Assessing acute nicotine impact on choroidal thickness: a randomized, double-blinded study comparing smoking cessation aids, including nicotine gum and electronic cigarettes

PURPOSE

To explore whether differences in choroidal thickness arise from nicotine consumption in healthy young individuals, specifically comparing the effects of nicotine gum to electronic cigarette (vaping), while maintaining a consistent 4 mg nicotine dosage.

METHODS

In a randomized double-blinded prospective cross-sectional study, 20 healthy participants (mean age ± standard deviation: 23 ± 2.36 years) were randomly assigned to either the nicotine gum or vaping group. Choroidal thickness (ChT) measurements were conducted using optical coherence tomography (OCT) (Topcon 3D OCT-1 Maestro System) at baseline, 30, and 60 min after ingesting 4 mg of nicotine, with ChT measurements taken from five different horizontal areas.

RESULTS

Neither the nicotine delivery method (gum or vaping) demonstrated a statistically significant impact on ChT mean scores among subjects in the five measured areas at baseline, 30, and 60 min (p > 0.05). However, significant differences were observed in ChT mean scores within subjects across the five areas (F (1.83, 72) = 36.43, p < 0.001), regardless of other study factors such as group, time, and visit (p > 0.05). A statistically significant interaction was identified between the factors of area and time concerning participants' ChT mean scores when stratified by the type of smoking (tobacco, vaping, and dual) (p = 0.003).

CONCLUSION

The results of this study revealed that nicotine, up to particular concentration of 4 mg, does not have a statistically significant vasoconstrictive effect on choroidal thickness, regardless of the delivery method, within the examined group. These findings offer valuable insights into the relationship between nicotine intake and choroidal dynamics in young adults.

Characterising smoking and nicotine use behaviours among women of reproductive age: a 10-year population study in England

BACKGROUND

Tobacco smoking affects women's fertility and is associated with substantial risks of adverse pregnancy outcomes. This study explored trends by socioeconomic position in patterns of smoking, use of non-combustible nicotine products, and quitting activity among women of reproductive age in England.

METHODS

Data come from a nationally representative monthly cross-sectional survey. Between October 2013 and October 2023, 197,266 adults (≥ 18 years) were surveyed, of whom 44,052 were women of reproductive age (18-45 years). Main outcome measures were current smoking, vaping, and use of nicotine replacement therapy (NRT), heated tobacco products (HTPs), and nicotine pouches; mainly/exclusively smoking hand-rolled cigarettes and level of dependence among current smokers; past-year quit attempts among past-year smokers; and success of quit attempts among those who tried to quit. We modelled time trends in these outcomes, overall and by occupational social grade (ABC1 = more advantaged/C2DE = less advantaged).

RESULTS

Smoking prevalence among women of reproductive age fell from 28.7% [95%CI = 26.3-31.2%] to 22.4% [19.6-25.5%] in social grades C2DE but there was an uncertain increase from 11.7% [10.2-13.5%] to 14.9% [13.4-16.6%] in ABC1. By contrast, among all adults and among men of the same age, smoking prevalence remained relatively stable in ABC1. Vaping prevalence among women of reproductive age more than tripled, from 5.1% [4.3-6.0%] to 19.7% [18.0-21.5%], with the absolute increase more pronounced among those in social grades C2DE (reaching 26.7%; 23.3-30.3%); these changes were larger than those observed among all adults but similar to those among men of the same age. The proportion of smokers mainly/exclusively smoking hand-rolled cigarettes increased from 40.5% [36.3-44.9%] to 61.4% [56.5-66.1%] among women of reproductive age; smaller increases were observed among all adults and among men of the same age. Patterns on other outcomes were largely similar between groups.

CONCLUSIONS

Among women of reproductive age, there appears to have been a rise in smoking prevalence in the more advantaged social grades over the past decade. Across social grades, there have been substantial increases in the proportion of women of reproductive age who vape and shifts from use of manufactured to hand-rolled cigarettes among those who smoke. These changes have been more pronounced than those observed in the general adult population over the same period.

Actívatexto: Feasibility and Acceptability of a Mobile Intervention That Promotes Smoking Cessation and Physical Activity among Latinos

The purpose of this study was to assess the feasibility and acceptability of a mobile intervention that promotes smoking cessation and physical activity among Latinos living in the United States. Twenty Latino adults who smoked and did not meet recommended levels of physical activity were recruited using community-based recruitment strategies. Participants received Actívatexto, a theory-based, culturally accommodated, 12-week text messaging intervention (available in English and Spanish) that promotes smoking cessation and physical activity. Actívatexto integrates four components: (i) a text messaging program, (ii) a wearable device, (iii) an online dashboard where the research team manages participants' incoming and outgoing data from both the text messaging program and wearable device, and (iv) nicotine replacement therapies (NRT). We assessed self-reported 7-day point prevalence smoking abstinence at month 3, weekly minutes of moderate to vigorous physical activity (MVPA), pharmacotherapy adherence, and satisfaction. At baseline, participants' mean age was 47.3 years old (SD 16.0), 55% of participants were female, and 60% indicated that Spanish was their language of preference. Seventy-five percent of participants smoked 1-10 cigarettes daily and 35% smoked their first cigarette within 5 minutes after waking up. At month 3, 14 participants (70%) self-reported 7-day point prevalence smoking abstinence (90% follow-up rate). Fitbit-assessed mean minutes of MVPA per week increased from 113 (SD 127; range: 0-399) at week 1 to 177 (SD 163; range: 0-513) at month 3 (P = 0.15). Sixteen participants (88.9%, 16/18) reported NRT use in the past 90 days. Most participants reported being extremely satisfied or satisfied with the intervention (88.9%, 16/18).

SIGNIFICANCE

Actívatexto resulted in a noteworthy cessation rate at month 3 (70%), increased mean weekly minutes of MVPA, produced high use of NRT, and was well received by participants. Additional testing in a randomized clinical trial is warranted to assess the efficacy of the intervention.

Effect of implementation strategies on the routine provision of antenatal care addressing smoking in pregnancy: study protocol for a non-randomised stepped-wedge cluster controlled trial

INTRODUCTION

Globally, guideline-recommended antenatal care for smoking cessation is not routinely delivered by antenatal care providers. Implementation strategies have been shown to improve the delivery of clinical practices across a variety of clinical services but there is an absence of evidence in applying such strategies to support improvements to antenatal care for smoking cessation in pregnancy. This study aims to determine the effectiveness and cost effectiveness of implementation strategies in increasing the routine provision of recommended antenatal care for smoking cessation in public maternity services.

METHODS AND ANALYSIS

A non-randomised stepped-wedge cluster-controlled trial will be conducted in maternity services across three health sectors in New South Wales, Australia. Implementation strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training and monitoring and feedback will be delivered sequentially to each sector over 4 months. Primary outcome measures will be the proportion of: (1) pregnant women who report receiving a carbon monoxide breath test; (2) smokers or recent quitters who report receiving quit/relapse advice; and (3) smokers who report offer of help to quit smoking (Quitline referral or nicotine replacement therapy). Outcomes will be measured via cross-sectional telephone surveys with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost effectiveness of the implementation intervention. Process measures including acceptability, adoption, fidelity and reach will be reported.

ETHICS AND DISSEMINATION

Ethics approval was obtained through the Hunter New England Human Research Ethics Committee (16/11/16/4.07; 16/10/19/5.15) and the Aboriginal Health and Medical Research Council (1236/16). Trial findings will be disseminated to health policy-makers and health services to inform best practice processes for effective guideline implementation. Findings will also be disseminated at scientific conferences and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry-ACTRN12622001010785.

Effectiveness of culturally tailoring smoking cessation interventions for reducing or quitting combustible tobacco: A systematic review and meta-analyses

BACKGROUND AND AIMS

Standard approaches to smoking cessation may not be as effective for certain populations, and tailoring on cultural factors could improve their effectiveness. This systematic review measured the effectiveness of culturally tailoring smoking cessation interventions on quitting or reducing smoking combustible tobacco.

METHOD

We searched MEDLINE, PsychInfo, Embase and Cochrane Central Register from inception to 21 June 2023 for randomized controlled trials (RCTs) of community-based, primary care or web-based interventions for smoking cessation in adults who smoked tobacco, with measurement of smoking abstinence or reduction at least 3 months following baseline. We examined comparisons between either an intensity-matched culturally tailored intervention and a non-tailored intervention or a standard non-tailored intervention and the same intervention plus a culturally tailored adjunct. We sub-grouped studies according to the level of tailoring and performed subgroup analyses where appropriate. We assessed risk of bias and certainty of evidence.

RESULTS

We identified 43 studies, 33 of which were meta-analyzed (n = 12 346 participants). We found moderate certainty evidence, limited by heterogeneity, that intensity-matched culturally tailored cessation interventions increased quit success when compared with non-tailored interventions at 3-month follow-up or longer (n = 5602, risk ratio [RR] = 1.29 95% confidence interval [CI] 1.10, 1.51, I2  = 47%, 14 studies). We found a positive effect of adding a culturally tailored component to a standard intervention compared with the standard intervention alone (n = 6674, RR = 1.47, 95% CI 1.10, 1.95, I2  = 74%, 18 studies), but our certainty in this effect was low due to imprecision and substantial statistical heterogeneity.

CONCLUSION

Culturally tailored smoking cessation interventions may help more people to quit smoking than a non-tailored intervention. Adapting or adding cultural components to smoking cessation interventions originally developed for majority populations could improve cessation rates in populations who do not fully identify with majority cultural norms.

[Tobacco cessation: one of the most effective medical measures]

Tobacco smoking is widespread in Germany. An increase in the number of teenagers and young adults that smoke has recently been a cause for concern. The high prevalence in Germany is contrasted by inadequate preventive measures compared to international standards. Smoking behavior should always be inquired about and documented in the same way as vital signs. All smokers, regardless of the reason for contact and motivation, should receive short, low-threshold advice, e.g. using the ABC approach (ask, brief advice, cessation). In addition to repeated advice and referral to further services, the use of nicotine replacement or drug therapy is essential for the success of quitting. The combination of long- and short-acting nicotine replacement products doubles the success rate. Electronic nicotine delivery systems are not recommended for smoking cessation.

Insomnia and parasomnia induced by validated smoking cessation pharmacotherapies and electronic cigarettes: a network meta-analysis

We aim to assess the relationship between validated smoking cessation pharmacotherapies and electronic cigarettes (e-cigarettes) and insomnia and parasomnia using a systematic review and a network meta-analysis. A systematic search was performed until August 2022 in the following databases: PUBMED, COCHRANE, CLINICALTRIAL. Randomized controlled studies against placebo or validated therapeutic smoking cessation methods and e-cigarettes in adult smokers without unstable or psychiatric comorbidity were included. The primary outcome was the presence of "insomnia" and "parasomnia." A total of 1261 studies were selected. Thirty-seven studies were included in the quantitative analysis (34 for insomnia and 23 for parasomnia). The reported interventions were varenicline (23 studies), nicotine replacement therapy (NRT, 10 studies), bupropion (15 studies). No studies on e-cigarettes were included. Bayesian analyses found that insomnia and parasomnia are more frequent with smoking cessation therapies than placebo except for bupropion. Insomnia was less frequent with nicotine substitutes but more frequent with bupropion than the over pharmacotherapies. Parasomnia are less frequent with bupropion but more frequent with varenicline than the over pharmacotherapies. Validated smoking cessation pharmacotherapies can induce sleep disturbances with different degrees of frequency. Our network meta-analysis shows a more favorable profile of nicotine substitutes for insomnia and bupropion for parasomnia. It seems essential to systematize the assessment of sleep disturbances in the initiation of smoking cessation treatment. This could help professionals to personalize the choice of treatment according to sleep parameters of each patient. Considering co-addictions, broadening the populations studied and standardizing the measurement are additional avenues for future research.

Is Abstinence from Alcohol and Smoking Associated with Less Anxiety and Depressive Symptoms Among People with HIV?

Achieving abstinence from alcohol, tobacco, or both may improve mental health, but is understudied in people with HIV (PWH). The St PETER HIV randomized clinical trial compared varenicline, cytisine, and nicotine replacement therapy on alcohol and smoking behavior among 400 PWH in Russia. The primary exposure was thirty-day point prevalence abstinence (PPA) from (1) alcohol, (2) smoking, (3) both, or (4) neither and was assessed at 1, 3, 6 and 12-months as were the study outcomes of anxiety (GAD-7) and depressive (CES-D) symptoms. The primary aim was to examine the association between smoking and/or alcohol abstinence and subsequent symptoms of depression and anxiety. Primary analysis used repeated measures generalized linear modeling to relate PPA with mental health scores across time. In secondary analyses, Kruskal-Wallis tests related PPA with mental health scores at each timepoint. Primary analyses did not identify significant differences in anxiety or depressive symptoms between exposure groups over time. Secondary analyses found CES-D scores across PPA categories were similar at 1-month (11, 10, 11, 11) and 6-months (10, 10, 11, 11) but differed at 3-months (9, 11, 10, 12; p = 0.035) and 12-months (10, 6, 11, 10; p = 0.019). GAD-7 scores did not vary across PPA categories at any time point. While abstinence was associated with fewer depressive symptoms at times, findings were not consistent during follow-up, perhaps reflecting intermittent relapse. PWH with polysubstance use and mental health comorbidity are complex, and larger samples with sustained abstinence would further elucidate effects of abstinence on mental health.

Do medications increase the efficacy of digital interventions for smoking cessation? Secondary results from the iCanQuit randomized trial

BACKGROUND AND AIMS

iCanQuit is a smartphone application (app) proven efficacious for smoking cessation in a Phase III randomized controlled trial (RCT). This study aimed to measure whether medications approved by the US Food and Drug Administration (FDA) for smoking cessation would further enhance the efficacy of iCanQuit, relative to its parent trial comparator-the National Cancer Institute's (NCI's) QuitGuide app.

DESIGN

Secondary analysis of the entire parent trial sample of a two-group (iCanQuit and QuitGuide), stratified, doubled-blind RCT.

SETTING

United States.

PARTICIPANTS

Participants who reported using an FDA-approved cessation medication on their own (n = 619) and those who reported no use of cessation medications (n = 1469).

INTERVENTIONS

Participants were randomized to receive iCanQuit app or NCI's QuitGuide app.

MEASUREMENTS

Use of FDA-approved medications was measured at 3 months post-randomization. Smoking cessation outcomes were measured at 3, 6 and 12 months. The primary outcome was 12-month self-reported 30-day point prevalence abstinence (PPA).

FINDINGS

The data retention rate at the 12-month follow-up was 94.0%. Participants were aged 38.5 years, 71.0% female, 36.6% minority race/ethnicity, 40.6% high school or less education, residing in all 50 US States and smoking 19.2 cigarettes/day. The 29.6% of all participants who used medications were more likely to choose nicotine replacement therapy (NRT; 78.8%) than other cessation medications (i.e. varenicline or bupropion; 18.3 and 10.5%, respectively) and use did not differ by app treatment assignment (all P > 0.05). There was a significant (P = 0.049) interaction between medication use and app treatment assignment on PPA. Specifically, 12-month quit rates were 34% for iCanQuit versus 20% for QuitGuide [odds ratio (OR) = 2.36, 95% confidence interval (CI) = 1.59, 3.49] among participants reporting any medication use, whereas among participants reporting no medication use, quit rates were 28% for iCanQuit versus 22% for QuitGuide (OR = 1.41, 95% CI = 1.09, 1.82). Results were stronger for those using only NRT: 40% quit rates for iCanQuit versus 18% quit rates for QuitGuide (OR = 3.57, 95% CI = 2.20, 5.79).

CONCLUSIONS

The iCanQuit smartphone app for smoking cessation was more efficacious than the QuitGuide smartphone app, regardless of whether participants used medications to aid cessation. Smoking cessation medications, especially nicotine replacement therapy, might enhance the efficacy of the iCanQuit app.

The Impact of a Nurse-Led Service on Tobacco Treatment Provision Within a Psychiatric Hospital: A Time Series Study

INTRODUCTION

Psychiatric hospitalization is an opportunity to provide evidence-based tobacco treatment to optimize cessation efforts among people living with mental illnesses (MI). The purpose of this study was to examine the effectiveness of nurse-driven initiatives to enhance tobacco treatment within an inpatient psychiatric setting.

AIMS

We assessed the 4-year impact of implementing a nurse-led tobacco treatment service offered to 11,314 inpatients at admissions in a tobacco-free psychiatric facility in Kentucky.

METHOD

Through a time-series design, we compared the differences in rates of screening for tobacco use and providing treatment from September to December 2015 (prior to implementing the nurse-led tobacco treatment services) to each subsequent year in a 4-year period (2016-2019).

RESULTS

Approximately 60.0% of inpatients were persons using tobacco during the assessment period. Although there were no changes in tobacco use prevalence over the 4-year evaluation duration, there were significant increases in the provision of practical counseling and Food and Drug Administration-approved nicotine replacement therapies for persons using tobacco.

CONCLUSIONS

Our findings support the effectiveness of implementing tobacco treatment programs at the organizational level. Psychiatric hospitalizations provide an opportunity to optimize nurse-driven efforts to deliver tobacco treatment to people with MI. Similar models of nurse-led tobacco treatment services can be adopted within inpatient and other mental and behavioral health settings.

Factors Associated With Successful E-Cigarette Cessation Among a Convenience Sample of Adult Users

Background: A growing body of literature suggests that many people who use e-cigarettes become dependent and have difficulty quitting. Most people who use e-cigarettes have interest in quitting, yet there is currently a lack of evidence to inform interventions for e-cigarette cessation. Objective: The purpose of this study was to identify factors associated with successful e-cigarette quit attempts among a large sample of people who use e-cigarettes. Methods: Participants (n=586) were people who use e-cigarettes who reported at least one lifetime attempt to quit their e-cigarette use. Adjusted logistic regression models were performed to examine differences in e-cigarette use characteristics and quit methods between people who currently use e-cigarettes and who quit e-cigarettes. Results: Most participants were people who currently use e-cigarettes and only 27.5% reported successfully quitting. Most participants (90.6%) used e-cigarettes that contained nicotine, and over half (54.0%) used closed-system e-cigarette devices with replaceable pre-filled pods or cartridges. The quit method most commonly used overall (63.1%) and for people who quit e-cigarettes (70.8%) was cold turkey. Past 30-day cigarette use and past 30-day other tobacco use was significantly associated with reduced odds of quitting, and there were no e-cigarette characteristics significantly associated with successful cessation. Nicotine replacement therapy was the only e-cigarette cessation method that was significantly associated with increased odds of quitting after adjusting for past 30-day cigarette and other tobacco use. Conclusions: These results suggests that cigarette use, other tobacco use, and quit method used may significantly influence the likelihood of e-cigarette cessation. Future research is needed to determine the effectiveness of interventions for e-cigarette cessation using nicotine replacement therapy.

Predictors of Nicotine Replacement Therapy Adherence: Mixed-Methods Research With a Convergent Parallel Design

BACKGROUND

Few studies have examined the effect of baseline attitudes toward nicotine replacement therapy (NRT) on its actual adherence in a smoking cessation intervention.

PURPOSE

This study (i) examined the predictability of baseline variables (quantitative data) on NRT adherence and (ii) explored the congruence of participants' statements about NRT products (qualitative data) during counseling sessions with their baseline attitudes.

METHODS

This is a mixed-methods research study using a convergent parallel design. Participants included 74 individuals in the treatment group who received behavioral counseling and combination NRT. A Poisson regression analysis was performed to identify baseline variables predicting NRT adherence. Thematic analysis was completed with a subset of participants (n = 38) who varied in NRT attitude scores and adherence. A joint display was created to integrate quantitative and qualitative data and discover convergence.

RESULTS

Approximately 59% of the participants (41/74) used NRT continuously for ≥5 weeks. Having negative attitudes toward NRT and depressive symptoms predicted NRT adherence even after controlling for education and anxiety symptoms. Thematic analysis revealed that NRT adherence is a learning process that consists of the following three distinctive but interrelated phases: (i) information needs, (ii) comprehensive readiness, and (iii) experiential learning. Of the 38 participants, 34 (89.5%) showed convergence between baseline attitude scores and statements about NRT made during counseling sessions.

CONCLUSIONS

Individuals who have negative attitudes toward NRT are less likely to use the products in a smoking cessation intervention. Counselors should assess attitudes toward NRT at baseline and address them proactively during counseling sessions.

'Quitlink': Outcomes of a randomised controlled trial of peer researcher facilitated referral to a tailored quitline tobacco treatment for people receiving mental health services

OBJECTIVE

The aim of this study was to test the effectiveness of a tailored quitline tobacco treatment ('Quitlink') among people receiving support for mental health conditions.

METHODS

We employed a prospective, cluster-randomised, open, blinded endpoint design to compare a control condition to our 'Quitlink' intervention. Both conditions received a brief intervention delivered by a peer researcher. Control participants received no further intervention. Quitlink participants were referred to a tailored 8-week quitline intervention delivered by dedicated Quitline counsellors plus combination nicotine replacement therapy. The primary outcome was self-reported 6 months continuous abstinence from end of treatment (8 months from baseline). Secondary outcomes included additional smoking outcomes, mental health symptoms, substance use and quality of life. A within-trial economic evaluation was conducted.

RESULTS

In total, 110 participants were recruited over 26 months and 91 had confirmed outcomes at 8 months post baseline. There was a difference in self-reported prolonged abstinence at 8-month follow-up between Quitlink (16%, n = 6) and control (2%, n = 1) conditions, which was not statistically significant (OR = 8.33 [0.52, 132.09] p = 0.131 available case). There was a significant difference in favour of the Quitlink condition on 7-day point prevalence at 2 months (OR = 8.06 [1.27, 51.00] p = 0.027 available case). Quitlink costs AU$9231 per additional quit achieved.

CONCLUSION

The Quitlink intervention did not result in significantly higher rates of prolonged abstinence at 8 months post baseline. However, engagement rates and satisfaction with the 'Quitlink' intervention were high. While underpowered, the Quitlink intervention shows promise. A powered trial to determine its effectiveness for improving long-term cessation is warranted.

Adolescent Tobacco/Nicotine Use and the Potential Role of Contingency Management-based Interventions

ABSTRACT

The high prevalence of tobacco/nicotine use among youth, including e-cigarettes, is a public health problem in the United States. Early exposure leads to an increased risk of dependence and health consequences in adulthood. We reviewed the literature on current treatment approaches for nicotine/tobacco use in adolescents/young adults and highlighted underexplored areas of treatment research. There are no current Food and Drug Administration-approved medications for treatment of nicotine/tobacco use disorders in adolescents. However, in research settings and on a case-to-case basis, clinical practice medications (including nicotine replacement therapy, bupropion, and varenicline) have been prescribed to this population with consideration of risk-benefit analysis when behavioral treatments are not sufficient to address dependence. Among the nonpharmacological interventions, there is evidence to support the potential for expanded use of contingency management in youth. Neural differences predisposing adolescents to substance use, along with higher attentiveness to value of options in decision making (flexible reward system) may enhance the effectiveness of reward-based approaches for treatment of substance use disorders in this population. The overall high rates of nonresponders across psychosocial and pharmacological treatments highlight the importance of considering novel strategies to improve existing interventions. We suggest that future research be done that considers unique characteristics of today's adolescents, such as high social activism and engagement with digital rewards to tailor contingency management for this age group and assess its effectiveness. Adolescents could potentially benefit from rewards administered through digital media (eg, video games, computer-based apps, and social media influencers).

Smoking Cessation Is Associated With Short-Term Improvement of Vascular Health in a Cohort of People Living With HIV in Rio de Janeiro, Brazil

Smoking is highly prevalent in people living with HIV/AIDS (PLHA), leading to detrimental effects in different tissues. We examined the effects of nicotine replacement therapy (NRT) on smoking cessation and vascular health. From December 2019 to October 2021, we prospectively enrolled PLHA who were actively smoking. The primary outcome was endothelial function measured by brachial artery flow-mediated dilatation (FMD). We evaluated the percent change in FMD compared to the baseline measure (Δ%FMD) to detect improvements among participants who quit smoking. To confirm the results, we used linear regression models to account for classical cardiovascular (CV) confounders. We included 117 participants with median age of 45.5 years (IQR= 36.4-54.8); 22 (20.4%) had hypertension, 9 (8.3%) had diabetes, almost half were smoking 20+ cigarettes/day (41.7%). After 12 weeks 30.76% participants quit smoking. Comparison of Δ%FMD change from baseline to week 12 showed that among participants adherent to therapy, there has been an increase in Δ%FMD when compared to those who relapsed (1.17% [0.29-2.98] vs -0.19% [-1.95-0.91], p<0.001). After adjustment for CV factors, multiple linear regression showed that Δ%FMD in participants who quit smoking presented a 2.54 mean increase in comparison to those who continued smoking (p=0.007). In conclusion, this study provides evidence that a strategy of NRT and counseling is modestly effective for smoking cessation in PLHA and improves vascular health in a short period of time. This reinforces the importance of the widespread anti-tobacco programs in HIV clinics and the expected impact lowering the incidence of future cardiovascular events.

Impact of Nicotine Replacement Therapy on Breast Surgery Outcomes

BACKGROUND

 Smoking cessation therapy, including nicotine replacement therapy (NRT), is used perioperatively to assist patients to reduce their tobacco smoke intake and consequently decrease their risk of smoking-associated complications. There are, however, theoretical concerns that nicotine-induced peripheral vasoconstriction could impair wound healing. This study investigated the effect of NRT on postoperative outcomes in patients undergoing breast surgery.

METHODS

 A retrospective chart review of patients undergoing breast surgery within the Yale New Haven Health System from the years 2014 to 2020 was performed. Documented smoking status within 6 months before surgery, use or prescription of NRT, type of surgery, and surgical complications of infection, wound dehiscence, tissue necrosis, hematoma, seroma, fat necrosis, and return to operating room within 30 days were recorded. Demographic and complication data were compared between patients with NRT usage and those without using t-tests and chi-square analyses. Multivariable logistic regression models were created to predict the effect of NRT usage on the occurrence of any complication.

RESULTS

 A total of 613 breast procedures met inclusion criteria, of which 105 (17.2%) had documented NRT use. The NRT cohort and the non-NRT cohort were well balanced with respect to demographics and procedural variables. Upon multivariable modeling for risk of any surgical complication, NRT was not a significant predictor (odds ratio [OR]: 1.199, p = 0.607 and OR: 0.974, p = 0.912, respectively), whereas procedure type, increased body mass index, and increased age were.

CONCLUSION

 NRT use was not associated with an increased risk of postoperative complications compared with not using NRT as part of smoking cessation therapy prior to operation.

Implementation of Quitline Financial Incentives to Increase Counseling Sessions Among Adults Who Use Menthol Tobacco Products

Since 2017, the Vermont Tobacco Control Program (VTCP) has worked to reduce the impact of flavored tobacco products on Vermonters. With the proposed U.S. Food and Drug Administration (FDA) rules banning menthol cigarettes and flavored cigars and proposed legislation banning sales of all menthol and flavored tobacco products in Vermont, VTCP prioritized resources to support cessation among Vermonters who use menthol tobacco products. In March 2021, VTCP began offering a tailored quitline protocol for adults who use menthol tobacco, including financial incentives, for completed coaching sessions. From March 2021 to May 2022, 66 quitline callers enrolled in the menthol incentive protocol, representing 8% of all quitline callers and 25% of participants in the state's quitline incentive programs. A greater proportion of callers in the menthol incentive program completed three or more quitline calls (58% vs. 38%) and enrolled in phone and text support (61% vs. 32%). Quitline callers enrolled in any incentive protocols (menthol, Medicaid/uninsured, or pregnant) were more likely to request one or two forms of nicotine replacement therapy (NRT). Quitlines remain an effective, evidence-based method of tobacco cessation, especially in reaching vulnerable populations. Given the targeted marketing of menthol brands to Black and African American populations, LGBTQ+ populations, youth, and neighborhoods with lower incomes, addressing menthol cigarette use is key to improving health equity and health of Vermonters. Early data indicates that the use of financial incentives can increase engagement with a state quitline among menthol tobacco users through greater completion of cessation coaching calls, enrollment in text message support, and NRT usage.

Efficacy of Electronic Cigarettes vs Varenicline and Nicotine Chewing Gum as an Aid to Stop Smoking: A Randomized Clinical Trial

Importance

Electronic cigarettes (ECs) are often used by smokers as an aid to stopping smoking, but evidence is limited regarding their efficacy compared with nicotine replacement therapy (NRT), and no evidence is available on how their efficacy compares with that of varenicline.

Objective

To evaluate whether ECs are superior to NRT and noninferior to varenicline in helping smokers quit.

Design, Setting, and Participants

This was a randomized clinical trial conducted at 7 sites in China and including participants who were smoking at least 10 cigarettes per day and motivated to quit, not using stop-smoking medications or EC, and willing to use any of the study products. Participants were first recruited in May 2021, and data analysis was conducted in December 2022.

Interventions

A cartridge-based EC (30 mg/mL nicotine salt for 2 weeks and 50 mg/mL after that), varenicline (0.5 mg, once a day for 3 days; 0.5 mg, twice a day for 4 days; and 1 mg, twice a day, after that), and 2 mg (for smokers of ≤20 cigarettes per day) or 4 mg (>20 cigarettes per day) nicotine chewing gum, all provided for 12 weeks and accompanied by minimal behavioral support (an invitation to join a self-help internet forum).

Main Outcomes and Measures

The primary outcome was sustained abstinence from smoking at 6 months as validated by an expired-air carbon monoxide reading (<8 parts per million). Participants lost to follow-up were included as nonabstainers.

Results

Of 1068 participants, 357 (33.5%) were female, and the mean (SD) age was 33.9 (3.1) years. A total of 409 (38.3%), 409 (38.3%), and 250 (23.4%) participants were randomized to the EC, varenicline, and NRT arms, respectively. The 6-month biochemically validated abstinence rates were 15.7% (n = 64), 14.2% (n = 58), and 8.8% (n = 22) in the EC, varenicline, and NRT study arms, respectively. The quit rate in the EC arm was noninferior to the varenicline arm (absolute risk reduction, 1.47%; 95% CI, -1.41% to 4.34%) and higher than in the NRT arm (odds ratio, 1.92; 95% CI, 1.15-3.21). Treatment adherence was similar in all study arms during the initial 3 months, but 257 participants (62.8%) in the EC arm were still using ECs at 6 months, with no further use in the 2 other study arms. The most common adverse reactions were throat irritation (32 [7.8%]) and mouth irritation (28 [6.9%]) in the EC arm, nausea (36 [8.8%]) in the varenicline arm, and throat irritation (20 [8.0%]) and mouth irritation (22 [8.8%]) in the NRT arm. No serious adverse events were recorded.

Conclusions and Relevance

The results of this randomized clinical trial found that when all treatments were provided with minimal behavior support, the efficacy of EC was noninferior to varenicline and superior to nicotine chewing gum.

Trial Registration

Chinese Clinical Trial Registry: ChiCTR2100048156.

Effects of interventions on smoking cessation: A systematic review and network meta-analysis

A network meta-analysis (NMA) including randomized controlled trials (RCTs) was conducted to evaluate the effects of different interventions on smoking cessation. Studies were collected from online databases including PubMed, EMBASE, Cochrane Library, and Web of Science based on inclusion and exclusion criteria. Eligible studies were further examined in the NMA to compare the effect of 14 interventions on smoking cessation. Thirty-four studies were examined in the NMA, including a total of 14 interventions and 28 733 participants. The results showed that health education (HE; odds ratio ([OR] = 200.29, 95% CI [1.62, 24 794.61])), other interventions (OI; OR = 29.79, 95% CI [1.07, 882.17]) and multimodal interventions (MUIs; OR = 100.16, 95% CI [2.06, 4867.24]) were better than self-help material (SHM). HE (OR = 243.31, 95% CI [1.39, 42531.33]), MUI (OR = 121.67, 95% CI [1.64, 9004.86]) and financial incentive (FI; OR = 14.09, 95% CI [1.21, 164.31]) had positive effects on smoking cessation rate than smoking cessation or quitting APP (QA). Ranking results showed that HE (83.6%) and motivation interviewing (MI; 69.6%) had better short-term effects on smoking cessation. HE and MUI provided more smoking cessation benefits than SHM and QA. FI was more effective at quitting smoking than QA. Also, HE and MI were more likely to be optimal smoking cessation interventions.

Implementing a tobacco-free workplace program at a substance use treatment center: a case study

BACKGROUND

People with substance use disorders smoke cigarettes at much higher rates than the general population in the United States and are disproportionately affected by tobacco-related diseases. Many substance use treatment centers do not provide evidence-based tobacco cessation treatment or maintain comprehensive tobacco-free workplace policies. The goal of the current work is to identify barriers and facilitators to a successful and sustainable implementation of a tobacco-free workplace program, which includes a comprehensive tobacco-free policy and evidence-based cessation treatment services, in a substance use treatment center.

METHODS

This study is based on an ethnographic approach and uses a qualitative case study design. Data were collected via interviews with staff (n = 6) and clients (n = 16) at the substance use treatment center and site visits (n = 8). Data were analyzed using thematic analysis guided by the extended Normalization Process Theory designed to inform the implementation of innovations in healthcare practice.

RESULTS

Staff at the substance use treatment center supported the implementation of the program and shared a good understanding of the purpose of the intervention and its potential benefits. However, the study identified significant challenges faced by the center during implementation, including widespread tobacco use among clients, contributing to attitudes among staff that tobacco cessation was a low-priority problem due to a perceived lack of interest in quitting and inability to quit among their clients. We identified several factors that contributed to changing this attitude, including provision of tobacco training to staff, active leadership support, low number of staff members who smoked, and access to material resources, including nicotine replacement products. The implementation and active enforcement of a comprehensive tobacco-free workplace program contributed to a gradual change in attitudes and improved the provision of evidence-based tobacco cessation care at the substance use treatment center.

CONCLUSIONS

Substance use treatment centers can integrate tobacco cessation practices in their daily operations, despite multiple challenges they face due to the complex behavioral health and socioeconomic needs of their clients. With proper support, substance use treatment centers can provide much needed tobacco cessation care to their clients who are disproportionately affected by tobacco-related health conditions and systemic health inequities.

Patient interest in acupuncture for smoking cessation: a survey

BACKGROUND/OBJECTIVE

Tobacco use remains the leading cause of preventable death in the United States. The most widely available treatment options to assist patients in smoking cessation are limited by side effects and moderate efficacy at best. Acupuncture may be an effective option for smoking cessation. The goal of this study was to establish the need for and interest in acupuncture therapy to potentially assist with smoking cessation from a patient perspective.

METHODS

We conducted a cross-sectional survey study among patients aged 18 years or older whose medical record reported current tobacco use with English as their preferred language. REDCap surveys were administered to patients during office visits and included questions regarding opinions and use of all treatments available for smoking cessation (including acupuncture) as well as perceived barriers to acupuncture treatment.

RESULTS

A total of 57 surveys were distributed, and 42 (74%) were completed. Most patients reported previous attempts at quitting (76%) and had tried a variety of treatments including nicotine replacement (45%), Chantix (varenicline; 23%), Wellbutrin (bupriopion; 19%), "cold turkey" (65%) and hypnosis (3%). No respondents reported having tried acupuncture for smoking cessation.

CONCLUSION

When comparing treatment options, patients reported more interest in acupuncture than other treatment options with a statistically significant difference in the level of interest between acupuncture and bupropion. All barriers (cost, time and effectiveness) were equally rated on a Likert-type scale with a median of 50 on a 101-point scale.

Development of two novel treatments to promote smoking cessation: Savor and retrieval-extinction training pilot clinical trial findings

Despite decades of progress, cigarette smoking remains a significant contributor to disease burden. This effect is especially pronounced for specific priority populations, such as individuals who live in rural communities, in that the burden of tobacco smoking is greater among these groups than in urban areas and the general population. The present study aims to evaluate the feasibility and acceptability of two novel tobacco treatment interventions delivered through remote telehealth procedures to individuals who smoke in the state of South Carolina. Results also include exploratory analyses of smoking cessation outcomes. Study I evaluated savoring, a strategy based on mindfulness practices, alongside nicotine replacement therapy (NRT). Study II evaluated retrieval-extinction training (RET), a memory-modification paradigm alongside NRT. In Study I (savoring), recruitment and retention data showed high interest and engagement in the intervention components, and participants who received this intervention decreased cigarette smoking throughout the course of the treatment (ps < .05). In Study II (RET), results showed high interest and moderate engagement in treatment, although exploratory outcome analyses did not demonstrate significant treatment effects on smoking behaviors. Overall, both studies showed promise in generating interest among individuals who smoke in participating in remotely delivered, telehealth smoking cessation interventions with novel therapeutic targets. A brief savoring intervention appeared to have effects on cigarette smoking throughout treatment, whereas RET did not. Gaining insight from the present pilot study, future studies may improve the efficacy of these procedures and incorporate the treatment components into more robust available treatments. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

[The e-cigarette - means of smoking cessation?]

After several years of declining tobacco consumption, the number of smokers in Germany is currently stagnating or rising again. The reasons seem to be manifold, e. g. stress caused by the pandemic with social isolation, rising cost of living and war in Europe.With tobacco use still widespread in the German population, evidence-based tobacco cessation is rarely implemented.According to recent studies, e-cigarettes are involved in the pathogenesis of lung disease, cardiac and vascular damage. In addition, their ingredients also have carcinogenic effects. However, clinical studies on long-term use are not yet available.E-cigarettes as a consumer product are not superior to nicotine replacement products and addiction-reducing medications recommended in guidelines. In the therapeutic setting, they are slightly more effective than nicotine replacement products. However, they are usually consumed continuously and thus perpetuate nicotine dependence. Their use increases the risk of relapse to tobacco smoking.Despite the various new approaches, such as Internet-based offerings, app, etc., talks and pharmacotherapy are the gold standard and more effective than any therapy on its own.

Overcoming challenges in dermal and transdermal delivery of herbal therapeutics with polymeric microneedles

Natural products are generally preferred medications owing to their low toxicity and irritancy potential. However, a good number of herbal therapeutics (HT) exhibit solubility, permeability and stability issues that eventually affect oral bioavailability. Transdermal administration has been successful in resolving some of these issues which has lead in commercialization of a few herbal transdermal products. Polymeric Microneedles (MNs) has emerged as a promising platform in transdermal delivery of HT that face problems in permeating the skin. Several biocompatible and biodegradable polymers used in the fabrication of MNs have been discussed. MNs have been exploited for cutaneous delivery of HT in management of skin ailments like skin cancer, acne, chronic wounds and hypertrophic scar. Considering the clinical need, MNs are explored for systemic delivery of potent HT for management of diverse disorders like asthma, disorders of central nervous system and nicotine replacement as it obviates first pass metabolism and elicits a quicker onset of therapeutic response. MNs of HT have found good number of aesthetic applications in topical delivery of HT to the skin. Interestingly, MNs have emerged as an attractive option as a minimally invasive diagnostic aid in sampling biomarkers from plants, skin and ocular interstitial fluid. The review updates the progress made by MN technology of HT for multiple therapeutic interventions along with the future challenges. An attempt is made to illustrate the challenging formulation strategies employed in the fabrication of polymeric MNs of HT. Efforts are on to extend the potential applications of polymeric MNs to HT for diverse therapeutic applications.

Temporal associations linking alcohol and cannabis use to cigarette smoking in young adults engaged in a tobacco cessation and relapse monitoring study

Young adulthood remains a developmental period in which cigarette smoking initiation and progression to dependence and regular use is common. Moreover, co-use of alcohol and/or cannabis with tobacco is common in this age group and may have detrimental effects on tobacco use rates and cessation outcomes. Although young adults are interested in quitting smoking, achieving abstinence remains difficult, even with evidence-based treatment strategies. Understanding proximal associations between other substance use (e.g., alcohol and cannabis) and smoking may have important treatment implications. This exploratory analysis investigated the role of alcohol and/or cannabis use in contributing to smoking events on the same day or next day among young adults engaged in a smoking cessation and relapse monitoring study. We used ecological momentary assessment (EMA) data from 43 young adults (ages 18-25; 932 observations) who smoked cigarettes daily and agreed to participate in a 5-week study that included a 2-day smoking quit attempt and provision of tobacco treatment in the form of nicotine replacement therapy, brief cessation counseling, and financial incentives for abstinence (incentives were provided only during the 2-day quit attempt). We tested multilevel time-series models of daily associations between alcohol use, cannabis use, and smoking. Consistent with hypotheses, days on which participants were more likely to drink alcohol predicted increased likelihood of smoking the next day (OR = 2.27, p =.003). This effect was significant after controlling for both the one-day lagged effect of smoking (i.e., autoregression) and the concurrent (i.e., same day) effects of drinking and cannabis use. Although there was a positive concurrent effect of cannabis use on smoking (OR = 12.86, p =.003), the one-day lagged effect of cannabis use and the concurrent effect of drinking was not significant, contrary to hypotheses. Results indicate that alcohol use presents a potential threat to successful smoking cessation that extends to the following day. This suggests a risk-window in which treatment could be supplemented with just-in-time interventions and extending the focus on co-use to include this lagged impact on cessation outcomes.

Quitline usage does not improve rates of smoking cessation in orthopaedic trauma patients unless combined with nicotine replacement therapy

PURPOSE

The negative effects of smoking following traumatic orthopaedic injury can lead to serious complications and decreased quality of life. The widely available quitline could be easily implemented in the orthopaedic postoperative period to improve outcome, but the effectiveness of this intervention in this population is unknown. The goal of this study was to determine if active referral to a quitline would improve rates of smoking cessation in this population.

METHODS

This is a secondary analysis of a randomized control trial assessing the effectiveness of an inpatient intervention with varying intensities to promote smoking cessation. Participants were actively referred to the quitline as part of their intervention. Participants were surveyed at 6 weeks, 3 months and 6 months following their injury for 7-day abstinence, chemically confirmed with exhaled carbon monoxide monitoring.

RESULTS

Smoking quitline use alone does not independently improve 7-day abstinence. Quitline and nicotine use are synergistic (OR, 5.6 vs. 2.3 at 3 months in patients who used nicotine patch and quitline vs. patch; OR, 7.8 vs. 2.1 at 3 months in patients who used any NRT and quitline vs. NRT alone).

CONCLUSIONS

NRT use improves smoking cessation rates in orthopaedic trauma patients. Although smoking quitline use might not independently improve cessation rates in orthopaedic trauma patients postoperatively, concomitant use of NRT with quitline improves quit rates over NRT alone. Patients referred to quitline should be encouraged to use NRT.

Is hospitalization a missed opportunity to intervene on tobacco cessation?

BACKGROUND

Although tobacco use is associated with elevated morbidity and mortality, its use remains widespread among adults within the United States. Nicotine Replacement Therapy (NRT) products are effective aids that improve rates of tobacco cessation. Many smokers interact with the medical system, such as during hospitalization, without their tobacco use addressed. Hospitalization is a teachable moment for patients to make health-related changes, including tobacco cessation.

METHODS

Retrospective cohort study of adult patients in a university-based patient-centered medical home from 2012 to 2021 evaluating the proportion of adults who smoke who received at least one prescription for NRT. Logistic regression models were used to analyze the association of being hospitalized and receipt of a NRT prescription.

RESULTS

Of the 4,072 current smokers identified, 1,182 (29%) received at least one prescription for NRT during the study period. Hospitalization was associated with increased odds of receiving a NRT prescription (OR 1.68). Of 1,844 current smokers with a hospitalization during the study period, 1,078 (58%) never received a prescription for NRT at any point. Only 87 (5%) of the smokers received a prescription for NRT during hospitalization or at the time of hospital discharge.

CONCLUSIONS

Despite hospitalization being associated with NRT prescribing, most patients who use tobacco and are hospitalized are not prescribed NRT. Hospitalization is an underutilized opportunity for both hospitalists and primary care physicians to intervene on smoking cessation through education and prescription of tobacco cessation aids.

Pregnancy and tobacco: Practice and knowledge of French midwives

OBJECTIVES

Evaluate the midwives' practices and knowledges with regard to the management of the smoking cessation in pregnant women and analyse the profile of midwives prescribing nicotine replacement therapy (NRT).

METHODS

A national practice survey amongst 23,541 French midwives was conducted from 1 September 2020 to 15 September 2021 using an online self-administered questionnaire.

RESULTS

The analysis of the 1,216 usable questionnaires (97, 7% women, mostly aged 30 to 49 years and non-smokers) showed that 93.4% of midwives frequently questioned pregnant women about their smoking consumption during pregnancy. The minimal counselling was known and practiced by 91% of midwives, the Fagerström test by 26.9% and the measurement of exhaled CO by 27.1%. Concerning NRT, 60% of the midwives prescribed them in a usual way and 36.8% were aware of the possibility of prescribing them to the pregnant woman's entourage. The profile of midwives prescribing NRT was significantly more concerned with smoking cessation in pregnant women; worked more frequently in a hospital; carried out 25% or more of antenatal monitoring consultations; and had significantly better knowledge of the evaluation tools, without influence of sex or smoking status.

CONCLUSIONS

Improving the training of midwives in the screening and management of smoking cessation during pregnancy seems necessary.

Nicotine and Cardiovascular Health: When Poison is Addictive - a WHF Policy Brief

Nicotine is universally recognized as the primary addictive substance fuelling the continued use of tobacco products, which are responsible for over 8 million deaths annually. In recent years, the popularity of newer recreational nicotine products has surged drastically in many countries, raising health and safety concerns. For decades, the tobacco industry has promoted the myth that nicotine is as harmless as caffeine. Nonetheless, evidence shows that nicotine is far from innocuous, even on its own. In fact, numerous studies have demonstrated that nicotine can harm multiple organs, including the respiratory and cardiovascular systems. Tobacco and recreational nicotine products are commercialized in various types and forms, delivering varying levels of nicotine along with other toxic compounds. These products deliver nicotine in profiles that can initiate and perpetuate addiction, especially in young populations. Notably, some electronic nicotine delivery systems (ENDS) and heated tobacco products (HTP) can deliver concentrations of nicotine that are comparable to those of traditional cigarettes. Despite being regularly advertised as such, ENDS and HTP have demonstrated limited effectiveness as tobacco cessation aids in real-world settings. Furthermore, ENDS have also been associated with an increased risk of cardiovascular disease. In contrast, nicotine replacement therapies (NRT) are proven to be safe and effective medications for tobacco cessation. NRTs are designed to release nicotine in a slow and controlled manner, thereby minimizing the potential for abuse. Moreover, the long-term safety of NRTs has been extensively studied and documented. The vast majority of tobacco and nicotine products available in the market currently contain nicotine derived from tobacco leaves. However, advancements in the chemical synthesis of nicotine have introduced an economically viable alternative source. The tobacco industry has been exploiting synthetic nicotine to circumvent existing tobacco control laws and regulations. The emergence of newer tobacco and recreational nicotine products, along with synthetic nicotine, pose a tangible threat to established tobacco control policies. Nicotine regulations need to be responsive to address these evolving challenges. As such, governments should regulate all tobacco and non-medical nicotine products through a global, comprehensive, and consistent approach in order to safeguard tobacco control progress in past decades.

Emerging Adults' Experiences with E-Cigarette Cessation

Background: The use of electronic nicotine delivery systems (ENDS) is one of the most common substance use behaviors in college students, yet most individuals show some interest in quitting. The current study added to the limited literature on ENDS cessation by examining readiness to quit and the use and perceived efficacy of ENDS cessation methods in a heterogeneous sample of college students. Methods: Students 18-24 years in Psychology courses (N = 1563; 73% female) from six US universities completed an online survey between September 2021-April 2022. Results: Nearly half the sample (n = 738, 47%) reported lifetime ENDS use and nearly half of lifetime users (n = 356, 48%) reported a quit attempt. Most ENDS users reported some readiness to quit (n = 251, 67%). Quitting "cold turkey", using willpower, and replacing ENDS use with another activity were endorsed most frequently; strategies were perceived as more helpful if students had direct experience with them. Social support (e.g., counseling, groups, family/friend support) and nicotine replacement products were perceived as effective but were utilized infrequently. Digital tools (i.e., apps, text messaging) were perceived to be least helpful and were utilized infrequently. Conclusion: Most college students who use ENDS are interested in quitting and have relied on unassisted methods for cessation. Our data suggest a significant opportunity for college personnel and public health officials to further enhance awareness and uptake of ENDS cessation resources for this demographic. Digital tools that integrate social support may be especially effective given their low cost, demonstrated efficacy, and alignment with students' preferences for social support.

Partner-Involved Financial Incentives for Smoking Cessation in Dual-Smoker Couples: A Randomized Pilot Trial

INTRODUCTION

Members of dual-smoker couples (in which both partners smoke) are unlikely to try to quit smoking and are likely to relapse if they do make an attempt. The purpose of this study was to investigate the feasibility, tolerability, and preliminary outcomes of dyadic adaptations of financial incentive treatments (FITs) to promote smoking cessation in dual-smoker couples.

AIMS AND METHODS

We enrolled 95 dual-smoker couples (N = 190) in a three-arm feasibility RCT comparing two partner-involved FITs (single vs. dual incentives) against a no-treatment control condition. Participants in all conditions were offered nicotine replacement and psychoeducation. A 3-month follow-up provided information about retention, tolerability (ie, self-reported benefits and costs of the study), and preliminary efficacy (ie, program completion, quit attempts, point-prevalent abstinence, and joint quitting).

RESULTS

Results suggest dyadic adaptations were feasible to implement (89% retention rate) and highly tolerable for participants (p < .001). Neither feasibility nor tolerability varied across the treatment arm. Preliminary efficacy outcomes indicated partner-involved FITs have promise for increasing smoking cessation in dual-smoker couples (OR = 2.36-13.06).

CONCLUSIONS

Dyadic implementations of FITs are feasible to implement and tolerable to participants.

IMPLICATIONS

The evidence that dyadic adaptations of FITs were feasible and tolerable, and the positive preliminary efficacy outcomes suggest that adequately powered RCTs formally evaluating the efficacy of dyadic adaptations of FITs for dual-smoker couples are warranted.

The Relationship Between Reported Daily Nicotine Dose from NRT and Daily Cigarette Consumption in Pregnant Women Who Smoke in an Observational Cohort Study

INTRODUCTION

For nonpregnant people unable to quit smoking, the NHS recommends nicotine replacement therapy (NRT) for smoking reduction. This is not recommended during pregnancy due to concerns about higher nicotine intake than smoking alone. We investigated the relationship between daily nicotine dose from NRT and cigarette consumption reported by pregnant women receiving smoking cessation support.

METHODS

We conducted secondary analysis of data from currently smoking pregnant women, recruited from antenatal clinics (Nottingham University Hospitals, UK) or online between June 2019-September 2020. Participants set a quit date, received a prototype NRT adherence intervention, and reported cigarettes per day (CPD) and daily NRT dose (mg) via smartphone app for 28 days.

RESULTS

388 women were screened, 32 (8%) were eligible and joined the study. 24 (75%) submitted 510 app reports in total. 17 (71%) reported smoking and using NRT concurrently on at least one day, with concurrent use reported on 109 (21%) of app reports.The relationship between daily NRT dose and CPD followed an exponential decay curve of approximately 7%. In multilevel repeated measures modelling using 4 linear splines (knots 17, 40, and 85 mg/NRT), significant fixed effects of daily NRT dose on CPD were observed for splines 1, 3, and 4. The strongest association was spline 1 (0-17 mg/NRT), where each 10 mg NRT increase was associated with a 0.6 CPD reduction (24% on average).

CONCLUSIONS

Among women in a cessation study, many smoked and used NRT concurrently; within these women, daily nicotine dose and heaviness of smoking were inversely related.

IMPLICATIONS

Findings have implications for the design of future interventions intended to reduce harm associated with smoking in pregnancy. They suggest using NRT alongside smoking in pregnancy could help some women reduce the number of cigarettes they smoke per day.

A phone-based tobacco use cessation program for people living with HIV in Uganda and Zambia: study protocol for a randomized controlled trial

BACKGROUND

Nicotine replacement therapy (NRT) and short messaging service (SMS)-based tobacco cessation interventions have demonstrated effectiveness in reducing tobacco use in many populations, but evidence is needed on which tailored treatments are most efficacious in meeting the complex medical and psychosocial factors confronting people living with HIV (PLWH) in sub-Saharan Africa (SSA). This paper describes the protocol of a study to test the efficacy of both NRT and a tailored SMS-based tobacco use cessation intervention among PLWH in Uganda and Zambia.

METHODS

In a randomized controlled trial, 800 adult PLWH who use tobacco will be recruited by health care professionals at HIV treatment centers where they are receiving care. Participants will be randomized to one of the four study arms: (1) standard of care [SOC; brief clinician advice to quit combined with HIV education and information aimed at encouraging HIV treatment adherence (with no mention of tobacco) delivered via text messages]; (2) SOC + 12 weeks of NRT; (3) SOC + 6 weeks of SMS text messages to support quitting tobacco use (SMS); or (4) SOC + NRT + SMS. Participants will receive a cell phone and solar panel with power bank for charging the phone. The main outcome is cessation of tobacco use by study participants verified by urinary cotinine (< 15 ng/mL) at 6 months post-enrollment. As a secondary tobacco use outcome, we will measure 7-day point-prevalence abstinence (7 consecutive days of no tobacco use) measured by self-report and biochemically-verified at 4 weeks, 8 weeks, and 3 months post enrollment.

DISCUSSION

Our study will provide insight into the efficacy, feasibility and applicability of delivering tobacco cessation interventions through health care professionals combined with tailored tobacco cessation SMS text messaging in two countries with different tobacco use patterns, policy environments, and health care resources and provide needed information to providers and policymakers looking for cost-effective tobacco cessation interventions. The previously tested SMS-platform to be used in our study is uniquely positioned to be scaled in low- and middle-income countries worldwide, in which case evidence of even modest success in reducing the prevalence of tobacco consumption among PLWH could confer enormous health and economic benefits.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT05487807. Registered August 4, 2022, https://clinicaltrials.gov/ct2/show/record/NCT05487807.

Update of statistical analysis plan for: Integration of smoking cessation into standard treatment for patients receiving opioid agonist therapy who are smoking tobacco: protocol for a randomised controlled trial (ATLAS4LAR)

This protocol paper presents an updated statistical analysis plan of the protocol of a randomised controlled trial. The randomised controlled trial investigates the effect of integrating smoking cessation interventions at outpatient opioid agonist therapy (OAT) clinics for persons with opioid dependency receiving OAT medication. The intervention group receives weekly follow-up including a short behavioural intervention and provision of nicotine replacement products. The control group receives standard treatment. The duration of the intervention is 16 weeks and the follow-up was completed by the end of October 2023. The primary outcome is defined as the proportion of participants reducing the number of cigarettes smoked by at least a 50% at week 16 of the intervention period. The primary outcome will be analysed according to intention-to-treat principles. Missing outcome data will be set equal to the baseline values. Development and reporting of the statistical analysis plan follow the Guidelines for the Content of Statistical Analysis Plans in Clinical Trials.Trial registration ClinicalTrials.gov NCT05290025. Registered on 22 March 2022.

Clinical study protocol on electronic cigarettes and nicotine pouches for smoking cessation in Pakistan: a randomized controlled trial

BACKGROUND

Pakistan is one of most vulnerable low- and middle-income countries with 29 million adult active tobacco users. Smoking cessation services are lacking as the tobacco control initiatives have largely failed to address the smoking endemic. Over the last 5 years, Pakistan has witnessed the use of innovative tobacco harm reduction (THR) products such as e-cigarettes and nicotine pouches. However, their use remains limited. THR products are imported legally as consumer goods and are taxable. The lack of sufficient data for THR and its application is a challenge in gauging their effectiveness in assisting smokers quit combustible smoking. Evidence-based studies can help in measuring the effectiveness of e-cigarettes and nicotine pouches as smoking cessation aids.

METHOD

Keeping in view the study objectives, a sample size of 600 participants will be sufficient to assess the effectiveness of e-cigarettes and nicotine pouches for smoking cessation in Pakistan. Of these, 200 participants each will receive e-cigarettes and nicotine pouches along with basic care counselling, while the remaining 200 participants will only receive basic care counselling for 48 weeks. The association of participants' characteristics with smoking and health status will be based on the bivariate and multivariate analysis. The simple t-test and variance analysis will assess the differences in intervention indicators between the control and treatment groups. For the inferential analysis, the average treatment impact will be based on the quasi-experimental techniques such as difference in difference (DID) or propensity score matching (PMS).

DISCUSSION

The study will evaluate the participants at the baseline as they decide the quit date. After every 12 weeks, a follow-up survey with the participants will be conducted. Results are anticipated to inform the public, decision-makers, and researchers about the effects of using e-cigarettes and nicotine pouches in the short- and medium-term periods. Critically, the potential of e-cigarettes and other alternative nicotine delivery systems as smoking cessation aid will be assessed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05715164 . Registered on February 6, 2023.

PROTOCOL VERSION

Protocol version 1.0, 14-12-2022 Trial in progress and not yet recruiting participants. Estimated primary data collection date-April 2024.

Intentions to Quit, Quit Attempts, and the Use of Cessation Aids Among Malaysian Adult Smokers: Findings From the 2020 International Tobacco Control (ITC) Malaysia Survey

This study examined quitting behavior and use of cessation aids (CAs) among Malaysian adult smokers aged ≥18 years (n = 1,047). Data were from the 2020 International Tobacco Control (ITC) Malaysia Survey were analyzed. A total of 79.9% of Malaysian smokers attempted to quit in the past 12 months and 85.2% intended to quit in the next 6 months. The most common CAs were e-cigarettes (ECs) (61.4%), medication/nicotine replacement therapies (NRTs; 51.0%), and printed materials (36.7%); the least common CA was infoline/quitline services (8.1%). Multivariable logistic regression analysis was performed to examine the association between sociodemographic variables and CAs use. Male smokers were more likely to use infoline/quitline services (adjusted odds ratio [aOR] = 3.27; P = .034). Malay smokers were more likely to use infoline/quitline services (aOR = 3.36; P = .002), ECs (aOR = 1.90; P = .004), printed materials (aOR = 1.79; P = .009), and in-person services (aOR = 1.75; P = .043). Most Malaysian smokers wanted to quit smoking. Furthermore, ECs were the most popular CAs, highlighting the need to assess the effectiveness of ECs for quitting smoking in Malaysia.

Learning to quit: can reinforcement theories predict the success of smoking cessation attempts using nicotine replacement therapy patches in a general population sample of smokers at 8-weeks and 6-months follow-up?

Primary, secondary, and tertiary reinforcement contribute to the maintenance of smoking behaviour and may influence the efficacy of different cessation treatments. This analysis examined these relationships in a large general population sample and investigated how previous experiences of the different reinforcement mechanisms impacted future quit attempts. Random digit telephone dialing was used to recruit a sample of Canadian adults who smoked and were interested in being part of a hypothetical program that would provide nicotine replacement therapy (NRT) patches free by mail and half of the eligible participants were randomized to actually receive a five-week supply of NRT patches. During the interviews, reasons for relapse to smoking during previous quit attempts were collected and coded by two reviewers (disagreements were settled by a third reviewer). Binary logistic regression was used to determine if type of reinforcer moderated the intervention effect of the patches. Participants who made cessation attempts in the past year were more likely to report negative (p = .039), secondary (p = .041), and tertiary (p = .010) reinforcers and less likely to report positive reinforcers (p = .016) compared to those who did not attempt to quit. Logistic regressions revealed no significant conditional effects of the intervention on the relationship between reinforcer type and quit attempts or 30-day smoking abstinence. Analysis including all three reinforcers showed negative reinforcers decreased but tertiary reinforcers increased the odds participants reported a cessation attempt before the baseline interview and between baseline and 8-weeks. Understanding the different ways nicotine reinforces smoking behaviour could help guide individuals to more effective treatment options.

Identification of Sociodemographic, Clinical, and Genetic Factors to Aid Alaska Native and American Indian People to Successfully Quit Smoking

INTRODUCTION

Alaska Native and American Indian (ANAI) people have a smoking prevalence of 23%. Nicotine metabolite ratio (NMR) and genetic testing may enable tailored selection of tobacco cessation medication.

AIMS AND METHODS

The purpose of this study was to evaluate the relative contributions of NMR, cessation medication, demographics, and tobacco use history to cessation. Participants were recruited into an observational cohort study consisting of a baseline visit prior to their quit date and 6-week follow-up. Demographic and tobacco use surveys and blood, urine, and breath samples were collected at each visit. Electronic health records were queried for cessation medications. NMR was categorized into slow or normal nicotine metabolism phenotypes (<0.31 and ≥ 0.31, respectively). The main outcome was cessation at 6 weeks. Analyses consisted of descriptive statistics, medication and phenotype concordance, and estimates of relative risk (RR) of quitting.

RESULTS

We enrolled 151 ANAI adults who smoked cigarettes daily. Two-thirds had normal nicotine metabolism phenotype. Retrospective medication and phenotype concordance was 39%. The overall quit rate was 25%. No demographic factors or tobacco use history were associated with quit success. Varenicline and bupropion increased the likelihood of quitting (RR = 2.93 [1.42, 6.03] and RR = 2.52 [1.12, 5.64], respectively) compared to nicotine replacement therapy. Non-optimal medication and phenotype concordance decreased likelihood of quit success (RR = 0.44 [0.22, 0.91]) compared to optimal concordance.

CONCLUSIONS

This exploratory study found associations between quit success and tobacco cessation medication as well as medication and phenotype concordance. Additional research is needed to assess use of NMR for treatment selection among ANAI people.

IMPLICATIONS

These results broadly support additional community-engaged research to improve medication and phenotype concordance in tribal health settings. Such future research on implementing meditcation and phenotype concordance holds promise to improve expectations, quit success, and health outcomes amongst individuals attempting to quit smoking.

[Chronic diarrhoea and weight loss secondary to nicotine use in an adolescent]

Chronic diarrhoea is described as diarrhoea lasting more than 4 weeks. The underlying causes are multiple and the diagnostic orientation depends on several anamnestic and clinical elements. The basic work-up includes biology and stool analysis. We present the case of a 14-year-old adolescent with chronic diarrhoea and weight loss for several months. Extensive complementary analyses were performed, all being totally negative. A careful repeated clinical history revealed that the patient had a significant nicotine intake, confirmed by a urine cotinine test. Withdrawal led to a resolution of the symptomatology. Nicotine consumption in the form of nicotine replacement products among young people is increasing rapidly. Nicotine has multiple health effects, including neurological, gastrointestinal and immune adverse effects.

Quantitation of Urine Nicotine, Cotinine, and 3-OH-Cotinine by Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS)

Nicotine is a naturally occurring and highly addictive chemical used in e-cigarettes, cigarettes, chewing tobacco, and other tobacco products as well as in nicotine replacement therapies. The negative health consequences of using nicotine-containing products are well known. In fact, smoking remains the leading cause of preventable disease, disability, and death in the United States. Measurement of nicotine and its metabolites, cotinine and 3-OH-cotinine, offers an objective method to evaluate nicotine exposure and the associated health risks. In this chapter, we describe a quick and reliable isotope dilution LC-MS/MS method for the quantitation of these three compounds in 60 μL of human urine following a simple sample preparation procedure. Electrospray Ionization (ESI) in positive mode is used to introduce the analytes into the mass spectrometer and quantitation is achieved using Multiple Reaction Monitoring (MRM). The analytical measurable ranges for nicotine and cotinine are 10-2500 ng/mL and 20-5000 ng/mL for 3-OH-cotinine.

Immediate, Short-term, Medium-term, and Long-term effects of Acceptance and Commitment Therapy for Smoking Cessation: A Systematic Review and Meta-Analysis

INTRODUCTION

Acceptance and commitment therapy (ACT) is increasingly being studied as a treatment for smoking cessation. However, its immediate, short-, and long-term effects have rarely been reviewed.

METHODS

This systematic review aimed to evaluate the effectiveness of immediate, short-, medium-, and long-term smoking cessation rates in ACT and comparators at less than 3-month, 3 to 4-month, 6-, and 12-month follow-ups. Randomized controlled trials (RCTs) were searched in eight databases until April 20, 2023. We assessed the quality of RCTs and the certainty of evidence of outcomes.

RESULTS

Nineteen RCTs involving 7885 smokers across six countries were included. The majority (72.81%) of RCTs were graded as low risk across six domains. For complete-case outcomes, meta-analyses were conducted, and the results revealed a significant effect in favor of ACT [risk ratio: 1.70-1.80 at <3-month, 3 to 4-month, and 6 months follow-up] compared with comparators. For outcomes using missing data management, meta-analyses found an overall effect in favor of ACT, but a significant effect was found at 3 to 4-months only. However, 12-month follow-ups revealed no significant reduction in smoking cessation for both outcomes. Moderate and substantial heterogeneities were found among four meta-analyses that may lead to inaccurate estimates of effects. The certainty of evidence of all outcomes was rated as low and very low.

CONCLUSION

ACT may be an effective intervention for smoking cessation with immediate, short-term, and medium-term effects. Caution must be applied in the interpretation of the results due to the limited trials and low certainty of evidence.

IMPLICATION

ACT can be implemented adjuvant to the usual treatment for smoking cessation. Additional RCTs with follow-up data using biochemically verified measures in non-US countries are warranted.

[Top 4 Research Studies of the month for Italian Primary Care Physicians: December 2023.]

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) According to a high-quality network meta-analysis, oral isotretinoin is the most effective therapy for decreasing the number of inflammatory and non-inflammatory skin lesions in patients with acne vulgaris. 2) Non-steroidal anti-inflammatory drug (Nsaid) use is associated with a small increase (0.004%) in the risk of venous thromboembolism. Combining Nsaid use with a medium-risk hormonal contraceptive increases the risk to 0.011%; the addition of a high-risk hormonal contraceptive increases the risk to 0.023%. 3) For adults who wish to quit smoking, nicotine delivery via e-cigarettes, plus counseling, may be more effective than other means of nicotine replacement, or counseling alone for long-term smoking cessation. 4) We can reassure our patients that nonerosive gastroesophageal reflux disease (Gerd) does not increase the likelihood of esophageal cancer. Erosive Gerd, however, is associated with a doubled - but still low - risk of developing cancer, with the likelihood increasing over time.

Do Determinants of Smoking Cessation and Relapse Differ between Men and Women? Data from a French National Study

Introduction: There is limited understanding of different predictors of smoking cessation success (SCS) among women and men, despite well-documented differences in smoking behavior.Methods: Using data from DePICT (Description des Perceptions, Images, et Comportements liés au Tabagisme), a national survey of French adults which recruited 2377 regular and former smokers we investigated whether major determinants of SCS differed by sex. Factors associated with unsuccessful vs. No successful quit attempt; vs. SCS were studied using multivariate multinomial logistic regression analyses stratified by sex.Results: Women and men share some determinants of SCS including no cannabis use, living in a nonsmoker household and importance giving to being a nonsmoker. However, no e-cigarette use, low-to-moderate alcohol consumption, early smoking initiation, and higher education were associated with SCS only among women. No use of nicotine replacement, having family members who smoke, family opinion on smoking and current employment, were associated with SCS only among men. Neutral or negative friends' opinion on smoking or living with a smoker were associated with unsuccessful smoking attempts among men.Conclusions: Our results show differences between determinants of SCS according to sex, which highlights the importance of developing tailored interventions that account for sex/gender differences in smoking cessation.

Use of nicotine replacement therapy to reduce children's exposure to second-hand smoke in the home: a qualitative pilot study involving local community pharmacies

BACKGROUND

In Scotland, and in several other countries, most second-hand smoke exposure now occurs in low-income households, where housing constraints and sole parenting often make it harder to create a smoke-free home. This pilot study provided people who smoke with a free 12-week supply of nicotine replacement therapy through local community pharmacies to reduce smoking indoors.

METHODS

Twenty-five parents/caregivers who smoked in the home and cared for children at least weekly were recruited via Facebook during the COVID-19 pandemic. Air quality (PM2.5) was monitored in participant homes for seven days before their first pharmacy visit and 12 weeks later. Qualitative interviews (N = 14) were conducted with 13 participants who completed the study and one who withdrew part-way through. The interviews explored views/experiences of using nicotine replacement therapy to help create a smoke-free home. Another participant took part in a shorter telephone discussion at their request, with detailed notes taken by the interviewer, because of their speech disorder.

RESULTS

Three participants reported smoking outdoors only, one of whom subsequently quit smoking. Six participants reported reduced cigarette consumption by 50% in the home, four reported no (sustained) reduction and one reported increased smoking indoors. Self-reported outcomes were not always consistent with PM2.5 readings. Participants' experiences of accessing nicotine replacement therapy through community pharmacies varied. Some suggested ongoing support to use nicotine replacement products could better assist behavioural change, and that access could be streamlined by posting products to the home. Several suggested that focusing on changing home smoking behaviours using nicotine replacement therapy might facilitate a future quit attempt.

CONCLUSION

Access to free nicotine replacement therapy for temporary use indoors may support some people who smoke to reduce children's exposure to second-hand smoke. Our findings confirm the need to modify the intervention before undertaking a definitive trial to assess the effectiveness of this approach. This work is now underway.

College students' preferences for tobacco treatment: a discrete choice experiment

The purpose of this study was to elicit preferences for the 'format' and 'content' of tobacco treatment among college student smokers, using an online discrete choice experiment (DCE) survey. A DCE survey, supplemented with a think-aloud method, was conducted among 54 college students who smoked combustible cigarettes and/or e-cigarettes. Conditional logistic regression models were constructed to determine optimal profiles of treatment. Cutting down nicotine rather than quitting 'cold turkey' (P < 0.001) and two-way communication (P < 0.001) were viewed as the most critical attributes for the intervention 'format'; changing behaviors rather than social groups/peers (P < 0.001) and autonomy (P < 0.001) were viewed as the most critical attributes for the intervention 'content'. Some preferences varied based on smoking subgroups. Combustible cigarette users preferred interventions with a longer time commitment (P < 0.05) and without nicotine replacement therapies (NRTs) (P < 0.001). Think-aloud data supported the DCE findings and further revealed a strong desire for cutting down nicotine and keeping social groups/peers and misconceptions regarding NRTs. Our study findings can guide tobacco treatment tailored to college students. These treatments should be tailored to specific smoker subgroups.

Safety and efficacy of e-cigarettes in those with atherosclerotic disease: a review

Smoking cessation is the most effective intervention to reduce mortality in patients with established atherosclerotic cardiovascular disease (ASCVD), with 'e-cigarettes' becoming an increasingly used intervention to achieve smoking cessation. The current review aims to summarise the current evidence base for their efficacy and safety in the ASCVD cohort. A search of the PUBMED and MEDLINE databases using the terms 'e-cigarette', 'cessation', 'safety' and 'efficacy' since 2012 yielded 706 results. Both observational and experimental studies were included, while those with an unavailable full text, non-English or duplicates were excluded, yielding 78 relevant articles, with 13 subsequent additional articles included from a search of reference lists, for a total of 91 included papers. E-cigarette vapour contains many known pro-atherosclerotic substances and has been demonstrated to potentiate traditional atherosclerotic mechanisms. While e-cigarettes may be more effective in promoting smoking cessation in the general population over a medium term (>6 months), when compared with nicotine replacement therapy (NRT), few studies specifically examined those with ASCVD, despite the latter having a higher baseline quit rate (52% vs 2%). Most studies compare e-cigarettes with NRT alone and do not include pharmacotherapy, which may be more effective in the ASCVD cohort. The single randomised controlled trial addressing the research question favoured traditional methods. Those that successfully quit smoking using e-cigarettes are more likely to continue to use the intervention at 1 year (90% vs 9%). Conflicting advice exists regarding the utilisation of e-cigarettes for smoking cessation. E-cigarettes may be inferior to standard care for smoking cessation in those with ASCVD, and their use is likely to promote the key drivers of the atherosclerotic process already active in this cohort.

Clinical impacts of an integrated electronic health record-based smoking cessation intervention during hospitalisation

OBJECTIVE

To assess the effects of an electronic health record (EHR) intervention that prompts the clinician to prescribe nicotine replacement therapy (NRT) at hospital admission and discharge in a large integrated health system.

DESIGN

Retrospective cohort study using interrupted time series (ITS) analysis leveraging EHR data generated before and after implementation of the 2015 EHR-based intervention.

SETTING

Kaiser Permanente Northern California, a large integrated health system with 4.2 million members.

PARTICIPANTS

Current smokers aged ≥18 hospitalised for any reason.

EXPOSURE

EHR-based clinical decision supports that prompted the clinician to order NRT on hospital admission (implemented February 2015) and discharge (implemented September 2015).

MAIN OUTCOMES AND MEASURES

Primary outcomes included the monthly percentage of admitted smokers with NRT orders during admission and at discharge. A secondary outcome assessed patient quit rates within 30 days of hospital discharge as reported during discharge follow-up outpatient visits.

RESULTS

The percentage of admissions with NRT orders increased from 29.9% in the year preceding the intervention to 78.1% in the year following (41.8% change, 95% CI 38.6% to 44.9%) after implementation of the admission hard-stop intervention compared with the baseline trend (ITS estimate). The percentage of discharges with NRT orders increased acutely at the time of both interventions (admission intervention ITS estimate 15.5%, 95% CI 11% to 20%; discharge intervention ITS estimate 13.4%, 95% CI 9.1% to 17.7%). Following the implementation of the discharge intervention, there was a small increase in patient-reported quit rates (ITS estimate 5.0%, 95% CI 2.2% to 7.8%).

CONCLUSIONS

An EHR-based clinical decision-making support embedded into admission and discharge documentation was associated with an increase in NRT prescriptions and improvement in quit rates. Similar systemic EHR interventions can help improve smoking cessation efforts after hospitalisation.