Smoking cessation intervention: an evidence-based approach

Preliminary Efficacy of a Cognitive Behavioral Therapy-Based Smartphone App for Smoking Cessation in China: Randomized Controlled Pilot Trial

BACKGROUND

The overall prevalence of cigarette smokers in China is very high, and China's total cigarette consumption makes up more than 40% of the world's consumption. In view of the lack of smoking cessation services and social support in China and the effectiveness of mobile phone apps for quitting smoking in other countries, we carried out a smartphone app-based smoking cessation trial in China.

OBJECTIVE

This study aimed to evaluate the efficacy of a cognitive behavioral therapy (CBT)-based smoking cessation smartphone app among smokers seeking treatment in China.

METHODS

We conducted a randomized controlled, web-based pilot clinical trial in China between February 23 and June 27, 2021. Eligible participants were randomly assigned to the smoking cessation app intervention group or the control group in a ratio of 1:1. The intervention group received the CBT smoking cessation intervention using a smartphone app, and the control group received a "thank you" message. The intervention was 4 weeks long, and the patients were followed up for 4 weeks. The primary outcome was self-reported continuous smoking abstinence at week 4 after the quit date. The secondary outcomes included self-reported 7-day point prevalence of smoking abstinence; reduction of the number of cigarettes smoked per day at weeks 1, 2, 3, and 4; and program acceptability.

RESULTS

A total of 973 people were recruited to quit smoking, of whom 262 completed basic information, 56 were excluded, and 206 were randomized and included in the final analysis. There were 189 (91.7%) men and 17 (8.3%) women, with an average age of 34.46 (SD 7.53) years and an average daily smoking rate of 15.93 (SD 7.10) cigarettes/day. We found 30 (29.7%) of the 101 participants in the intervention group and 7 (6.7%) of the 105 participants in the control group reported continuous smoking cessation after the quit date at week 4 (odds ratio 5.92, 95% CI 3.78-9.26; P<.001). The 7-day point prevalence abstinence rate of the intervention group varied from 42.6% (43/101) to 46.5% (47/101) after 1, 2, 3, and 4 weeks, while the control group varied from 18.1% (19/105) to 26.7% (28/105). Compared to the control group, continued smokers consumed 1.5-3.0 fewer cigarettes per day in the intervention group. The overall program got positive user feedback with a high satisfaction rate (66/87, 76%) and an average Mobile Application Rating Scale user version score of 3.46.

CONCLUSIONS

Our pilot study provided preliminary evidence that the CBT-based smoking cessation smartphone app led to improved smoking quit rates versus control in Chinese smokers. The study demonstrated the CBT-based smartphone app may be an effective and feasible digital treatment model to help smokers quit, which may improve smoking cessation service quality and accessibility in China.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04421170; https://clinicaltrials.gov/study/NCT04421170.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2020-041985.

Adult perceptions of cigarettes and e-cigarettes: A Pakistan focus group study

Objective

Evidence suggests that the popularity of Reduced Risk Products' (RRPs) is growing globally, and they are being considered as effective aids for tobacco cessation. To explore different policy options for reducing disease burden, this qualitative study investigates the perceptions of the urban adult population regarding the use of e-cigarettes (EC), combustible cigarettes, or both, and the factors influencing their choices.

Methods

Twelve focus group discussions (FGDs), involving 132 participants, (68 male, 64 female), aged 18-60, were conducted from August to October 2022 in three metropolitan cities of Pakistan. Thematic analyses were conducted using the NVivo software. The Standards for Reporting Qualitative Research were employed for reporting and conducting purposes.

Results

The findings indicate that while all participants discussed the health risks associated with combustible cigarettes and EC and expressed intensions to quit, many continued to smoke or vape. Reasons cited included perceived stress relief, alleviation of medical issues, or addiction hindering cessation efforts. Among the youth, EC use gained popularity due to its social acceptability and the inclusion of appealing flavours and fragrances. Additionally, participants managed the higher costs of ECs by sharing and pooling expenses. Some users of combustible cigarettes transitioned to ECs with the expectation of achieving better health outcomes.

Conclusion

This study establishes a foundation for undertaking quantitative research to identify pathways for assisting policymakers in mitigating the growing disease burden. Additionally, it aims to contribute to the achievement of Sustainable Development Goals 3a and 3.4 for Pakistan.

Evaluation of a pharmacy supported e-cigarette smoking cessation intervention in Northwest England

BACKGROUND

Cigarette smoking cessation has been described as the world's most important public health intervention. Electronic cigarettes are a relatively new tool for assisting smoking cessation but there is a lack of data on their efficacy. This article reports on a pharmacy supported e-cigarette smoking cessation intervention undertaken in a metropolitan area in the north of England.

METHODS

Longitudinal mixed-methods evaluation incorporating analysis of secondary data, interviews with service users, and interviews with service providers at 3-month and 12-month follow-up, with an additional text message survey of service users at 12-month follow-up.

RESULTS

The four-week follow-up data suggest that for every twenty people given an e-cigarette, six quit smoking tobacco and three people cut their cigarette intake by more than five cigarettes per day. Long-term follow-up results were positive but only a small number of participants were still engaged with the study at 12 months. Service users and providers spoke positively about the combination of e-cigarettes and pharmacy support.

CONCLUSIONS

E-cigarette distribution combined with pharmacy support appears to be an agreeable and effective intervention for smoking cessation, but further data are needed on long-term quit rates and health effects.

Psychological Effects of Aromatherapy on Smokers With Depressive Tendencies During Smoking Cessation Treatment: Protocol for a Pre-Post Single-Arm Clinical Trial

Background

Cessation of smoking can markedly reduce the incidence of cardiovascular disease, improve health economics, and benefit society. Aromatherapy has the potential to be a novel option as an adjuvant therapy for smoking cessation that may alleviate depressive symptoms. However, research on the efficacy of aromatherapy as an adjuvant therapy for smoking cessation is scarce.

Objective

The aim of this study was to examine the potential effects of aromatherapy on psychological states in smokers with depressive tendencies and to determine if it is reasonable to proceed to the next step (ie, a phase III trial).

Methods

This is a pre-post single-arm clinical trial. Smokers with depression will be subjected to aromatherapy during smoking cessation treatment for 12 weeks. We will evaluate changes in scores on the Zung Self-Rating Depression Scale and the Profile of Mood States from pretreatment screening to 4 weeks and 12 weeks after the start of aromatherapy. Moreover, we will compare the group treated with aromatherapy with the group that received standard treatment in our previous randomized controlled trial (ie, the control group in that study). Furthermore, we will compare successful smoking cessation rates after 12 weeks. In addition, we will conduct an exploratory analysis of the efficacy of aromatherapy. The target sample size is 100, which is the number of subjects expected to be enrolled in this study during the 2-year study period.

Results

This study was approved by the Kyoto Medical Center Institutional Review Board (IRB approval No. 19-016). Enrollment started on July 1, 2019. As of May 2022, 76 patients have been recruited. In the original plan, recruitment should have been finished on June 30, 2021. However, the number of subjects decreased due to the COVID-19 pandemic, and the study inclusion period was extended by 1 year (ie, until the end of June 2022) with the approval of the IRB on May 17, 2021. Analyses of the results will be completed subsequently.

Conclusions

This study has some limitations. This is not a rigorous validation study because it compares the same subjects who received standard treatment in a previous study. Moreover, the sample size and methods of statistical analysis were not fully set with prior consideration of statistical rigor. To address these limitations, we plan to conduct a phase III trial that will reflect the exploratory findings of this study. This is the first study to evaluate the psychological effects of aromatherapy during a smoking cessation program, and it may help improve the quality of treatment for smoking cessation in the future.

Trial Registration

UMIN Clinical Trials Registry UMIN000043102; https://tinyurl.com/tn3hvt9w

International Registered Report Identifier (IRRID)

DERR1-10.2196/38626

Smoking Cessation Rate and Its Predictors among Heavy Smokers in a Smoking-Free Hospital in Taiwan

Smoking poses critical risks for heart disease and cancers. Heavy smokers, defined as smoking more than 30 pack-year, are the most important target for smoking cessation. This study aimed to obtain the cessation rate and its predictors among heavy smokers. We collected data from heavy smokers who visited a smoking-free hospital in Taiwan during 2017. All patients were prescribed either varenicline or nicotine replacement therapy (NRT) for smoking cessation, and their smoking status was followed for six months. Successful smoking cessation was defined by self-reported no smoking over the preceding seven days (7-day point abstinence). In total, 280 participants with a mean aged of 53.5 years were enrolled, and 42.9% of participants successfully stopped smoking in 6 months. The results revealed that quitters were older, with hypertension, fewer daily cigarettes, and being prescribed with varenicline. Multiple logistic regressions analyses identified that fewer daily cigarettes and being prescribed with varenicline were predictors of successful smoking cessation. Therefore, we suggest that varenicline use may help heavy smokers in smoking cessation.

Smartphone health apps for tobacco Cessation: A systematic review

BACKGROUND

Given the low retention and lack of persistent support by traditional tobacco cessation programs, evidence-based smartphone app-supported interventions can be an important tobacco control component. The objective of this systematic review was to identify and evaluate the types of studies that use smartphone apps for interventions in tobacco cessation.

METHODS

We conducted a systematic review of PubMed (1946-2019), EMBASE (1974-2019), and PsycINFO (1806-2019) databases with keywords related to smartphone-supported tobacco cessation. Included articles were required to meet 3 baseline screening criteria: 1) be written in English, 2) include an abstract, and 3) be a full, peer-reviewed manuscript. The criteria for the second level of review were: 1) primary outcome of tobacco cessation, 2) intervention study, and 3) smartphone app as primary focus of study.

RESULTS

Of 1973 eligible manuscripts, 18 met inclusion criteria. Most studies (n = 17) recruited adult participants (18 + years); one included teens (16 + years). Tobacco cessation was usually self-reported (n = 11), compared to biochemical verification (n = 3) or both (n = 4). There were 11 randomized controlled trials, 4 of which reported statistically significant results, and 7 single-arm trials that reported a mean abstinence rate of 33.9%.

DISCUSSION

The majority of studies that use tobacco cessation apps as an intervention delivery modality are mostly at the pilot/feasibility stage. The growing field has resulted in studies that varied in methodologies, study design, and inclusion criteria. More consistency in intervention components and larger randomized controlled trials are needed for tobacco cessation smartphone apps.

Leukocytosis and Tobacco Use: An Observational Study of Asymptomatic Leukocytosis

PURPOSE

This study aimed to characterize the white blood cell differential of tobacco smoking-induced leukocytosis and describe the longitudinal impact of smoking cessation on this peripheral blood abnormality.

METHODS

Medical records of patients undergoing evaluation by hematologists for persistent leukocytosis were reviewed. Patients in whom leukocytosis was determined to be secondary to tobacco use after exclusion of other causes were identified. Demographic and laboratory data were collected at time of diagnosis. Patients were longitudinally followed and information regarding smoking cessation and follow-up white blood cell values were recorded.

RESULTS

Forty patients were determined to have smoking-induced leukocytosis. The median age was 49.5 years (range: 28-75 years), 24 patients were female, and the mean body mass index (BMI) was 31.5 kg/m². The mean white blood cell count was 13.3 × 10⁹/L (range: 9.8-20.9 × 10⁹/L); 39 patients had absolute neutrophilia (98%), 21 had lymphocytosis (53%), 20 had monocytosis (50%), and 19 had basophilia (48%). During follow-up, 11 patients either quit (n = 9) or reduced (n = 2) tobacco use. Reduction in tobacco smoking led to a significant decrease in mean white blood cell count (13.2 × 10⁹/L vs 11.1 × 10⁹/L, P = 0.02). The median time to decrease in white blood cell count following reduction in tobacco use was 8 weeks (range: 2-49 weeks).

CONCLUSIONS

Tobacco-induced leukocytosis was characterized by a mild elevation in total white blood cell count and was most commonly associated with neutrophilia, lymphocytosis, monocytosis, and basophilia. Cessation of smoking led to improvement in leukocytosis. Tobacco history should be elicited from all patients presenting with leukocytosis to limit unnecessary diagnostic testing, and counseling regarding smoking cessation should be offered.

'Time to first tobacco cigarette soon after waking' occurs more often among underage newly incident smokers in the United States, 2004-2017

AIMS

Time to first cigarette (TTFC) after waking is a highly regarded and readily measured manifestation of a tobacco dependence process. We aim to estimate short TTFC as it occurs very soon after the onset of cigarette smoking (CS) in a community sample of newly incident smokers, all 12-21 years of age, and to study risk variation with the age of CS onset.

METHODS

United States National Surveys on Drug Use and Health, 2004-2017, drew large nationally representative samples of 12-to-21-year-old community residents, and used computerized self-interviews to measure tobacco cigarette smoking, the Fagerstrom TTFC construct, and related variables. A 'short' TTFC was defined as smoking the first cigarette after waking up within 30 min vs. 'long' TTFC or smoking more than 30 min. We studied 8188 newly incident smokers, all assessed within six months after the first puff. Estimated age-specific cumulative incidence proportions (CIP) and odds ratios (OR) are estimated and compared, with due attention to complex survey design and weights.

RESULTS

Among underage newly incident smokers (12-17 years old), an estimated 5.2% experienced short TTFC within 6 months after CS onset (95% CI = 4.4%, 6.2%), versus 3.7% for older new smokers (18-21 years; 95% CI = 2.8%, 4.6%). Underage smokers are 1.5 times more likely to develop short TTFC compared to older initiates (95% CI = 1.1, 2.1). No male-female variations are seen, but exploratory analysis disclosed findings that involve Census-defined race-ethnicity subgroups. Non-Hispanic African-American initiates are twice as likely to develop short TTFC, and Hispanic initiates are less likely to develop short TTFC, as compared with non-Hispanic White smokers.

CONCLUSIONS

Based on US community samples our study offers new evidence about TTFC formation observed within six months after the first puff when cigarette smoking starts before age 18 years.

Determining the effects of exercise after smoking cessation therapy completion on continuous abstinence from smoking: Japanese study protocol

BACKGROUND

Despite a steady world-wide decline over recent decades, rates of smoking remain high in developed countries. In Japan, 30% of men and 10% of women are smokers. Based on these rates, 18.8 million (14.06 million men and 4.74 million women) in Japan are smokers. The rate of success for smoking cessation has recently improved due to the widespread availability of drug therapy; however, the success rate for quitting smoking one year after beginning therapy is only around 50%. Previous studies have demonstrated that exercise can relieve mental stress during continuous abstinence from smoking and curb smoking resumption. To date, no large-scale, randomized controlled trials have examined the effects of exercise on smoking cessation. The present study aims to determine the effects of exercise instruction on continuous abstinence from smoking after completion of smoking cessation therapy.

METHODS

This is a multicenter, prospective, parallel-group, randomized controlled trial in Japan. We will enroll 300 individuals visiting a smoking cessation clinic (over 3 months) who have abstained from smoking in the second month after their initial visit as potential participants. Participants will not habitually exercise and will need to consent to participate. Participants will be randomly assigned to the exercise intervention group or control group. The intervention group will receive instruction on exercises that can be incorporated into their daily lives. The control group will be followed during the standard smoking cessation support program. The primary endpoint will be the continuous abstinence rate, and secondary endpoints will be weight, blood pressure, exhaled carbon monoxide concentration, psychological state, and blood test results. These indices will be compared between the intervention and control groups, with follow-up periods of 9 months in both groups.

DISCUSSION

By examining the effects of exercise instruction after completion of 12-week smoking cessation therapy, this study should yield quality information that can be used to develop protocols to improve the continuous abstinence rate and inhibit weight gain after smoking cessation therapy.

TRIAL REGISTRATION

UMIN Clinical Trials Registry, UMIN000014615. Registered on 1 October 2014.

Experimentation with tobacco during adolescence as a factor influencing treatment of smoking in adulthood. A retrospective cohort

BACKGROUND

There are still few studies on predictors of smoking cessation in Brazilian samples. Experimentation with tobacco during adolescence (ETA) may be one of the important predictors.

OBJECTIVE

This study aimed, within the context of a treatment-seeking group of subjects, to test the hypothesis that ETA negatively affects the outcome of smoking cessation during adulthood.

DESIGN AND SETTING

Retrospective (historic) cohort study conducted at a psychosocial care center in São Paulo, Brazil, between 2007 and 2010.

METHODS

Data on sociodemographics, smoking and medical profiles were obtained through self-report questionnaires that were completed at the baseline and at any follow-up appointment. Logistic regression models were constructed to describe factors associated with the outcome of smoking cessation, measured according to the self-reported four-week success rate among 367 outpatient smokers.

RESULTS

ETA was found to be associated with not quitting smoking through the treatment (odds ratio = 0.57; 95% confidence interval = 0.33-0.96; P < 0.05), even after adjustment for dependence level, sociodemographics, nicotine patch use and number of years of smoking.

CONCLUSIONS

Early exposure to nicotine may lead to higher risk of continuing smoking after treatment, in adulthood.

Effects of Smoking Cessation with Nicotine Replacement Therapy on Vascular Endothelial Function, Arterial Stiffness, and Inflammation Response in Healthy Smokers

The effects of nicotine replacement therapy (NRT)-aided smoking cessation on vascular function are not fully clarified. We investigated 100 healthy smokers who were motivated to quit and received NRT for a 3-month period. Vascular endothelial function (measured by reactive hyperemia-peripheral arterial tonometry [RH-PAT]), arterial stiffness (measured by augmentation index [AI] and brachial-ankle pulse wave velocity [baPWV]), and systemic inflammation markers (including serum soluble intercellular adhesion molecule-1 [sICAM-1] and interleukin-1β [IL-1β]) were assessed at baseline and 3 and 12 months of follow-up. After 3 months of intervention, endothelial function, arterial stiffness, and inflammatory markers significantly improved (RH-PAT increased, AI and baPWV decreased, sICAM-1 and IL-1β decreased, all P < .05) for the participants who abstained from smoking completely, but for those who did not abstained completely, RH-PAT, AI, baPWV, and IL-1β remained unchanged. At 12 months follow-up, endothelial function (RH-PAT), arterial stiffness (AI and baPWV), and inflammatory markers (sICAM-1 and IL-1β) were further improved in participants who abstained from smoking (P < .001), while the above parameters deteriorated in continued smokers (P < .05). In conclusion, vascular dysfunction can be reversible after NRT-aided smoking cessation in healthy smokers and vascular function could be further damaged if they continue smoking.

Support for Patients Who Have Difficulty Quitting Smoking: A Review

Smoking cessation plays a crucial role in reducing preventable morbidity and mortality. However, some smokers find smoking cessation difficult, despite receiving treatment. This includes heavy smokers with chronic obstructive pulmonary disease, smokers with a psychiatric disorder, and female and underage smokers. This review article describes smoking cessation approaches for patients who find it difficult to quit smoking.

Classifying smoking urges via machine learning

BACKGROUND AND OBJECTIVE

Smoking is the largest preventable cause of death and diseases in the developed world, and advances in modern electronics and machine learning can help us deliver real-time intervention to smokers in novel ways. In this paper, we examine different machine learning approaches to use situational features associated with having or not having urges to smoke during a quit attempt in order to accurately classify high-urge states.

METHODS

To test our machine learning approaches, specifically, Bayes, discriminant analysis and decision tree learning methods, we used a dataset collected from over 300 participants who had initiated a quit attempt. The three classification approaches are evaluated observing sensitivity, specificity, accuracy and precision.

RESULTS

The outcome of the analysis showed that algorithms based on feature selection make it possible to obtain high classification rates with only a few features selected from the entire dataset. The classification tree method outperformed the naive Bayes and discriminant analysis methods, with an accuracy of the classifications up to 86%. These numbers suggest that machine learning may be a suitable approach to deal with smoking cessation matters, and to predict smoking urges, outlining a potential use for mobile health applications.

CONCLUSIONS

In conclusion, machine learning classifiers can help identify smoking situations, and the search for the best features and classifier parameters significantly improves the algorithms' performance. In addition, this study also supports the usefulness of new technologies in improving the effect of smoking cessation interventions, the management of time and patients by therapists, and thus the optimization of available health care resources. Future studies should focus on providing more adaptive and personalized support to people who really need it, in a minimum amount of time by developing novel expert systems capable of delivering real-time interventions.

[Psychotherapy and pharmacotherapy for harmful tobacco use and tobacco dependency]

Tobacco consumption is one of the major preventable health risk factors. In Germany approximately 110,000 people prematurely die from tobacco-related diseases and approximately 50% of regular smokers are considered to be tobacco dependent. Nevertheless, motivation to quit smoking is low and the long-term abstinence rates after attempts to stop smoking without professional support are far below 10%. As part of the S3 treatment guidelines 78 recommendations for motivation and early interventions for smokers unwilling to quit as well as psychotherapeutic and pharmacological support for smokers willing to quit were formulated after an systematic search of the current literature. More than 50 professional associations adopted the recommendations and background information in a complex certification process. In this article the scientific evidence base regarding the psychotherapeutic and pharmacological treatment options as well as recommendations and further information about indications and treatment implementation are presented. By following these guidelines for treatment of heavy smokers who are willing to quit combined with individual and group therapies on the basis of behavioral treatment strategies and pharmacological support, long-term success rates of almost 30% can be achieved.

An assessment of factors associated with quality of randomized controlled trials for smoking cessation

To reduce smoking-related diseases, a research priority is to develop effective interventions for smoking cessation, and evidence from randomized controlled trials (RCTs) is usually considered to be the most valid. However, findings from RCTs may still be misleading due to methodological flaws. This study aims to assess the quality of 1083 RCTs of smoking cessation interventions in 41 relevant Cochrane Systematic Reviews (CSRs). Logistic regression analysis was performed to identify significant variables associated with the quality of RCTs. It was found that evidence for smoking cessation from RCTs was predominantly from high income countries, and the overall quality was high in only 8.6% of the RCTs. High quality RCTs tended to have a larger sample size, to be more recently published, and conducted in multiple countries belonging to different income categories. In conclusion, the overall quality of RCTs of smoking cessation interventions is far from perfect, and more RCTs in less developed countries are required to generate high grade evidence for global tobacco control. Collaboration between researchers in developed and less developed countries should be encouraged.

The Risk of Getting Worse: Predictors of Deterioration After Decompressive Surgery for Lumbar Spinal Stenosis: A Multicenter Observational Study

OBJECTIVE

To investigate the frequency and predictors of deterioration after decompressive surgery for single and 2-level lumbar spinal stenosis.

METHODS

Prospectively collected data were retrieved from the Norwegian Registry for Spine Surgery. Clinically significant deterioration was defined as an 8-point increase in Oswestry disability index (ODI) between baseline and 12 months' follow-up.

RESULTS

There were 2181 patients enrolled in the study. Of 1735 patients with complete 12 months follow-up, 151 (8.7%) patients reported deterioration. The following variables were significantly associated with deterioration at 12 months' follow-up; decreasing age (odds ratio [OR] 1.02, 95% confidence interval [95% CI] 1.00-1.04, P = 0.046), tobacco smoking (OR 2.10, 95% CI 1.42-3.22, P = 0.000), American Society of Anesthesiologists grade ≥3 (OR 1.80, 95% CI 1.07-2.94, P = 0.025), decreasing preoperative ODI (OR 1.05, 95% CI 1.02-1.07, P = 0.000), previous surgery at the same level (OR 2.00, 95% CI 1.18-3.27, P = 0.009), and previous surgery at other lumbar levels (OR 2.10, 95% CI 1.19-3.53, P = 0.009).

CONCLUSIONS

Overall risk of clinically significant deterioration in patient-reported pain and disability after decompressive surgery for lumbar spinal stenosis is approximately 9%. Predictors for deterioration are decreasing age, current tobacco smoking, American Society of Anesthesiologists grade ≥3, decreasing preoperative ODI, and previous surgery at same or different lumbar level. We suggest that these predictors should be emphasized and discussed with the patients before surgery.

Olfactory aversive conditioning during sleep reduces cigarette-smoking behavior

Recent findings suggest that novel associations can be learned during sleep. However, whether associative learning during sleep can alter later waking behavior and whether such behavioral changes last for minutes, hours, or days remain unknown. We tested the hypothesis that olfactory aversive conditioning during sleep will alter cigarette-smoking behavior during ensuing wakefulness. A total of 66 human subjects wishing to quit smoking participated in the study (23 females; mean age, 28.7 ± 5.2 years). Subjects completed a daily smoking diary detailing the number of cigarettes smoked during 7 d before and following a 1 d or night protocol of conditioning between cigarette odor and profoundly unpleasant odors. We observed significant reductions in the number of cigarettes smoked following olfactory aversive conditioning during stage 2 and rapid eye movement (REM) sleep but not following aversive conditioning during wakefulness (p < 0.05). Moreover, the reduction in smoking following aversive conditioning during stage 2 (34.4 ± 30.1%) was greater and longer lasting compared with the reduction following aversive conditioning during REM (11.9 ± 19.2%, p < 0.05). Finally, the reduction in smoking following aversive conditioning during sleep was significantly greater than in two separate control sleep experiments that tested aversive odors alone and the effects of cigarette odors and aversive odors without pairing. To conclude, a single night of olfactory aversive conditioning during sleep significantly reduced cigarette-smoking behavior in a sleep stage-dependent manner, and this effect persisted for several days.

Greater γ-tocopherol status during acute smoking abstinence with nicotine replacement therapy improved vascular endothelial function by decreasing 8-iso-15(S)-prostaglandin F2α

Nicotine replacement therapy (NRT) improves the long-term success rate of smoking cessation, but induces oxidative stress and inflammatory responses that may delay the restoration of vascular endothelial function (VEF). No studies have examined co-therapy of NRT-assisted smoking abstinence with γ-tocopherol (γ-T), a vitamin E form with antioxidant and anti-inflammatory activities, on improvements in VEF. In a randomized, double-blind, placebo-controlled study, healthy smokers (25 ± 1 y old; mean ± SEM) received NRT and abstained from smoking for 24 h with placebo (n = 12) or oral administration of γ-T-rich mixture of tocopherols (γ-TmT; n = 11) that provided 500 mg γ-T. Brachial artery flow-mediated dilation (FMD), and biomarkers of nitric oxide metabolism, antioxidant status, inflammation, and lipid peroxidation [8-iso-prostaglandin F2α stereoisomers (8-iso-15(R)-PGF2α and 8-iso-15(S)-PGF2α)] were measured prior to and after 24 h of smoking abstinence. Smoking abstinence with NRT regardless of γ-TmT similarly decreased urinary naphthol (P < 0.05) without affecting plasma cotinine. γ-TmT increased plasma γ-T by 4-times and the urinary metabolite of γ-T, γ-carboxyethyl-chromanol, by three times. Smoking abstinence with γ-TmT, but not smoking abstinence alone, increased FMD without affecting plasma nitrate/nitrite or the ratio of asymmetric dimethylarginine/arginine. Urinary 8-iso-15(S)-PGF2α decreased only in those receiving γ-TmT and was inversely correlated to FMD (R = -0.43, P < 0.05). Circulating markers of inflammation were unaffected by smoking abstinence or γ-TmT. Short-term NRT-assisted smoking abstinence with γ-TmT, but not NRT-assisted smoking abstinence alone, improved VEF by decreasing 8-iso-15(S)-PGF2α, a vasoconstrictor that was otherwise unaffected by NRT-assisted smoking abstinence.

Retention predictors of a smoking treatment provided by a public psychosocial unit in Brazil

Psychosocial units in Brazil (CAPS) provide access to mental health and addiction patients, who are not routinely treated for nicotine dependence. The present study analysed predictors of retention of a 6-week treatment provided by a CAPS unit to 367 smokers with a high rate of psychiatric disorders and addictions for the period 2007-2010. Several baseline variables were collected. Retention was defined as the presence of the individual in all four medical consultations and six group sessions. Multivariate discrete time Cox survival regression models were used to test for the outcome of interest. Timetables were used to explore in which moment of the treatment each predictor was important. Time to smoking the first cigarette (TTFC) 5 min or later after waking and nicotine patch use (nicotine replacement therapy, NRT) were associated with retention. The present study supports the importance of the variables TTFC and NRT when used in treatment retention for a sample with a high rate of psychiatric and alcohol disorders. NRT seems to be very important in the beginning of the treatment, probably because of withdrawal symptoms. Individuals currently undergoing psychiatric treatment and with alcohol problems had good retention rates comparable to the other individuals.

What characterises smokers who quit without using help? A study of users and non-users of cessation support among successful ex-smokers

BACKGROUND

A variety of smoking cessation aids are available; however, the majority of smokers quit unaided. We know little of the differences between users and non-users of cessation support.

METHODS

A cross-sectional study based on the Danish Health Examination Survey (DANHES) conducted in 2007-2008. In all, 6445 persons reporting quitting successfully within the last 5 years were included in analyses. Users and non-users of cessation aid (medical or behavioural support) were compared with regards to age, education, years smoked, tobacco amount, tobacco type and smoking-related disease using logistic regression analysis.

RESULTS

Quitting unaided was reported by 63%. Adjusted analyses showed that men were more likely to quit unaided than women, and younger compared with older were more likely to quit unaided (eg, OR among women age 45-59 versus age 14-29 were 0.18, 95% CI 0.12 to 0.20). Additionally, those who had smoked for 15 years or more also had lower odds of quitting unaided. Smoking 15 or more grams of tobacco daily was inversely associated with quitting unaided (eg, OR among men were 0.38, 95% CI 0.31 to 0.46).

CONCLUSIONS

Quitting smoking without the use of formalised aid was the most common cessation approach. Quitting unaided was more likely among men, younger age groups, those with a shorter history of smoking and those who were light smokers. These results indicate that awareness of unaided cessation in general and to those for whom it is especially relevant should be increased. This could lead to a more efficient use of resources for cessation support.

Smoking Behaviour of Asthmatic Patients in Primary Care: A Cross-Sectional Study

Introduction:

One-third of adult asthma patients smoke cigarettes despite smoking being a known trigger of asthma exacerbation. This study aims to describe the behaviour of asthmatic patients who smoke and explore the reasons why they continue to smoke cigarettes even when unwell.

Methods:

A cross-sectional questionnaire survey was conducted on adult asthma patients at primary care clinics in Singapore. One hundred and seventy-four asthmatic smokers (AS) of four ethnic groups, both genders, aged 21–50 years were recruited. Demographic data and smoking characteristics, reasons for smoking, and experiences during their attempts to quit were collected and analysed using the statistical software STATA version 12.

Results:

The median age of AS was 30 years. Seventy-five percent were males and mostly Malays (58%). Seventy-one percent had at least secondary education. Eighty-six percent started smoking before 20 years old. Ninety-eight percent smoked less than 10 sticks per day and 51% smoked ≤5 pack-years. Thirty-eight percent smoked within 5 minutes of awakening. AS cited reasons such as stress relief (79%), peer pressure (36%), influence from family members who smoke (40%), think better (35%), staying alert (57%), and relaxed (53%). Although 77% believed smoking worsened their asthma, they continued to smoke. Restlessness (43%), mood swings (27%), difficulties in concentration (25%) and irritability (24%) were common symptoms encountered in those who attempted to quit. About 44% did not refrain from smoking even when they were ill.

Conclusion:

Adult asthmatic smokers continued cigarette smoking to relieve stress, maintain mental alertness and avoid withdrawal symptoms. Implementing a programme to address smoking behaviour and withdrawal symptoms is paramount towards successful smoking cessation.

Utilization of smoking-cessation pharmacotherapy among chronic obstructive pulmonary disease (COPD) and lung cancer patients

OBJECTIVE

Smoking is one of the major risk factors causing morbidity and mortality in chronic obstructive pulmonary disease (COPD) and lung cancer patients. Use of smoking cessation pharmacotherapy is an effective way to help quit smoking. The purpose of the study was to determine the prevalence of smoking and the proportion of patients using smoking cessation agents, and to identify the socio-demographic factors that affect the use of these agents among COPD and lung cancer patients.

RESEARCH DESIGN AND METHODS

A retrospective study was done to identify smokers having COPD (ICD-9: 490-492) or lung cancer (ICD-9: 162), and those who use smoking cessation agents from 2006-2010, using Medical Expenditure Panel Survey (MEPS) data. A multiple logistic regression model was built to identify significant socio-demographic predictors associated with the use of smoking cessation agents.

RESULTS

Around 16.8% of COPD patients and 15.1% of lung cancer patients reported smoking after diagnosis. Out of the total smokers, 8.8% patients with COPD and 12.6% patients with lung cancer reported use of smoking cessation agents during the 5 year period. Logistic regression showed that odds for smoking cessation use in COPD patients were lower for Hispanics (OR = 0.107, 95% CI 0.023-0.502) and higher for patients having insurance coverage (OR = 3.453, 95% CI 1.240-9.617).

CONCLUSION

Results showed that a large number of patients continued to smoke even after the diagnosis of COPD and lung cancer; whereas only a few among them used smoking cessation agents. Ethnicity disparities and insurance status were associated with the use of smoking cessation agents. Differential use among population sub-groups suggests a requirement for need based smoking cessation programs and appropriate prescription drug coverage. Further research needs to be done to evaluate reasons for disparities in smoking cessation agents' use. The study had limitations common to research designs based on observational and self-reported datasets.

Smoking cessation counselling practices of family physicians in Jordan

Objectives: To assess the smoking cessation counselling practices of family physicians in Jordan and assess their perception about the availability of smoking cessation resources and about the barriers to effective smoking cessation practices. Methods: A pre-structured questionnaire was distributed to 124 family physicians practicing in teaching and Ministry of Health medical centres in Jordan. All participants were asked about their smoking cessation practices and about the barriers to effective smoking cessation practices. Results: Only 39.8% reported that they assess the willingness of the patients to quit smoking and 28.2% reported that they discuss counselling options with smokers. Considerably fewer percentages of physicians reported that they prepare their patients for withdrawal symptoms (11.6%), discuss pharmacotherapies (4.9%), describe a nicotine patch (5.0%), and provide patients with self-help materials (6.7%). The two factors cited most often by physicians as significant barriers to smoking cessation counselling were lack or too few available cessation programmes (90.3%) and limited training for physicians on tobacco and cessation interventions (90.3%). Conclusion: While a high proportion of Jordanian family physicians reported that they usually ask patients about smoking status and advise them to stop smoking, they do not regularly provide extensive assistance to help their patients to quit smoking. Lack or too few available cessation programmes and limited training for physicians on smoking cessation interventions were identified as the two major barriers to effective smoking cessation counselling.

Mental health promotion and illness prevention: a challenge for psychiatrists

Mental health is essential for individual and public health. To improve mental health, promotion, prevention, and the treatment of disease are required. These three kinds of interventions are interrelated but independent from one another. Although separate efforts for mental health promotion and prevention are needed as well as the public need of mental health promotion and well-being, psychiatrists usually are not accustomed to mental health promotion and prevention. This review introduces an overview of the concept, subjects according to target populations, and various intervention strategies for mental health promotion and prevention of mental illnesses. Based on literatures to date, understanding of developmental psychology, lifestyle medicine, and biopsychosocial contributors of mental health with a macroscopic perspective might help to practice mental health promotion and illness prevention.

Ghrelin and ghrelin receptor modulation of psychostimulant action

Ghrelin (GHR) is an orexigenic gut peptide that modulates multiple homeostatic functions including gastric emptying, anxiety, stress, memory, feeding, and reinforcement. GHR is known to bind and activate growth-hormone secretagogue receptors (termed GHR-Rs). Of interest to our laboratory has been the assessment of the impact of GHR modulation of the locomotor activation and reward/reinforcement properties of psychostimulants such as cocaine and nicotine. Systemic GHR infusions augment cocaine stimulated locomotion and conditioned place preference (CPP) in rats, as does food restriction (FR) which elevates plasma ghrelin levels. Ghrelin enhancement of psychostimulant function may occur owing to a direct action on mesolimbic dopamine function or may reflect an indirect action of ghrelin on glucocorticoid pathways. Genomic or pharmacological ablation of GHR-Rs attenuates the acute locomotor-enhancing effects of nicotine, cocaine, amphetamine and alcohol and blunts the CPP induced by food, alcohol, amphetamine and cocaine in mice. The stimulant nicotine can induce CPP and like amphetamine and cocaine, repeated administration of nicotine induces locomotor sensitization in rats. Inactivation of ghrelin circuit function in rats by injection of a ghrelin receptor antagonist (e.g., JMV 2959) diminishes the development of nicotine-induced locomotor sensitization. These results suggest a key permissive role for GHR-R activity for the induction of locomotor sensitization to nicotine. Our finding that GHR-R null rats exhibit diminished patterns of responding for intracranial self-stimulation complements an emerging literature implicating central GHR circuits in drug reward/reinforcement. Finally, antagonism of GHR-Rs may represent a smoking cessation modality that not only blocks nicotine-induced reward but that also may limit weight gain after smoking cessation.

What do most erectile dysfunction guidelines have in common? No evidence-based discussion or recommendation of heart-healthy lifestyle changes and/or Panax ginseng

Sexual health or erectile dysfunction (ED) state of the art guidelines provide a thorough overview of conventional prescription or other notable extrinsic treatment options. Yet, over the past 10-15 years, a plethora of international researchers have established that individual and comprehensive lifestyle changes can prevent and potentially improve ED. We review the lifestyle evidence that should equate to grade A or level 1 evidence recommendations for ED. We also review the evidence for Panax ginseng, an over-the-counter (OTC) dietary supplement with a 35-year history of laboratory investigations, multiple positive randomized trials over approximately 15 years and several independent meta-analyses and systematic reviews. Perhaps it is time to at least discuss and even emphasize lifestyle and other non-conventional interventions in ED guidelines so that patients can explore a diversity of potentially synergistic choices with their physicians and can improve their quality and quantity of life. Ignoring the consistent, positive data on lifestyle modifications in ED guidelines, for example, is tantamount to ignoring diet and lifestyle changes to reduce the risk of or ameliorate cardiovascular diseases.

Phenanthrene metabolism in smokers: use of a two-step diagnostic plot approach to identify subjects with extensive metabolic activation

Polycyclic aromatic hydrocarbons (PAHs) in cigarette smoke are among the most likely causes of lung cancer. PAHs require metabolic activation to initiate the carcinogenic process. Phenanthrene (Phe), a noncarcinogenic PAH, was used as a surrogate of benzo[α]pyrene and related PAHs to study the metabolic activation of PAHs in smokers. A dose of 10 μg of deuterated Phe ([D₁₀]Phe) was administered to 25 healthy smokers in a crossover design, either as an oral solution or by smoking cigarettes containing [D₁₀]Phe. Phe was deuterated to avoid interference from environmental Phe. Intensive blood and urine sampling was performed to quantitate the formation of deuterated r-1,t-2,3,c-4-tetrahydroxy-1,2,3,4-tetrahydrophenanthrene ([D₁₀]PheT), a biomarker of the diol epoxide metabolic activation pathway. In both the oral and smoking arms approximately 6% of the dose was metabolically converted to diol epoxides, with a large intersubject variability in the formation of [D₁₀]PheT observed. Two diagnostic plots were developed to identify subjects with large systemic exposure and significant lung contribution to metabolic activation. The combination of the two plots led to the identification of subjects with substantial local exposure. These subjects produced, in one single pass of [D₁₀]Phe through the lung, a [D₁₀]PheT exposure equivalent to the systemic exposure of a typical subject and may be an indicator of lung cancer susceptibility. Polymorphisms in PAH-metabolizing genes of the 25 subjects were also investigated. The integration of phenotyping and genotyping results indicated that GSTM1-null subjects produced approximately 2-fold more [D₁₀]PheT than did GSTM1-positive subjects.

Smoking cessation and its predictors: results from a community-based pharmacy tobacco cessation program in New Mexico

BACKGROUND

The New Mexico Pharmaceutical Care Foundation received funding through the Tobacco Use Prevention and Control Program (TUPAC) to provide support for pharmacist-delivered tobacco cessation services. The goal of the program was to increase the availability of tobacco cessation services to residents of New Mexico. Program outcomes are presented, using data from the first 2 fiscal years.

OBJECTIVE

To assess tobacco quit rates among smokers who participated in the community pharmacist-based program and identify the predictors of quitting at the end of a 6-month program.

METHODS

Pharmacists, who had received Rx for Change training, provided tobacco cessation services. Patients were scheduled for an initial visit and then were seen at regularly scheduled follow-up visits at 1 month, 3 months, and 6 months from the initial visit. Data collected at the initial visit included demographics, smoking history, and readiness for quitting. Smoking status was collected at each of the follow-up visits. Data were analyzed using SAS (SAS Institute) and STATA (StataCorp LP) statistical software. Tobacco quit rates were calculated at 1, 3, and 6 months. Multivariate regression analysis was performed to assess predictors of quitting. Standard errors were adjusted for repeated observation.

RESULTS

Data were available for 346 participants. The average quit rate at the end of 6 months was 25%. Significant predictors of quitting were high confidence levels in quitting at baseline, individuals who had first cigarettes at least 30 minutes after waking up, first cessation attempt, and nonwhite patients.

CONCLUSIONS

A smoking cessation program delivered through trained community pharmacists with prescriptive authority is an effective approach to reducing smoking. Further research should be conducted to compare the effectiveness of pharmacists with that of other providers of tobacco cessation services.

Effect of self-administered auricular acupressure on smoking cessation--a pilot study

Background

Tobacco smoking is still a worldwide health risk. Current pharmacotherapies have at best, a success rate of no more than 50%. Auricular (ear) acupressure has been purported to be beneficial in achieving smoking cessation in some studies, while in others has been deemed insignificant. We hereby describe the protocol for a three-arm randomised controlled trial to examine the possible benefits of self-administered acupressure for smoking cessation.

Methods

Sixty consenting participants with confirmed habit of tobacco smoking will be recruited and randomized into three arms to receive either auricular acupressure at five true acupoints (NADA protocol), auricular acupressure at five sham points, or no auricular acupressure at all. Participants having auricular acupressure will exert firm pressure to each acupoint bilaterally via the bead in the attached plasters whenever they feel the urge to smoke. The treatment phase will last for six weeks during which all participants will be assessed weekly to review their smoking log, state of abstinence, end-exhalation carbon monoxide levels and possible adverse effects including withdrawal reactions and stress levels. At any time, a successful quit date will be defined with continuous abstinence for the following consecutive 7 days. From then on, participants will be evaluated individually for continuous abstinence rate (CAR), end-exhalation carbon monoxide levels and adverse effects of stress and withdrawal at specified intervals up to 26 weeks. Expectancy of treatment will be assessed with a four-item Borkovec and Nau self-assessment credibility scale during and after intervention.

Discussion

We incorporate validated outcome measures of smoking cessation into our randomised controlled trial design with the objectives to evaluate the feasibility and possible benefits of self-administered auricular acupressure as a non-invasive alternative to pharmacotherapy for smoking cessation.

Trial Registration

ClinicalTrials.gov: NCT01389622 (registered Jul 7 2011)

Repeated administration of the GABAB receptor positive modulator BHF177 decreased nicotine self-administration, and acute administration decreased cue-induced reinstatement of nicotine seeking in rats

RATIONALE

γ-Aminobutyric acid (GABA) is the major inhibitory neurotransmitter in the brain and is implicated in the modulation of central reward processes. Acute or chronic administration of GABA(B) receptor agonists or positive modulators decreased self-administration of various drugs of abuse. Furthermore, GABA(B) receptor agonists inhibited cue-induced reinstatement of nicotine- and cocaine-seeking behavior. Because of their fewer adverse side effects compared with GABA(B) receptor agonists, GABA(B) receptor positive modulators are potentially improved therapeutic compounds for the treatment of drug dependence compared with agonists.

OBJECTIVES AND METHODS

We examined whether the acute effects of the GABA(B) receptor positive modulator N-[(1R,2R,4S)-bicyclo[2.2.1]hept-2-yl]-2-methyl-5-[4-(trifluoromethyl)phenyl]-4-pyrimidinamine (BHF177) on nicotine self-administration and food-maintained responding under a fixed-ratio 5 schedule of reinforcement were maintained after repeated administration. The effects of acute BHF177 administration on cue-induced nicotine- and food-seeking behavior, a putative animal model of relapse, were also examined.

RESULTS

Repeated administration of BHF177 for 14 days decreased nicotine self-administration, with small tolerance observed during the last 7 days of treatment, whereas BHF177 minimally affected food-maintained responding. Acute BHF177 administration dose-dependently blocked cue-induced reinstatement of nicotine-, but not food-, seeking behavior after a 10-day extinction period.

CONCLUSIONS

These results showed that BHF177 selectively blocked nicotine self-administration and prevented cue-induced reinstatement of nicotine seeking, with minimal effects on responding for food and no effect on cue-induced reinstatement of food seeking. Thus, GABA(B) receptor positive modulators could be useful therapeutics for the treatment of different aspects of nicotine dependence by facilitating smoking cessation by decreasing nicotine intake and preventing relapse to smoking in humans.

Developing a smoking cessation program for Turkish-speaking migrants in Switzerland: novel findings and promising effects

INTRODUCTION

Recent studies show that smoking prevalence in the Turkish-speaking migrant population in Switzerland is substantially higher than in the general population. A specific group treatment for Turkish-speaking migrants was developed and tested in order to provide the migrant population with equal access to smoking cessation programs and to improve the migration-sensitive quality of such programs by sociocultural targeting.

METHODS

The evaluation of the program included quantitative (questionnaires t1 and t2 and follow-up by telephone) and qualitative methods (participant observation and semi-structured interviews).

RESULTS

The results showed that 37.7% of the 61 participants were smoke free at the 12-month follow-up. The factors of being in a partnership and using nicotine replacement products during the program were positively associated with successful cessation. We also demonstrated the importance of "strong ties" (strong relationships between participants) and the sensitivity of the program to sociocultural (e.g., social aspects of smoking in Turkish culture, which were addressed in relapse prevention), socioeconomic (e.g., low financial resources, which were addressed by providing the course for free), and migration-specific (e.g., underdeveloped access to smoking cessation programs, which was addressed using outreach strategy for recruiting) issues.

CONCLUSIONS

Overall, the smoking cessation program was successfully tested and is now becoming implemented as a regular service of the Swiss Public Health Program for Tobacco Prevention (by the Swiss Association for Smoking Prevention).