willingness to quit.

METHODS

Anonymous surveys were given to vascular surgery clinic patients in a single institution over a 5-month period. Demographic information, smoking status, cessation attempts, and barriers to quitting were obtained. Nicotine dependence was determined using the Fagerstrom Test, and willingness to quit was assessed using a contemplation ladder. Patient's willingness to quit was evaluated in relation to symptomatic status, previous/planned operation, and nicotine dependence levels.

RESULTS

A total of 490 patients (92%) completed the survey with 109 (22%) current smokers, 195 (40%) former smokers, and 186 (38%) never smokers. Never smokers were more likely to be female and employed while smokers were more likely to be disabled. Although 51% of smokers displayed moderate/high nicotine dependence, 54% demonstrated willingness to consider quitting within 6 months. The primary barrier to cessation identified was previous failed attempt(s) to quit in 44%. Most (90%) had previously attempted quitting, 63% attempted 3 or more times, and the most common technique used was "quitting cold turkey". Fifty-nine percent of patients reported physicians' had offered assistance in cessation, but only 2% had been in a cessation program. There was no correlation between willingness to consider quitting and symptomatic status, previous/planned operation, or nicotine dependence. Smokers of less than 10 cigarettes/day had a lower nicotine dependence level (P = 0.0001) and higher willingness to consider quitting (P = 0.0015), as did those who had fewer failed prior attempts to quit and who did not believe it was too late to quit.

CONCLUSIONS

Most of our vascular patients self-report as nonsmokers. Over half of those who smoke demonstrate willingness to consider quitting within 6 months, which is not dependent on nicotine dependence, previous/planned operation, or symptomatic status. Those who smoke less than 10 cigarettes per day, have fewer past failed attempts to quit, and believe that it is not too late to quit are more likely to consider quitting. Vascular surgeons should be more aware of previous quit attempts and patterns of smoking and be proactive in assisting patients in cessation attempts.

Interventions for tobacco use cessation in people in treatment for or recovery from substance use disorders

BACKGROUND

Smoking rates in people with alcohol and other drug dependencies are two to four times those of the general population. Concurrent treatment of tobacco dependence has been limited due to concern that these interventions are not successful in this population or that recovery from other addictions could be compromised if tobacco cessation was combined with other drug dependency treatment.

OBJECTIVES

To evaluate whether interventions for tobacco cessation are associated with tobacco abstinence for people in concurrent treatment for or in recovery from alcohol and other drug dependence.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and clinicaltrials.gov databases, with the most recent search completed in August 2016. A grey literature search of conference abstracts from the Society on Nicotine Research and Treatment and the ProQuest database of digital dissertations yielded one additional study, which was excluded.

SELECTION CRITERIA

We included randomised controlled trials assessing tobacco cessation interventions among people in concurrent treatment for alcohol or other drug dependence or in outpatient recovery programmes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study risk of bias and extracted data. We resolved disagreements by consensus. The primary outcome was abstinence from tobacco use at the longest period of follow-up, and the secondary outcome was abstinence from alcohol or other drugs, or both. We reported the strictest definition of abstinence. We summarised effects as risk ratios and 95% confidence intervals (CI). Two clustered studies did not provide intraclass correlation coefficients, and were excluded from the sensitivity analysis. We used the I² statistic to assess heterogeneity.

MAIN RESULTS

Thirty-five randomised controlled trials, one ongoing, involving 5796 participants met the criteria for inclusion in this review. Included studies assessed the efficacy of tobacco cessation interventions, including counselling, and pharmacotherapy consisting of nicotine replacement therapy (NRT) or non-NRT, or the two combined, in both inpatient and outpatient settings for participants in treatment and in recovery. Most studies did not report information to assess the risk of allocation, selection, and attrition bias, and were classified as unclear.Analyses considered the nature of the intervention, whether participants were in treatment or recovery and the type of dependency. Of the 34 studies included in the meta-analysis, 11 assessed counselling, 11 assessed pharmacotherapy, and 12 assessed counselling in combination with pharmacotherapy, compared to usual care or no intervention. Tobacco cessation interventions were significantly associated with tobacco abstinence for two types of interventions. Pharmacotherapy appeared to increase tobacco abstinence (RR 1.60, 95% CI 1.22 to 2.12, 11 studies, 1808 participants, low quality evidence), as did combined counselling and pharmacotherapy (RR 1.74, 95% CI 1.39 to 2.18, 12 studies, 2229 participants, low quality evidence) at the period of longest follow-up, which ranged from six weeks to 18 months. There was moderate evidence of heterogeneity (I² = 56% with pharmacotherapy and 43% with counselling plus pharmacotherapy). Counselling interventions did not significantly increase tobacco abstinence (RR 1.33, 95% CI 0.90 to 1.95).Interventions were significantly associated with tobacco abstinence for both people in treatment (RR 1.99, 95% CI 1.59 to 2.50) and people in recovery (RR 1.33, 95% CI 1.06 to 1.67), and for people with alcohol dependence (RR 1.47, 95% CI 1.20 to 1.81) and people with other drug dependencies (RR 1.85, 95% CI 1.43 to 2.40).Offering tobacco cessation therapy to people in treatment or recovery for other drug dependence was not associated with a difference in abstinence rates from alcohol and other drugs (RR 0.97, 95% CI 0.91 to 1.03, 11 studies, 2231 participants, moderate evidence of heterogeneity (I² = 66%)).Data on adverse effect of the interventions were limited.

AUTHORS' CONCLUSIONS

The studies included in this review suggest that providing tobacco cessation interventions targeted to smokers in treatment and recovery for alcohol and other drug dependencies increases tobacco abstinence. There was no evidence that providing interventions for tobacco cessation affected abstinence from alcohol and other drugs. The association between tobacco cessation interventions and tobacco abstinence was consistent for both pharmacotherapy and combined counselling and pharmacotherapy, for participants both in treatment and in recovery, and for people with alcohol dependency or other drug dependency. The evidence for the interventions was low quality due primarily to incomplete reporting of the risks of bias and clinical heterogeneity in the nature of treatment. Certain results were sensitive to the length of follow-up or the type of pharmacotherapy, suggesting that further research is warranted regarding whether tobacco cessation interventions are associated with tobacco abstinence for people in recovery, and the outcomes associated with NRT versus non-NRT or combined pharmacotherapy. Overall, the results suggest that tobacco cessation interventions incorporating pharmacotherapy should be incorporated into clinical practice to reduce tobacco addiction among people in treatment for or recovery from alcohol and other drug dependence.

Helping patients to reduce tobacco consumption in oncology: a narrative review

The present overview focuses on evidence of smoking cessation approaches in oncology settings with the aim to provide health personnel a critical perspective on how to help their patients. This narrative review is structured in two main sections: the first one describes the psycho-cognitive variables involved in the decision to continue smoking after a cancer diagnosis and during the treatment; the second section relates methods and tools may be recommended, being evidence-based, to support smoking cessation in oncology settings. Active smoking increases not only susceptibility to common cancers in the general population, but also increases disease severity and comorbidities in cancer patients. Nowadays, scientific evidence has identified many strategies to give up smoking, but a lack of knowledge exists for treatment of nicotine dependence in the cancer population. Health personnel is often ambiguous when approaching the problem, while their contribution is essential in guiding patients towards healthier choices. We argue that smoking treatments for cancer patients deserve more attention and that clinical features, individual characteristics and needs of the patient should be assessed in order to increase the attempts success rate. Health personnel that daily work and interact with cancer patients and their caregivers have a fundamental role in the promotion of the health changing. For this reason, it is important that they have adequate knowledge and resources in order to support cancer patients to stop tobacco cigarette smoking and promoting and healthier lifestyle.

Trends in Smoking Status and Utilization of Smoking Cessation Agents Among Females with Cardiovascular Diseases

BACKGROUND

In the United States, cigarette smoking accounts for almost 20% of all deaths attributed to heart disease. More women than men die each year of cardiovascular diseases (CVDs). Women who smoke have shown to be at a higher risk of cardiac deaths. The current study aims to determine the trend in smoking prevalence among women with CVD and their utilization of smoking cessation agents from 2004 to 2011.

MATERIALS AND METHODS

This was a retrospective exploratory study using Medical Expenditure Panel Survey data from 2004 to 2011. All female respondents with any one cardiovascular condition were identified. Descriptive statistics were carried out to obtain the number of female patients with CVD, their smoking status, and their use of smoking cessation agents. Furthermore, disparities in smoking status and smoking cessation agent utilization with respect to race and ethnicity were studied.

RESULTS

Among total CVD patients, 53% were females, which corresponded to 25.3 million females in the United States. Around 12.3% among them were current smokers. Only 6.9% among these females used smoking cessation agents. Smoking trends in females were inconsistent throughout the 8 years. Overall, the trend showed a decrease in the percentage of female smokers, while use of smoking cessation agents remained low from 2004 to 2011. Whites and non-Hispanics had more current smokers and women using smoking cessation agents.

CONCLUSION

The eight-year trend shows that the use of smoking cessation agents among females is very low, particularly among non-whites and Hispanics. This is of great concern and future efforts could focus on increasing the utilization of smoking cessation agents and collectively decreasing the risk of smoking in CVD by healthcare professionals.

Treatment Outcomes From a Specialist Model for Treating Tobacco Use Disorder in a Medical Center

Cigarette smoking causes premature mortality and multiple morbidity; stop smoking improves health. Higher rates of smoking cessation can be achieved through more intensive treatment, consisting of medication and extended counseling of patients, but there are challenges to integrating these interventions into healthcare delivery systems. A care model using a master-level counselor trained as a tobacco treatment specialist (TTS) to deliver behavioral intervention, teamed with a supervising physician/prescriber, affords an opportunity to integrate more intensive tobacco dependence treatment into hospitals, clinics, and other medical systems. This article analyzes treatment outcomes and predictors of abstinence for cigarette smokers being treated using the TTS-physician team in a large outpatient clinic over a 7-year period.This is an observational study of a large cohort of cigarette smokers treated for tobacco dependence at a medical center. Patients referred by the primary healthcare team for a TTS consult received a standard assessment and personalized treatment planning guided by a workbook. Medication and behavioral plans were developed collaboratively with each patient. Six months after the initial assessment, a telephone call was made to ascertain a 7-day period of self-reported abstinence. The univariate association of each baseline patient characteristic with self-reported tobacco abstinence at 6 months was evaluated using the chi-squared test. In addition, a multiple logistic regression analysis was performed with self-reported tobacco abstinence as the dependent variable and all baseline characteristics included as explanatory variables.Over a period of 7 years (2005-2011), 6824 cigarette smokers who provided general research authorization were seen for treatment. The 6-month self-reported abstinence rate was 28.1% (95% confidence interval: 27.7-30.1). The patients most likely to report abstinence were less dependent, more motivated to quit, and did not have a past year diagnosis of depression or alcoholism.Predictable patient characteristics such as level of dependence did predict abstinence, but all patient groups achieved comparable abstinence outcomes. While this study has limitations inherent in a single-center retrospective cohort study, it does suggest that the TTS model is an effective way to integrate more intensive tobacco dependence treatment into outpatient settings.

Assessment of compliance with U.S. Public Health Service clinical practice guideline for tobacco by primary care physicians

Background

The US Public Health Service Clinical Practice Guideline Treating Tobacco Use and Dependence: 2008 Update established an expanded standard of care, calling on physicians to consistently identify their patients who use tobacco and treat them using counseling and medication.

Findings

To assess compliance, we examined the extent to which physicians self-report following four of the five components of the 5A model: Ask about tobacco use, Advise patients who use tobacco to quit, Assist the patient in making a quit attempt, and Arrange for follow-up care. We used data from a Web-based panel survey administered to a convenience sample of 1,253 primary care providers (family/general practitioners, internists, and obstetrician/gynecologists). We found that 97.1% of the providers reported that they consistently Asked and documented tobacco use, while 98.6% reported that they consistently Advised their patients to quit using tobacco. Among the family/general practitioners and internists, 98.3% recommended “any” (medication, counseling, counseling and medication, telephone quitline) smoking cessation strategies (Assist). Among all providers, 48.0% reported that they consistently scheduled a follow-up visit (Arrange).

Conclusions

This study revealed that most primary care physicians reported that they Ask their patients about tobacco use, Advise them to quit, and Assist them in making a quit attempt, but only half reported that they Arrange a follow-up visit. Tobacco use screening and intervention are among the most effective clinical preventive services; thus, efforts to educate, encourage, and support primary care physicians to provide evidence-based treatments to their patients should be continued.

Tobacco dependence, the most important cardiovascular risk factor: treatment in the Czech Republic

Smoking is the most important cardiovascular (CV) risk factor. Stopping smoking halves the CV risk. Every clinician should provide a brief intervention with smokers. Intensive treatment should be available to those who need it. There are 37 Centers for Tobacco Dependence in the Czech Republic, which offer treatment including a psychobehavioral intervention and pharmacotherapy (varenicline, nicotine, bupropion). Czech physicians, pharmacists and nurses are regularly educated about smoking cessation. We describe the results of intensive treatment offered by our centers. Treatment includes screening (1 h), an intervention (2 h), and follow-up visits during the next 12 months. Among 3532 patients, 34.3 % had CO-validated abstinence at 12-months (including 489 patients who attended the screening visit + only the 12-month follow up visit). Among patients who underwent the intervention, the abstinence rate was 38.2 %. The majority of patients who underwent the intervention (N=2470) used some form of pharmacotherapy. After one year, the abstinence rate was 43.4 %, compared to 15.9 % (N=573) without pharmacotherapy. Only 28 % of patients came on the recommendation of a physician. Despite the decrease in CV risk following smoking cessation and the effectiveness of treatment, centers are underutilized.

Electronic cigarettes: a friend or foe in tobacco control?

Many dental practitioners will be aware of patients using electronic cigarettes over the last few years. These products are now widely used, but are they of help in tobacco control? And what are the implications of their use? The regulatory framework concerning these products is evolving rapidly with many opinions on what their final legal status should be. This paper explains their origin, explores some of the arguments and looks at possible future developments.

Effectiveness of pharmacologic therapies on smoking cessation success: three years results of a smoking cessation clinic

BACKGROUND

Pharmacologic therapies have an important role in the success of interventions for smoking cessation. This study aims to determine the efficacy of several pharmacologic treatments in patients who applied to a smoking cessation clinic.

METHODS

This retrospective study includes 422 patients who presented to our smoking cessation clinic between January 2010 and June 2013, used the pharmacologic treatment as prescribed and completed the one-year follow-up period. All patients were assessed using the Fagerström Test for Nicotine Dependence (FTND) and received both behavioral therapy and pharmacotherapy. Patients' smoking status at one year was assessed by telephone interview.

RESULTS

The patients were 24.3% female (103/422) and 75.7% male (319/422) with a mean age of 38 ± 10 years. Patients were divided into three groups: varenicline (166 patients), bupropion (148 patients) and nicotine replacement therapy (108 patients).The smoking cessation rates of these groups were 32.5%, 23% and 52.8%, respectively, and were statistically significant (p > 0.001). The overall success rate was 35%. Further analysis revealed that pharmacologic therapy (p > 0.001) and gender (p = 0.01) were factors that showed statistically significant effects on smoking cessation rates. Males had higher success rates than females. The overall relapse rate was 21.6% and the bupropion group showed the highest relapse rate among treatment groups. Lack of determination emerged as the most important factor leading to relapse.

CONCLUSION

Nicotine replacement therapy was found to be more effective at promoting abstinence from smoking than other pharmacologic therapies.

Parental tobacco screening and counseling in the pediatric emergency department: practitioners' attitudes, perceived barriers, and suggestions for implementation and maintenance

INTRODUCTION

The pediatric emergency department (PED) is a venue that underuses parental tobacco screening and brief cessation counseling. We sought to explore PED practitioners' attitudes and perceived barriers regarding the implementation and adoption of tobacco screening/cessation counseling of parental smokers in the PED setting, as well as to solicit suggestions for improving the sustainability and maintenance of such practices.

METHODS

We conducted an exploratory, qualitative study of a convenience sample of PED practitioners using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Individual, focused interviews were conducted to determine factors that would maximize the implementation and maintenance of parental tobacco screening and intervention counseling as standard PED practice.

RESULTS

Thirty interviews were conducted from which relevant data, patterns, and themes were identified. Reach factors included targeting parental smokers with children with respiratory diseases, having adequate training of practitioners, and providing "prearranged" counseling packages. Effectiveness factors included practitioner desire for outcome data about intervention effectiveness (eg, changes in children's secondhand smoke exposure and parental quit rates). Solutions to increase intervention adoption included quick electronic health record prompts and the provision of onsite tobacco cessation experts. Implementation suggestions emphasized the importance of financial support and the alignment of tobacco screening/counseling with strategic plans. Maintenance factors included institutional and technical support, as well as the importance of intervention "champions" in the PED.

DISCUSSION

By highlighting important viewpoints of practitioners regarding tobacco screening and counseling, the findings can help guide and direct the development and evaluation of sustainable interventions to facilitate tobacco use treatment in the PED.

How to minimize children's environmental tobacco smoke exposure: an intervention in a clinical setting in high risk areas

BACKGROUND

Despite the low prevalence of daily smokers in Sweden, children are still being exposed to environmental tobacco smoke (ETS), primarily by their smoking parents. A prospective intervention study using methods from Quality Improvement was performed in Child Health Care (CHC). The aim was to provide nurses with new methods for motivating and supporting parents in their efforts to protect children from ETS exposure.

METHOD

Collaborative learning was used to implement and test an intervention bundle. Twenty-two CHC nurses recruited 86 families with small children which had at least one smoking parent. Using a bundle of interventions, nurses met and had dialogues with the parents over a one-year period. A detailed questionnaire on cigarette consumption and smoking policies in the home was answered by the parents at the beginning and at the end of the intervention, when children also took urine tests to determine cotinine levels.

RESULTS

Seventy-two families completed the study. Ten parents (11%) quit smoking. Thirty-two families (44%) decreased their cigarette consumption. Forty-five families (63%) were outdoor smokers at follow up. The proportion of children with urinary cotinine values of >6 ng/ml had decreased.

CONCLUSION

The intensified tobacco prevention in CHC improved smoking parents' ability to protect their children from ETS exposure.

Interventions for tobacco use cessation in people in treatment for or recovery from substance abuse

This is the protocol for a review and there is no abstract. The objectives are as follows: To evaluate the effectiveness of tobacco cessation therapy offered concurrently with treatment for drug and alcohol addiction.

Smoking cessation post-discharge following nicotine replacement therapy use during an inpatient admission

BACKGROUND

Cigarette smoking remains a health issue despite declining prevalence in Australia. The burden of tobacco-related morbidity affects hospitals, particularly those in lower socioeconomic areas where prevalence is highest.

AIM

We have shown that nicotine replacement therapy (NRT) use during hospitalization increases motivation to quit post-discharge. We postulated that subjects using the nicotine patch post-discharge, in comparison to the inhaler, would have higher rates of abstinence at 12 months after discharge. The aim was to compare the efficacy of the nicotine patch or inhaler formulation for cessation post-discharge, following use during admission.

METHODS

Post-discharge, subjects chose their preferred formulation (patch or inhaler) based on their experience with NRT during admission. Tailored, medium-intensity support was provided with subsidized NRT during outpatient visits. Subjects were followed for 12 months. Exhaled breath CO confirmed non-smoking.

RESULTS

Of 123 subjects enrolled, 37 elected to use the inhaler, 50 the patch and 36 no NRT. At 12 months continuous abstinence rates were 38%, 38% and 25% respectively.

DISCUSSION

This study built upon the 'teachable moment' provided by hospitalization and the inpatient use of NRT, encouraging cessation post-discharge. Both NRT formulations provided similar 12 month cessation rates, and were superior to those achieved by subjects electing not to use NRT. Although the patch was the most popular formulation, the inhaler provided an equally efficacious alternative which addressed other facets of cigarette addiction. Subjects electing not to use NRT were less successful. Continuous abstinence rates were equivalent to community-based studies using NRT. We recommend a similar programme to other hospitals.

Tobacco use treatment at the U.S. National Cancer Institute's designated Cancer Centers

INTRODUCTION

Tobacco use is a leading cause of cancer, and continued use after cancer diagnosis puts patients at greater risk for adverse health outcomes, including increased risk for cancer recurrence. This study surveyed National Cancer Institute (NCI)-designated Cancer Centers to assess the availability of tobacco use treatment (TUT) services.

METHODS

Directors and oncology providers of 58 NCI-designated Cancer Centers received invitations to participate in an online survey. The questionnaire asked about attitudes, awareness, policies, and practices related to TUT; barriers to treatment provision; and factors likely to increase services.

RESULTS

All 58 Cancer Centers participated. Twelve (20.7%) Centers reported no TUT services for their patients. Of the remainder, 34 (58.6%) reported a TUT program within their Center and 12 (20.7%) reported external TUT services in their health care system or affiliated university. Only 62% of Centers reported routinely providing tobacco education materials to patients, just over half reported effective identification of patient tobacco use, and less than half reported an employee dedicated to providing TUT services or a clear commitment to providing TUT services from Center leadership. The 34 centers with internal TUT programs reported significantly greater services and administration support for TUT Services.

CONCLUSIONS

These data demonstrate a national need for Cancer Centers to embrace and incorporate recommended standards for TUT. Tying TUT services to NCI recognition and providing stable funding for TUT services in Cancer Centers could lead to better health outcomes, treatment efficacy, and satisfaction for all U.S. Cancer Centers and their patients.

How the Most Trusted Venues for Health-Related Information Influence Physician Referrals to Smoking Cessation Services

Public health programs seek to educate physicians by using a variety of venues. Therefore, it is important to understand which health information sources physicians are using and how these sources affect referrals. We explored how venues for health-related information affect physicians’ referral practices to smoking cessation services. The 2008 DocStyles survey asked physicians to rank a list of their most trusted sources of health-related information. The analysis was restricted to 1,617 physicians who responded to all variables of interest. In this sample, the most trusted sources of health-related information cited by physicians were medical journals (95.9%), government health agencies (82.2%), other physicians (76.4%), professional medical societies (75.2%), and medical Web sites or podcasts (65.9%). Medical providers were more likely to refer tobacco users to cessation services if they used professional medical societies as a source to obtain patient health-related information, compared with medical providers not using this source (multivariate odds ratio = 1.31; 95% confidence interval = 1.03–1.66). Physicians use many health information sources. Therefore, to reach physicians effectively, a broad dissemination of guidelines and best practices in tobacco control is needed and should include information for medical societies.

Smoking patterns in cancer survivors

INTRODUCTION

More than 11 million cancer survivors are at risk for new cancers, yet many are receiving inadequate guidance to reduce their risk. This study describes smoking trends among a group of cancer survivors (CaSurvivors) compared with a no cancer (NoCancer) control group.

METHODS

The Health Information National Trends Survey 2003, 2005, and 2007 cross-sectional surveys were used in this secondary data analysis. Descriptive statistics were produced, and logistic regressions of current smokers were performed on weighted samples using SUDAAN. The sample included 2,060 CaSurvivors; the average age was 63 years; and the majority of respondents were female (67%), White (80.6%), married, or partnered (52.5%), with at least some college education (57%). The mean time since diagnosis was 12 years; 28.7% reported fair or poor health status.

RESULTS

The overall smoking rate was 18.7% for CaSurvivors and 21.7% for the NoCancer group. Education (less than college), age (younger), marital status (widowed or divorced), and health care access (none or partial) were significant personal variables associated with a greater likelihood of being a current smoker. Controlling for these variables, there were no differences between the CaSurvivors and NoCancer groups over time. Women with cervical cancer were still more likely to be smokers (48.9%) than other CaSurvivors (p < .001).

CONCLUSIONS

CaSurvivors' current smoking trends were similar to the control group. While most variation was explained by demographic variables, women with cervical cancer, a smoking-related cancer, had the highest prevalence of smoking. Smoking cessation interventions should be targeted to this high-risk group.

A cessation program for snuff-dippers with long-term, extensive exposure to Swedish moist snuff: A 1-year follow-up study

OBJECTIVE

Smokeless tobacco (Swedish moist 'snus') users are often strongly addicted to nicotine. Compared to the large number of smoking-cessation studies, there have been few evaluated clinical cessation programs in conjunction with nicotine replacement therapy (NRT). The aim of this study was to evaluate a cessation program for snus users with a weekly use of >2 cans/week for >10 years.

MATERIAL AND METHODS

A prospective, open, non-randomized intervention trial was undertaken including baseline oral examination and soft tissue biopsy, minor physical examination, brief cessation advice, NRT recommendations and five prospective follow-up visits within 12 months. Individual cessation counseling was given, together with oral examination in the dental office. Fifty snus users with a minimum consumption of 100 g/week who were actively seeking cessation treatment were recruited through advertising. Self-reported abstaining, including random-sample biochemical verification, and NRT use were evaluated at 6 weeks and 3, 6 and 12 months.

RESULTS

At the 3-, 6- and 12-month visits, 58%, 46% and 30% of subjects, respectively were tobacco-abstinent. All nicotine abstinence was randomly controlled during the study except at 12 months, where all subjects claiming abstinence were confirmed biochemically and clinically.

CONCLUSION

Smokeless tobacco cessation achieved together with suitable NRT seems a promising way to improve a persistent tobacco-free condition.

Varenicline for smoking cessation: efficacy, safety, and treatment recommendations

Smoking is the leading preventable cause of morbidity and mortality in the US, and decreasing smoking prevalence is a public health priority. Patients achieve the greatest success when quit attempts involve behavioral therapy combined with pharmacotherapy. Varenicline is the most recent addition to the pharmacotherapeutic armamentarium for the treatment of tobacco dependence. Varenicline is efficacious and cost-effective. Smoking relapse and adverse treatment-related side effects may decrease medication adherence and patient satisfaction with varenicline. In the clinical setting, varenicline treatment can be optimized by reducing doses in patients who experience intolerable side effects, increasing the dose in partial responders, and providing long-term maintenance therapy for relapse prevention.

Current treatment options in smoking cessation

Cigarette smoking is the most important modifiable risk factor for premature mortality. Many common and serious diseases, including coronary artery disease, chronic obstructive lung disease, stroke, and cancer, are strongly linked to cigarette smoking. Smoking cessation is difficult due to nicotine addiction and withdrawal symptoms. Comprehensive programs for tobacco control can substantially reduce the frequency of tobacco use. Physicians can improve screening and increase cessation rates by asking patients about tobacco use at every office visit. The spectrum of available smoking cessation interventions ranges from simple advice to intensive behavioral support and pharmacological treatment. Medications currently approved by the US Food and Drug Administration for smoking cessation include nicotine replacement therapy (patch, gum, lozenge, inhaler, and nasal spray), bupropion, and varenicline. Nortriptyline and clonidine have been used in patients who do not tolerate first-line agents. New drug therapies, such as nicotine vaccines, are being developed. The US Public Health Service Guideline, published in 2008, recommends a combination of behavioral support and pharmacologic therapy. In summary, smoking cessation should be based on a patient's coexisting medical conditions, level of smoking, compliance, previous experience with cessation agents, and the cost of therapy.