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.

Prenatal passive smoking at home: The experiences of women in Thailand

Background

Passive smoking poses a threat to the well-being of an unborn baby; however, women's understanding and practice in this regard remain unclear.

Objective

This study aimed to describe prenatal passive smoking at home based on the experiences of women in Thailand.

Methods

A qualitative descriptive approach was employed. Data were collected between September 2020 and April 2022 through semi-structured in-depth interviews with 16 postpartum women purposively selected from five hospitals. Thematic analysis was used for data analysis.

Results

Three themes emerged. The first theme, 'safeguard for an unborn baby,' was performed through smoking reduction, far distance, abstinence from smoke/odor inhalation, and residual elimination since harm was highly aware. However, justifying safety from the absence of smoke and foul odor was misperceived. The second theme, 'intervention for smoking cessation,' was attempted through various methods, including acquired empathy, persuasion, compromise, and supportiveness. They also needed family/friend assistance in warning and professional care in terms of advice, health education, learning materials, cessation therapy, care continuation, and dealing with complex situations. The last theme, 'maternal perseverance,' was acquired by the motives of safety goals, rights/responsibilities, changeable norms, and a golden period.

Conclusion

Pregnant women persistently aimed to prevent their husbands from smoking and safeguard their unborn babies from passive smoking. However, misunderstandings and improper practices were observed. Healthcare and nursing services need comprehensive approaches to enhance understanding, perseverance, and tailored practices catering to women's needs.

E-cigarette support for smoking cessation: Identifying the effectiveness of intervention components in an on-line randomized optimization experiment

AIMS, DESIGN AND SETTING

The aim of this study was to determine which combination(s) of five e-cigarette-orientated intervention components, delivered on-line, affect smoking cessation. An on-line (UK) balanced five-factor (2 × 2 × 2 × 2 × 2 = 32 intervention combinations) randomized factorial design guided by the multi-phase optimization strategy (MOST) was used.

PARTICIPANTS

A total of 1214 eligible participants (61% female; 97% white) were recruited via social media.

INTERVENTIONS

The five on-line intervention components designed to help smokers switch to exclusive e-cigarette use were: (1) tailored device selection advice; (2) tailored e-liquid nicotine strength advice; (3): tailored e-liquid flavour advice; (4) brief information on relative harms; and (5) text message (SMS) support.

MEASUREMENTS

The primary outcome was 4-week self-reported complete abstinence at 12 weeks post-randomization. Primary analyses were intention-to-treat (loss to follow-up recorded as smoking). Logistic regressions modelled the three- and two-way interactions and main effects, explored in that order.

FINDINGS

In the adjusted model the only significant interaction was a two-way interaction, advice on flavour combined with text message support, which increased the odds of abstinence (odds ratio = 1.55, 95% confidence interval = 1.13-2.14, P = 0.007, Bayes factor = 7.25). There were no main effects of the intervention components.

CONCLUSIONS

Text-message support with tailored advice on flavour is a promising intervention combination for smokers using an e-cigarette in a quit attempt.

Real-world, anti-tobacco environmental impact upon price-induced smoking reduction among urban Chinese men: Evidence from China's 2015 cigarette tax increase

INTRODUCTION

Raising the price of cigarettes via taxation has been promoted by the World Health Organization as an important tobacco control strategy. Price elasticity of cigarettes is not uniform and is dependent upon individual and environmental determinants. Many studies have examined the determinants of price-induced smoking, taking into account sociodemographic characteristics and consumption patterns. Little research has been conducted on the association between anti-smoking environments and price-induced smoking behavior. This study addresses the deficit within the Chinese context.

METHODS

Participants were 2852 male smokers identified through a multi-stage survey sampling process encompassing 6 cities in China between July and December 2016. A standardized questionnaire tapped price-induced smoking reduction and related information. Both unadjusted and adjusted logistic regression methods were applied in the analyses.

RESULTS

In all, 25.5% (95% CI: 22.5-27.9) of smokers in this study decreased their smoking expenditures following the 2015 excise tax increase. The adjusted logistic regression analysis showed that increased exposures to an anti-smoking information environment (AOR=1.39; 95% CI: 1.10-1.79), restricted smoking in their home (AOR=1.67; 95% CI: 1.32-2.08) and workplace (AOR=1.43; 95% CI: 1.09-1.85) were more likely to report diminished cigarette smoking following the tax increases.

CONCLUSIONS

This study adds to understanding price-induced smoking behavior among urban male Chinese smokers. Strengthening of excise tax policies needs to intensify environmental smoking restrictions and public education campaigns to increase the sensitivity of cigarette price changes among smokers.

Effectiveness of Health Coaching in Smoking Cessation and Promoting the Use of Oral Smoking Cessation Drugs in Patients with Type 2 Diabetes: A Randomized Controlled Trial

INTRODUCTION

This study looked into the effectiveness of a 6 month health coaching intervention in smoking cessation and smoking reduction for patients with type 2 diabetes.

METHODS

The study was carried out via a two-armed, double-blind, randomized-controlled trial with 68 participants at a medical center in Taiwan. The intervention group received health coaching for 6 months, while the control group only received usual smoking cessation services; some patients in both groups participated in a pharmacotherapy plan. The health coaching intervention is a patient-centered approach to disease management which focuses on changing their actual behaviors. By targeting on achieving effective adult learning cycles, health coaching aims to help patients to establish new behavior patterns and habits.

RESULTS

In this study, the intervention group had significantly more participants who reduced their level of cigarette smoking by at least 50% than the control group (p = 0.030). Moreover, patients participating in the pharmacotherapy plan in the coaching intervention group had a significant effect on smoking cessation (p = 0.011), but it was insignificant in the control group.

CONCLUSIONS

Health coaching can be an effective approach to assisting patients with type 2 diabetes participating in a pharmacotherapy plan to reduce smoking and may help those who participate in pharmacotherapy plan to quit smoking more effectively. Further studies with higher-quality evidence on the effectiveness of health coaching in smoking cessation and the use of oral smoking cessation drugs in patients with type 2 diabetes are needed.

Effectiveness and cost-effectiveness of behavioural support for prolonged abstinence for smokers wishing to reduce but not quit: Randomised controlled trial of physical activity assisted reduction of smoking (TARS)

AIMS

For smokers unmotivated to quit, we assessed the effectiveness and cost-effectiveness of behavioural support to reduce smoking and increase physical activity on prolonged abstinence and related outcomes.

DESIGN

A multi-centred pragmatic two-arm parallel randomised controlled trial.

SETTING

Primary care and the community across four United Kingdom sites.

PARTICIPANTS

Nine hundred and fifteen adult smokers (55% female, 85% White), recruited via primary and secondary care and the community, who wished to reduce their smoking but not quit.

INTERVENTIONS

Participants were randomised to support as usual (SAU) (n = 458) versus multi-component community-based behavioural support (n = 457), involving up to eight weekly person-centred face-to-face or phone sessions with additional 6-week support for those wishing to quit.

MEASUREMENTS

Ideally, cessation follows smoking reduction so the primary pre-defined outcome was biochemically verified 6-month prolonged abstinence (from 3-9 months, with a secondary endpoint also considering abstinence between 9 and 15 months). Secondary outcomes included biochemically verified 12-month prolonged abstinence and point prevalent biochemically verified and self-reported abstinence, quit attempts, number of cigarettes smoked, pharmacological aids used, SF12, EQ-5D and moderate-to-vigorous physical activity (MVPA) at 3 and 9 months. Intervention costs were assessed for a cost-effectiveness analysis.

FINDINGS

Assuming missing data at follow-up implied continued smoking, nine (2.0%) intervention participants and four (0.9%) SAU participants achieved the primary outcome (adjusted odds ratio, 2.30; 95% confidence interval [CI] = 0.70-7.56, P = 0.169). At 3 and 9 months, the proportions self-reporting reducing cigarettes smoked from baseline by ≥50%, for intervention versus SAU, were 18.9% versus 10.5% (P = 0.009) and 14.4% versus 10% (P = 0.044), respectively. Mean difference in weekly MVPA at 3 months was 81.6 minutes in favour of the intervention group (95% CI = 28.75, 134.47: P = 0.003), but there was no significant difference at 9 months (23.70, 95% CI = -33.07, 80.47: P = 0.143). Changes in MVPA did not mediate changes in smoking outcomes. The intervention cost was £239.18 per person, with no evidence of cost-effectiveness.

CONCLUSIONS

For United Kingdom smokers wanting to reduce but not quit smoking, behavioural support to reduce smoking and increase physical activity improved some short-term smoking cessation and reduction outcomes and moderate-to-vigorous physical activity, but had no long-term effects on smoking cessation or physical activity.

[Identifying non-pharmacological strategies for reduction and cessation of tobacco use in university studentsIdentificação de estratégias não farmacológicas para reduzir e suspender o consumo de tabaco por estudantes universitários]

Objective

Identify non-pharmacological strategies for reduction and cessation of tobacco use, aimed at the community of undergraduate university students.

Methods

Classic systematic review of experimental scientific literature published in the last 20 years in databases and grey literature. The search algorithm consisted of using the maximum amount of terminology that described the research question, resulting in the largest number of results in the different databases. Evidence tables were constructed with the FLC 3.0 assessment tool and Excel 2021. Use of the GRADE tool enabled assessment of the quality of scientific evidence. Risk of bias was estimated in accordance with recommendations in the Cochrane Handbook of Systematic Reviews of Interventions. A narrative summary of the included studies was provided, given the high degree of heterogeneity established by I2 statistics.

Results

A search of databases and grey literature obtained 40 823 articles. After the application of inclusion and exclusion criteria, seven articles were included: one study with impact on cessation, two studies on reduction, and four studies with an impact on both the reduction and cessation of tobacco use. The methodological quality was "good" according to the GRADE tool. The overall risk of bias was 'low'. The high clinical and methodological heterogeneity of the studies prevented grouping for the construction of a meta-analysis.

Conclusion

Data from the seven articles show that non-pharmacological interventions can result in reduction and cessation of tobacco use in the university student population, although the evidence is still limited. Further studies are necessary in order to develop strong recommendations for implementation.

[Epidemiology of smoking in the male population in Tunisia. HSHS Study 6]

OBJECTIVES

To determine the prevalence of smoking in the male population of Hammam Sousse (Tunisia), to describe its modalities and to analyse its determining factors.

METHODS

This was a "community-based" study, carried out on a random sample of households, including a population of males aged 20 or over. The data were collected, at home, using a specific support consisting of a lifestyle questionnaire, a physical examination, and a biological assessment, oriented towards cardiovascular risk factors. Smoking behaviour covered both forms of cigarettes and Narghile. "Current smokers" included all men declaring that they smoked at the time of the survey, including "regular smokers", who smoked daily at the time of the survey, and "occasional smokers", less than once a day. The group of "non-smokers" at the time of the survey was the sum of "ex-smokers" and those "who had never smoked". The prevalences were calculated after their weighting according to age and the adjusted odds ratios were measured following a multivariate study by logistic regression.

RESULTS

The study population was composed of 481 men with an average age of 49.6±16.35 years and a median of 49 years. Mean body mass index and systolic blood pressure were 26.9 kg/m2 ±4.20 and 151.9 mmHg±24.36, respectively. After adjusting for age, the proportions of current users, former users and subjects who had never used tobacco (all forms combined) were respectively 50.4% (95% CI [49.49-51.3]), 17.4% (95% CI [16.71-18.08]) and 30.9% (95% CI [30.06-31.73]). Daily cigarette consumption was characterized by an average onset at age 20.1±6.91 years, an average duration of 27.0±15.22 years and an average amount of 17.6±9.8 cigarettes smoked per day. After adjusting for age, level of education, and socioeconomic level, smoking behaviour was attributed to a single independent risk factor: the presence of a smoker in the family, with an adjusted OR of 45.17 (p (p<10^-3) for regular cigarette smokers, and 29.66 for regular tobacco users of all forms.

CONCLUSION

Smoking would be a real endemic in Tunisia, threatening the cardiovascular health of the country. The national health system is called upon to strengthen its action plan for the prevention and control of smoking, in all living environments: family, school, work, health centre, etc.

Associations of changes in smoking-related practices with quit attempt and smoking consumption during the COVID-19 pandemic: A mixed-methods study

INTRODUCTION

How changes in smoking routine due to COVID-19 restrictions (e.g. refraining from smoking outdoors and stockpiling tobacco products) influence smoking behaviors remains understudied. We examined the associations of changes in smoking-related practices with quit attempts and smoking consumption in current smokers using a mixed-methods design.

METHODS

In a community-based telephone survey conducted between the second and third wave of the COVID-19 pandemic in Hong Kong, 659 smokers (87.1% male; 45.2% aged 40-59 years) were asked about quit attempts and changes in cigarette consumption and five smoking-related practices since the COVID-19 outbreak. Logistic regression was used to calculate adjusted odds ratio (AOR), adjusting for sex, age, education level, chronic disease status, heaviness of smoking (HSI), psychological distress (PHQ-4) and perceived danger of COVID-19. A subsample of 34 smokers provided qualitative data through semi-structured interviews for thematic analyses.

RESULTS

Favorable changes in smoking-related practices, including having avoided smoking on the street (prevalence: 58.9%) and reduced going out to buy cigarettes (33.5%), were associated with a quit attempt (AOR: 2.09 to 2.26; p<0.01) and smoking reduction (AOR: 1.76 to 4.97; p<0.05). Avoiding smoking with other smokers (50.5%) was associated with smoking reduction (AOR=1.76; p<0.05) but not quit attempt (AOR=1.26; p>0.05). Unfavorable changes, including having increased smoking at home (25.0%) and stockpiled tobacco products (19.6%), were associated with increased smoking (AOR: 2.84 to 6.20; p<0.05). Low HSI (0-2) was associated with favorable changes (p<0.01), while high HSI score (3-6) was associated with unfavorable changes (p<0.01). Qualitative interviews revealed a double-edged effect of staying at home on smoking consumption and that pandemic precautionary measures (e.g. mask-wearing) reduced outdoor smoking.

CONCLUSIONS

Amid the pandemic, favorable changes in smoking-related practices in smokers were mostly associated with quit attempts and smoking reduction, while unfavorable changes were associated with increased smoking. Smokers with higher nicotine dependence were more negatively impacted.

The old and familiar meets the new and unknown: patient and clinician perceptions on e-cigarettes for smoking reduction in UK general practice, a qualitative interview study

BACKGROUND AND AIMS

Clinicians could promote e-cigarettes for harm reduction to people who smoke but cannot stop, but many clinicians feel uneasy doing so. In a randomized controlled trial (RCT), primary care clinicians offered free e-cigarettes and encouraged people with chronic diseases who were unwilling to stop smoking to switch to vaping. We interviewed clinicians and patients to understand how to adopt harm reduction in routine practice.

DESIGN

Qualitative analysis nested within an RCT, comprising thematic analysis of semi-structured interviews with primary care clinicians who delivered the trial intervention, and patients who took part.

SETTING

Primary care clinics in England.

PARTICIPANTS/CASES

Twenty-one patients and 11 clinicians, purposively sampled from an RCT.

MEASUREMENTS

We qualitatively explored patients' and clinicians' experiences of: being offered/offering an e-cigarette, past and current perceptions about e-cigarettes and applying a harm reduction approach.

FINDINGS

Four themes captured clinicians' and patients' reported perspectives. These were: (1) concepts of safety/risk, with clinicians concerned about recommending a product with unknown long-term risks and patients preferring the known risks of cigarettes; (2) clinicians felt they were going out on a limb by offering these as though they were prescribing them, whereas patients did not share this view; (3) equating quitting with success, as both patients and clinicians conceptualized e-cigarettes as quitting aids; and (4) unchanged views, as clinicians reported that training did not change their existing views about e-cigarettes. These themes were united by the higher-order concept: 'The old and familiar meets the new and unknown', as a contradiction between this new approach and long-established methods underpinned these concerns.

CONCLUSIONS

A qualitative analysis found barriers obstructing clinicians and patients from easily accepting e-cigarettes for harm reduction, rather than as aids to support smoking cessation: clinicians had difficulty reconciling harm reduction with their existing ethical models of practice, even following targeted training, and patients saw e-cigarettes as quitting aids.

Trends in premature mortality rates among the Polish population due to cardiovascular diseases

OBJECTIVES

At the end of the 20th century, after years of negligence in the prevention of cardiovascular diseases, Poland was struggling with very high premature mortality. The period of 1991-2005 brought significant improvements since the general public introduced beneficial dietary modifications. This paper aims to analyze the changes in the rate of premature mortality due to tobacco-dependent cardiovascular diseases in Poland in 2008-2017.

MATERIAL AND METHODS

The time trends of deaths occurring under the age of 65 years caused by ischemic heart disease, cerebrovascular disease, atherosclerosis and aortic aneurysm were analyzed. Both standardized and crude premature mortality rates were used, as well as mortality rates for patients grouped into 5-year age ranges with a breakdown by gender. The joinpoint model was used to determine these time trends.

RESULTS

Premature mortality due to the analyzed cardiovascular diseases decreased linearly in 2008-2017. In the case of ischemic heart disease and cerebrovascular diseases, the decrease amounted to approx. 5% per year, both in the female and male population. However, in the case of atherosclerosis and aortic aneurysms, the rate of mortality reduction ranged 4-7% per year. The reduction concerned all the examined age groups, but with different dynamics. The most considerable annual decrease was observed in the group of patients aged 40-44 years (7.9% for females and 8.9% for males). Along with the increase in age, the dynamics of reduction decreased.

CONCLUSIONS

In 2008-2017, Poland experienced a decline in premature mortality due to tobacco-related cardiovascular diseases, particularly in the age group of 40-44 years. The decline may have been associated, among other things, with a reduction in exposure to tobacco smoke, one of the cardiovascular risk factors. Int J Occup Med Environ Health. 2022;35(1):27-38.

Monthly Motivational Interview Counseling and Nicotine Replacement Therapy for Smoking Parents of Pediatric Patients: A Randomized Controlled Trial

BACKGROUND

Parental smoking is the dominant source of passive smoke exposure in the pediatric population. The current randomized controlled trial (RCT) study aimed to evaluate the effectiveness of a multi-component smoking reduction intervention in parental smoking reduction and children's environmental tobacco smoke exposure reduction in clinical settings.

METHODS

A single-blinded, 6-month randomized controlled trial recruited smoking parents (N = 210) of children who attended the pediatric wards or clinics at the Prince of Wales Hospital. Participants allocated to the intervention group (n = 105) received monthly motivational interviews on smoking reduction with emphasis on health hazards related to children's passive smoke exposure, 8-week nicotine replacement therapy, and referral to smoking cessation service if the parents preferred. The control group (n = 105) received simple verbal advice on smoking cessation. Primary outcomes were parental urine cotinine validated and self-reported ≥50% smoking reduction rates at 6 months.

RESULTS

Smoking parents in the intervention group had significantly more biochemically validated ≥50% smoking reduction than the control: 27.1 vs. 10.0% (OR = 3.34, 95% CI: 1.16-9.62, P = 0.02). The rate of self-reported ≥50% smoking reduction was also significantly higher in the intervention group than the control: 51.9 vs. 20.2% (OR = 4.40, 95% CI: 2.38-8.12, P < 0.001). For secondary outcomes, the rate of parental self-reported smoking cessation was higher in the intervention arm: 10.5 vs. 1.0% (OR = 12.17, 95% CI: 1.54-96.07, P < 0.001), however, no differences were detected in biochemically validated cessation and changes in children's passive smoke exposure between the groups.

CONCLUSION

Monthly smoking reduction counseling together with nicotine replacement therapy is more effective than simple verbal cessation advice in the smoking reduction for parents of pediatric patients. However, this study did not demonstrate differences in smoking cessation or reduction in children's passive smoke exposure with a 6-month follow-up. Achievement of a smoke-free environment remains challenging.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT03879889.

Duration of the effectiveness of nicotine electronic cigarettes on smoking cessation and reduction: Systematic review and meta-analysis

BACKGROUND

The success of pharmacotherapies for smoking cessation in real-life remains limited, with a significant number of long-term relapses. Despite first promising results, the duration of the effectiveness of electronic cigarettes is still unknown. Our objective was to assess the duration of the effectiveness of electronic cigarettes on smoking cessation and reduction in daily smokers.

METHODS

The databases EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov and PUBMED were consulted until March 23, 2022. We selected only randomized controlled trials with daily adult smokers. The intervention was the nicotinic electronic cigarette vs. non-nicotine electronic cigarette or other validated pharmacotherapies (varenicline, bupropion and nicotine replacement therapy). The minimum duration of the intervention was 3 months, with a follow-up of at least 6 months. Two independent reviewers used the PRISMA guidelines. The primary endpoint was smoking cessation at the end of the intervention and follow-up periods confirmed by a reduction in expired CO < 10 ppm. The reduction was defined as at least 50% of the initial consumption or by a decrease of daily mean cigarette consumption at the end of the intervention and follow-up periods.

RESULTS

Abstinence at the end of the intervention and follow-up periods was significantly higher in the nicotine electronic cigarette group, compared to nicotine replacement therapy (NRT) [respectively: RR: 1.37 (CI 95%: 1.32-2.93) and RR: 1.49 (CI 95%: 1.14-1.95)] and to the non-nicotine electronic cigarette condition [respectively: RR: 1.97 (CI 95%: 1.18-2.68) and RR: 1.66 (CI 95%: 1.01-2.73)]. With regard to smoking reduction, the electronic cigarette with nicotine is significantly more effective than NRT at the end of the intervention and follow-up periods [respectively RR: 1.48 (CI 95%: 1.04-2.10) and RR: 1.47 (CI 95%: 1.18-1.82)] and non-nicotine electronic cigarette in the long term [RR: 1.31 (CI 95%: 1.02-1.68)].

CONCLUSIONS

This meta-analysis shows the duration of the effectiveness of the nicotine electronic cigarette vs. non-nicotine electronic cigarette and NRT on smoking cessation and reduction. There are still uncertainties about the risks of its long-term use and its potential role as a gateway into smoking, particularly among young people.

Evaluating four motivation-phase intervention components for use with primary care patients unwilling to quit smoking: a randomized factorial experiment

AIMS

To assess the effectiveness of intervention components designed to increase quit attempts and promote abstinence in patients initially unwilling to quit smoking.

DESIGN

A four-factor, randomized factorial experiment.

SETTING

Sixteen primary care clinics in southern Wisconsin.

PARTICIPANTS

A total of 577 adults who smoke (60% women, 80% White) recruited during primary care visits who were currently willing to reduce their smoking but unwilling to try to quit. Interventions Four factors contrasted intervention components administered over a 1-year period: (i) nicotine mini-lozenge versus none; (ii) reduction counseling versus none; (iii) behavioral activation (BA) counseling versus none; and (iv) motivational 5Rs counseling versus none. Participants could request cessation treatment at any time.

MEASUREMENTS

The primary outcome was 7-day point-prevalence abstinence at 52 weeks post enrollment; secondary outcomes were point-prevalence abstinence at 26 weeks and making a quit attempt by weeks 26 and 52.

FINDINGS

No abstinence main effects were found but a mini-lozenge × reduction counseling × BA interaction was found at 52 weeks; P = 0.03. Unpacking this interaction showed that the mini-lozenge alone produced the highest abstinence rate (16.7%); combining it with reduction counseling produced an especially low abstinence rate (4.1%). Reduction counseling decreased the likelihood of making a quit attempt by 52 weeks relative to no reduction counseling (P = 0.01).

CONCLUSIONS

Nicotine mini-lozenges may increase smoking abstinence in people initially unwilling to quit smoking, but their effectiveness declines when used with smoking reduction counseling or other behavioral interventions. Reduction counseling decreases the likelihood of making a quit attempt in people initially unwilling to quit smoking.

Effectiveness and Safety Profile of Alternative Tobacco and Nicotine Products for Smoking Reduction and Cessation: A Systematic Review

BACKGROUND

Alternative tobacco and nicotine products such as electronic cigarettes (EC), smokeless tobacco, and nicotine replacement therapy (NRT) are currently being assessed as options in tobacco harm reduction due to their potential role in smoking reduction and smoking cessation.

OBJECTIVE

To provide the current evidence on the effectiveness and safety of various alternative tobacco and nicotine products for smoking reduction and cessation.

METHODS

A systematic review using databases from MEDLINE (PubMed), EMBASE, and The Cochrane Library was conducted up to December 2020 to identify eligible experimental and observational studies assessing the use of alternative tobacco and nicotine products on smoking reduction and smoking cessation and the safety of these products. The Cochrane Risk of Bias 2 (RoB 2) and ROBINS-I tools were used to assess the risk of bias of the included studies. Results were described through a narrative synthesis of the evidence.

RESULTS

From 1955 retrieved references, 44 studies (31 randomized controlled trials/RCTs and 13 prospective cohort studies) met the inclusion criteria and were included in the review. Twenty-nine studies were assessing EC, one study evaluated heat-not-burn (HNB) product, five studies were focused on snus, and nine studies assessed NRT in the form of nicotine patch, gum, etc. The overall results suggested that alternative tobacco and nicotine products in the form of EC, snus, and NRT can moderately reduce daily cigarette consumption and has potential to assist smoking cessation attempts, with fewer adverse events.

CONCLUSION

The findings suggested that alternative tobacco and nicotine products have a potential role in assisting smoking reduction and cessation, highlighting their role in the tobacco harm reduction approach. Further studies should focus on investigating long-term outcomes, safety, and effectiveness of alternative tobacco and nicotine products to better inform smoking reduction/cessation policy.

PROSPERO REGISTRATION NUMBER

CRD42020205830.

Effect of usual source of care on receiving smoking cessation advice: Korean National Health Panel data analysis

BACKGROUND

Despite various anti-smoking policies, the smoking rate in adults is still high in Korea. Doctors' advice is known to increase the smoking cessation success rate. However, few studies have reported the effect of having a usual source of care (USC) on receiving smoking cessation advice.

OBJECTIVE

To determine the effect of USC on receiving smoking cessation advice.

METHODS

We performed multiple panel logistic regression analyses to identify the effect of having a USC on the rate of receiving a doctor's smoking cessation advice using 2009, 2012 and 2013 datasets from the Korea Health Panel database. Only people who responded to questions regarding a USC and smoking cessation advice were analysed. Eventually, 5243 observations were included in the final analysis.

RESULTS

A higher percentage of people with a USC received smoking cessation advice from doctors (58.4% in 2009, 64.0% in 2012 and 59.6% in 2013) than those not having a USC (28.6% in 2009, 37.5% in 2012 and 34.8% in 2013). The odds ratios (ORs) of receiving smoking cessation advice in people with a USC were higher than those of people without a USC after performing multiple panel logistic regression analysis with random effects (OR: 2.24; 95% confidence interval: 1.90-2.63).

CONCLUSIONS

Having a USC increased the odds of receiving a doctor's smoking cessation advice in Koreans. The results of this study suggest that a health care policy that encourages having a USC is useful in receiving more smoking cessation advice in a Korean population.

Well-being and harm reduction, the consolidated reality of electronic cigarettes ten years later from this emerging phenomenon: A narrative review

Tobacco use is the greatest threat to public health worldwide, killing more than seven million people annually. This paper, about 10 years after the first review on electronic cigarettes, analyses the evolution that this tool has had in these years. It concludes with comments on the significance of the research and why it constitutes an original contribution. We searched PubMed (National Library of Medicine), and PsycINFO (Ovid) (2006-2020) for studies on e-cigarettes (harms and benefits, e-cigarette use, craving and smoking cessation) and smoking cessation treatment (smoking cessation treatment or varenicline or tobacco cessation or reduction or bupropion or NRT or behavioral treatment or ecigarette) and evidence suggests that they may effective as smoking cessation tool and may be less harmful alternatives to combustible cigarette smoking. Consequently, e-cigarettes could be considered as an applicable instrument for Tobacco Harm Reduction (THR) and smoking cessation.

Efficacy of Electronic Cigarettes for Smoking Cessation: A Systematic Review and Meta-Analysis

OBJECTIVE

to synthesize evidence about the efficacy of electronic cigarettes versus Nicotine Replacement Therapy and placebo to quit smoking.

DATA SOURCES

We searched for clinical trials with no publication date restriction until December 2019. The search included CENTRAL, MEDLINE, PsycINFO, Science Direct, Center for reviews and dissemination and HTA database and Trip database, clinical trials registries, gray literature and examined the references of relevant articles.

INCLUSION AND EXCLUSION CRITERIA

Two review authors independently checked the titles and abstracts then the full text of initial hits. Main outcomes were sustained continuous abstinence rate, 7-day point prevalence abstinence rate, sustained reduction of 50% or greater in baseline cigarette consumption and adverse effects.

DATA EXTRACTION AND SYNTHESIS

Two review authors independently extracted data and assessed risk of bias using the Cochrane RoB 2 tool. We conducted a random-effects model through the Mantel-Haenszel method.

RESULTS

We retrieved 12 trials involving 9863 participants. CO- validated 1-month continuous abstinence rate improved by 33% in the e-cigarettes group (range 6-66%, moderate evidence). We are uncertain if e-cigarettess influence continuous abstinence rate at 3-, 6- and 12 months as well as sustained reduction of 50% or greater in baseline cigarette consumption at different follow-up periods. One study of 884 participants displayed improved 12-month 7-day point abstinence by 46% (range 17%-82%). E-cigarettes may increase or do not affect the proportion of serious adverse effect at 6 and 12 months follow up.

CONCLUSION

Very low certainty evidence supported e-cigarettess to help quit smoking in the short term. There is not enough evidence to determine if e-cigarettess are a safe and efficacious means of smoking cessation in the long term (12+ months).

Alteration of smoking habit at time of first diagnosis influences survival of patients with HNSCC

The impact of smoking on survival in patients with squamous cell carcinoma of the head and neck is well established, despite some conflicting data in the literature. However, data on alterations of smoking habit following cancer diagnosis is sparse. In the present study, the effect of reduction of smoking compared with cessation on the course of disease was studied. Data from 643 patients with HNSCC from the tumor documentation registry of the Department of Otorhinolaryngology, Head and Neck Surgery of the Christian-Albrechts-University Kiel were collected and statistically analyzed, looking at pre- and post-treatment smoking habit and survival. Alteration of smoking at the first diagnosis of HNSCC led to a significantly beneficial effect on survival outcomes compared with continued smoking, without significant differences between reduction and cessation of smoking. Detailed analysis revealed that this effect was solely dependent on patients treated by surgery only. Lifelong non-smokers exhibited a significant survival advantage compared with active and former smokers, with no difference in survival between these last two groups. The positive influence of altered smoking habit following first time diagnosis on disease-specific survival paralleled the negative direct effect of active smoking on therapy, which is predominantly attributed to peritumoral tissue hypoxia leading to impaired efficacy of radiochemotherapy (RCT). In the present study cohort, the positive effect of smoking habit alterations were primarily observed in patients treated by surgery only instead of RCT, possibly due to fewer perioperative complications. These findings indicated that patients should be encouraged to at least minimize smoking following cancer diagnosis. Furthermore, for survival estimates and therapy planning, former smokers should be considered as active smokers.

The effectiveness of family counselling on reducing exposure to secondhand smoke at home among pregnant women in Iran

INTRODUCTION

Pregnant women are often exposed to secondhand smoke that affects them and their child. Our aim was to determine the effectiveness of family counselling using the BASNEF model on reducing exposure to secondhand smoke at home among pregnant women.

METHODS

A quasi-experimental study was conducted on 103 pregnant women exposed to secondhand smoke. They were selected using a multi-stage cluster sampling method and allocated into intervention (50 people) and control (53 people) groups. Four family counseling sessions using the BASNEF model were held for the intervention group while the control group received routine care. The outcomes were measured before and at one month after the last session of counselling.

RESULTS

In the timeframe before the intervention, the number of days in which there was reported exposure to secondhand smoke was 5.08 ± 1.1 in the intervention group, significantly decreasing to 3.5 ± 1.6 after the intervention (p<0.001). No significant change was observed in the control group (p=0.1). Also, the mean scores of all constructs of the BASNEF model increased significantly after the intervention compared to those of the control group (p<0.05).

CONCLUSIONS

Family counseling had a positive effect on decreasing the exposure to secondhand smoke at home among a sample of pregnant women. The BASNEF model is useful for implementing educational care programs in these settings.

Exposure to pictures of natural landscapes may reduce cigarette smoking

BACKGROUND AND AIMS

Reducing temporal discounting may help smokers to reduce their smoking by improving inhibitory control. This study aimed to assess whether viewing pictures of natural versus urban scenes would cause participants to smoke fewer cigarettes mediated by lower temporal discounting.

DESIGN

A single-factor (natural scene, urban scene and control) between-subjects design was employed.

SETTING

Laboratory at Kaohsiung Medical University, Taiwan.

PARTICIPANTS

A community sample of 93 daily smokers.

INTERVENTION AND COMPARATOR

Participants were exposed to pictures of natural or urban scenes or no images (control).

MEASUREMENTS

The discounting measure was implemented after the landscape exposure manipulation. Participants expressed their preferences related to winning a lottery by answering a series of nine binary choice questions, opting either to receive a certain amount of money immediately or varying amounts of money 1 year in the future. The dependent measure was cigarette consumption during an ostensible survey.

FINDINGS

Participants exposed to pictures of natural scenes smoked fewer cigarettes [mean = 1.1 cigarettes, 95% confidence interval (CI) = 0.7, 1.6] than did those exposed to pictures of urban scenes (mean = 2.1 cigarettes, 95% CI = 1.7, 2.6, 0.002) and control participants (mean = 1.8 cigarettes, 95% CI = 1.4, 2.3, 0.029). The discounting rate mediated the association between exposure to nature and the amount of smoking (B = -0.62, 95% CI = -1.07, -0.20, P < 0.01).

CONCLUSIONS

Exposing smokers to pictures of natural landscapes may lead to reduced smoking by lowering temporal discounting.

Primary care providers' views on a future lung cancer screening program

BACKGROUND

The National Lung Screening Trial demonstrated that screening with low-dose computed tomography significantly reduces mortality from lung cancer in high-risk individuals.

OBJECTIVE

To describe the role preferences and information needs of primary care providers (PCPs) in a future organized lung cancer screening program.

METHODS

We purposively sampled PCPs from diverse health regions of Ontario and from different practice models including family health teams and community health centres. We also recruited family physicians with a leadership role in cancer screening. We used focus groups and a nominal group process to identify informational priorities. Two analysts systematically applied a coding scheme to interview transcripts.

RESULTS

Four groups were held with 34 providers and administrative staff [28 (82%) female, 21 (62%) physicians, 7 (20%) other health professionals and 6 (18%) administrative staff]. PCPs and staff were generally positive about a potential lung cancer screening program but had variable views on their involvement. Informational needs included evidence of potential benefits and harms of screening. Most providers preferred that a new program be modelled on positive features of an existing breast cancer screening program. Lung cancer screening was viewed as a new opportunity to counsel patients about smoking cessation.

CONCLUSIONS

The development of a future lung cancer screening program should consider the wide variability in the roles that PCPs preferred. An explicit link to existing smoking cessation programs was seen as essential. As providers had significant information needs, learning materials and opportunities should be developed with them.

An online randomised controlled trial of mental contrasting with implementation intentions as a smoking behaviour change intervention

Objective: We assessed the effectiveness of mental contrasting with implementation intentions (MCII), an established self-regulatory strategy, as a brief online smoking behaviour change intervention. We expected that MCII would enhance smoking reduction among the highly cigarette dependent because MCII is most effective for challenging pursuits. Design: Participants interested in reducing or quitting smoking were recruited online via Amazon Mechanical Turk. At Time 1, we assessed cigarette dependence using the Cigarette Dependence Scale (CDS-5), then administered one of two brief self-help interventions: MCII (n = 172) or a government-promoted control strategy (n = 174). Participants were invited to complete an online follow-up survey 4 weeks later (Time 2). Main Outcome Measure: At Time 1 and Time 2, we measured recent cigarette smoking with a retrospective, self-report questionnaire. We used these reports to compute smoking reduction scores, with an intent-to-treat approach. Results: MCII increased smoking reduction compared to the control strategy at high, but not low, levels of cigarette dependence. Conclusion: We found preliminary evidence consistent with MCII, delivered as a brief online intervention, as an effective smoking reduction strategy for highly dependent cigarette smokers. Further research is needed on MCII as a smoking behaviour change intervention.

Australian School Student Perceptions of Effective Anti-tobacco Health Warnings

Background: Recent research posits that anti-tobacco health warnings on cigarette packaging may gradually lose their effectiveness in dissuading adolescents from tobacco products several years after implementation. Health warnings on individual cigarette sticks represent a novel warning medium, and may further educate adolescents on the dangers associated with smoking, and reduce tobacco experimentation amongst this vulnerable population. Methods: In an online survey of school students in Queensland, Australia, participants were requested to rate (on five-point Likert scales) and comment on the perceived effectiveness of current cigarette packaging warnings, and 12 text warnings on cigarette sticks, in preventing non-smokers from smoking, and encouraging current smokers to quit. The warnings were divided into four themes to establish the most effective types of anti-tobacco messages: mortality statistics, health condition consequences, social and financial consequences, and supportive messages. These themes were based on current anti-tobacco interventions within Australia, and the rising cost of tobacco products, and designed to align with the Health Belief Model. Results: Participants (N = 150; Age = 15-18) from five schools completed the survey, and generally viewed current packaging warnings as gross and disgusting, and rating them as somewhat effective in preventing non-smokers from smoking. Current warnings were however considered less effective in prompting current smokers to quit with participants describing them as being un-relatable to teenagers, and smokers as having become desensitized to the warnings used. One theme of cigarette-stick warning (mortality statistics) was rated as significantly more effective (p < 0.001) than current cigarette packaging, with an odds ratio (OR) of 2.77 (95% confidence interval [CI]: 1.67-4.62). Overall, warnings were considered to be 4.71 times (95%CI: 2.72-6.43, p < 0.001) more effective on non-smokers than on smokers. Over three-quarters of participants supported using health warnings on individual cigarette sticks. Conclusions: Current cigarette packaging warnings have retained some effectiveness in dissuading adolescents from smoking, though novel and thought-provoking text-only warnings on cigarette sticks may serve as an additional intervention in reducing tobacco use. Further research requires identification of the most effective warnings, and the perceptions of a more diverse participant base.

Efficiency and adverse events of electronic cigarettes: A systematic review and meta-analysis (PRISMA-compliant article)

BACKGROUND

Electronic cigarettes (e-cigarettes) are a prevalent smoking cessation aid worldwide; however, a consensus regarding their efficacy and safety has yet to be reached.

METHODS

We conducted a systematic review of the literature from related studies written in English or Chinese and published between January 1, 2003, and July 30, 2017. Eligible studies reporting the number of smokers who reduced or quit smoking and suffered from adverse events after e-cigarette use were selected according to predefined criteria; pertinent data were then extracted for a meta-analysis.

RESULTS

Our search produced 198 articles; of these publications, 14 including 35,665 participants were analyzed. The pooled efficacy rate of e-cigarettes ranged from 48.3% to 58.7% for smoking reduction and from 13.2% to 22.9% for smoking cessation. The pooled rate of adverse events associated with e-cigarettes ranged from 49.1% to 51.6% based on 11 studies including 16,406 participants. The most prevalent adverse events were mouth or throat irritation, anxiety, depressed mood, nausea, and insomnia. No significant differences in overall CO2 exhalation (eCO) levels were observed after e-cigarette use according to the data from 5 studies.

CONCLUSION

Our findings suggest that e-cigarettes are moderately effective with regard to smoking reduction and smoking cessation. eCO levels are unreliable for evaluating the efficacy of e-cigarettes. E-cigarette related adverse events frequently occur, especially due to high-dose nicotine-containing cartridges.

Lack of Substantial Post-Cessation Weight Increase in Electronic Cigarettes Users

Minimization of post-cessation weight gain in quitters is important, but existing approaches (e.g., antismoking medications) shows only limited success. We investigated changes in body weight in smokers who quit or reduced substantially their cigarette consumption by switching to electronic cigarettes (ECs) use. Body weight and smoking/vaping history were extracted from medical records of smokers and ex-smokers to match three study groups: (1) regular EC users on at least two consecutive follow-up visits; (2) regular smokers (and not using ECs); (3) subjects who reported sustained smoking abstinence after completing a cessation program. Review of their medical records was conducted at two follow-up visits at 6- (F/U 6m) and 12-months (F/U 12m). A total of 86 EC users, 93 regular smokers, and 44 quitters were studied. In the EC users study group, cigarettes/day use decreased from 21.1 at baseline to 1.8 at F/U 12m (p < 0.0001). Dual usage was reported by approximately 50% of EC users. Both within factor (time, p < 0.0001) and between factor (study groups, p < 0.0001) produced significant effect on weight (% change from baseline), with a significant 4.8% weight gain from baseline in the quitters study group at F/U 12m. For the EC users, weight gain at F/U 12m was only 1.5% of baseline. There was no evidence of post-cessation weight increase in those who reduced substantially cigarette consumption by switching to ECs (i.e., dual users) and only modest post-cessation weight increase was reported in exclusive EC users at F/U 12m. By reducing weight gain and tobacco consumption, EC-based interventions may promote an overall improvement in quality of life.

Impact of Different e-Cigarette Generation and Models on Cognitive Performances, Craving and Gesture: A Randomized Cross-Over Trial (CogEcig)

Introduction: Most electronic-cigarettes (e-cigarette) are designed to look like traditional cigarettes and simulate the visual, sensory, and behavioral aspects of smoking traditional cigarettes. This research aimed to explore whether different e-cigarette models and smokers' usual classic cigarettes can impact on cognitive performances, craving and gesture.

Methods: The study is randomized cross-over trial designed to compare cognitive performances, craving, and gesture in subjects who used first generation electronic cigarettes, second generation electronic cigarettes with their usual cigarettes. (Trial registration: ClinicalTrials.gov number NCT01735487).

Results: Cognitive performance was not affected by “group condition.” Within-group repeated measures analyses showed a significant time effect, indicating an increase of participants' current craving measure in group “usual classic cigarettes (group C),” “disposable cigalike electronic cigarette loaded with cartridges with 24 mg nicotine (group H), second generation electronic cigarette, personal vaporizer model Ego C, loaded with liquid nicotine 24 mg (group E). Measures of gesture not differ over the course of the experiment for all the products under investigation

Conclusion: All cognitive measures attention, executive function and working memory are not influenced by the different e-cigarette and gender showing that in general electronics cigarettes could become a strong support also from a cognitive point of view for those who decide to quit smoking. It seems that not only craving and other smoke withdrawal symptoms but also cognitive performance is not only linked to the presence of nicotine; this suggests that the reasons behind the dependence and the related difficulty to quit smoking needs to be looked into also other factors like the gesture.

Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT01735487.

Evaluation of a midwife- and nurse-delivered 5 A's prenatal smoking cessation program

INTRODUCTION

West Virginia has the highest rate of prenatal smoking in the United States. The aim of this pilot study was to evaluate the implementation of the American College of Obstetricians and Gynecologists' 5 A's smoking cessation intervention among pregnant women being cared for by 5 A's-trained midwives working with a team of nurse researchers in an effort to reduce prenatal smoking exposure. The evidence-based 5 A's smoking cessation program has been recommended for use in prenatal care by health care providers.

METHODS

A pilot study was conducted evaluating the implementation of the 5 A's prenatal smoking cessation program for 35 women who smoked during pregnancy. The women received consistent messages to quit or reduce smoking from the midwives and were followed by the nurse research team via telephone with continued support, guidance, and strategic planning for tobacco exposure reduction.

RESULTS

Among the 35 women who enrolled in the study, 32 (91.4%) decreased smoking and 3 (8.6%) quit smoking by one month after the intervention. For those who continued to smoke, the average number of cigarettes smoked was reduced from 10 cigarettes per day at baseline to 8 cigarettes per day at one month, 7 cigarettes per day at 2 months, and 6 cigarettes per day by the end of pregnancy. The women further reduced their tobacco exposure by delaying the timing of initiating smoking in the morning and by increasing indoor smoking restrictions.

DISCUSSION

Midwives and nurses can be trained in the implementation of the evidence-based 5 A's smoking cessation program for incorporation into regular prenatal care of pregnant women who smoke. By guiding women in techniques aimed at reducing the amount and frequency of cigarette smoking, nurses and midwives facilitate a decrease in prenatal smoking exposure.

Varenicline for smoking cessation and reduction in people with severe mental illnesses: systematic review and meta-analysis

AIMS

To determine the effectiveness and safety of varenicline in treating tobacco dependence in patients with severe mental illness.

DESIGN

A systematic review and meta-analysis of randomised controlled trials that compared varenicline with a placebo or an alternative intervention for smoking cessation or reduction.

SETTING

Both in- and out-patient settings in any country.

PARTICIPANTS

Adult patients aged 18 years and over with any type of severe mental illness. The systematic review included eight studies comprising 398 participants.

MEASURES

Primary outcome measures were (1) smoking cessation, (2) smoking reduction measured by changes in the number of cigarettes smoked per day and (3) number of psychiatric adverse events, which were collected at the end of treatment.

FINDINGS

The random-effect pooled estimates from the five studies that reported smoking-related outcomes found that varenicline is statistically superior to placebo in smoking cessation [risk ratios 4.33; 95% confidence interval (CI) = 1.96-9.56], and smoking reduction was higher in varenicline groups (mean reduced daily cigarettes was 6.39; 95% CI = 2.22-10.56). There is no significant difference regarding neuropsychiatric and other adverse events.

CONCLUSIONS

Varenicline appears to be significantly more effective than placebo in assisting with smoking cessation and reduction in people with severe mental illness. There appears to be no clear evidence that varenicline was associated with an increased risk of neuropsychiatric or other adverse events compared with placebo.

Comparative effectiveness of motivation phase intervention components for use with smokers unwilling to quit: a factorial screening experiment

AIMS

To screen promising intervention components designed to reduce smoking and promote abstinence in smokers initially unwilling to quit.

DESIGN

A balanced, four-factor, randomized factorial experiment.

SETTING

Eleven primary care clinics in southern Wisconsin, USA.

PARTICIPANTS

A total of 517 adult smokers (63.4% women, 91.1% white) recruited during primary care visits who were willing to reduce their smoking but not quit.

INTERVENTIONS

Four factors contrasted intervention components designed to reduce smoking and promote abstinence: (1) nicotine patch versus none; (2) nicotine gum versus none; (3) motivational interviewing (MI) versus none; and (4) behavioral reduction counseling (BR) versus none. Participants could request cessation treatment at any point during the study.

MEASUREMENTS

The primary outcome was percentage change in cigarettes smoked per day at 26 weeks post-study enrollment; the secondary outcomes were percentage change at 12 weeks and point-prevalence abstinence at 12 and 26 weeks post-study enrollment.

FINDINGS

There were few main effects, but a significant four-way interaction at 26 weeks post-study enrollment (P = 0.01, β = 0.12) revealed relatively large smoking reductions by two component combinations: nicotine gum combined with BR and BR combined with MI. Further, BR improved 12-week abstinence rates (P = 0.04), and nicotine gum, when used without MI, increased 26-week abstinence after a subsequent aided quit attempt (P = 0.01).

CONCLUSIONS

Motivation-phase nicotine gum and behavioral reduction counseling are promising intervention components for smokers who are initially unwilling to quit.

Randomized, placebo-controlled, double-blind trial of Swedish snus for smoking reduction and cessation

BACKGROUND

Epidemiological studies suggest that smokeless tobacco in the form of Swedish snus has been used by many smokers in Scandinavia to quit smoking, but the efficacy of snus has so far not been evaluated in controlled clinical trials.

METHODS

We conducted a randomized, double-blind, placebo-controlled, clinical trial aimed at assessing the efficacy of snus to help adult cigarette smokers in Serbia to substantially reduce, and, eventually, completely stop smoking. The study enrolled 319 healthy smokers aged 20-65 years at two occupational health centers in Belgrade, Serbia. Most of them (81%) expressed an interest to quit rather than just reduce their smoking. Study products were used ad libitum throughout the 48-week study period. The main study objective during the first 24 weeks was smoking reduction. The primary end-point was defined as a biologically verified reduction of ≥ 50% in the average number of smoked cigarettes per day during week 21-24 compared to baseline. During week 25-48 participants were actively instructed to stop smoking completely. Outcome measures of biologically verified, complete smoking cessation included 1-week point prevalence rates at clinical visits after 12, 24, 36, and 48 weeks, as well as 4-, 12- and 24-week continued cessation rates at the week 36 and 48 visits.

RESULTS

At the week 24 visit, the proportion of participants who achieved the protocol definition of a ≥ 50% smoking reduction was similar in the two treatment groups. However, the proportion that reported more extreme reductions (≥ 75%) was statistically significantly higher in the snus group than in the placebo group (p < 0.01). The results for biologically verified complete cessation suggested that participants in the snus group were more likely to quit smoking completely than the controls; the odds ratio (snus versus placebo) for the protocol estimates of cessation varied between 1.9 to 3.4, but these ratios were of borderline significance with p-values ranging from 0.04-0.10. Snus was well tolerated and only 2/158 (1.3%) participants in the snus group discontinued treatment due to an adverse event (in both cases unrelated to snus).

CONCLUSIONS

Swedish snus could promote smoking cessation among smokers in Serbia, that is, in a cultural setting without traditional use of oral, smokeless tobacco.

TRIAL REGISTRATION

www.clinicaltrials.gov, identifier: NCT00601042.

Future intentions regarding quitting and reducing cigarette use in a representative sample of Canadian daily smokers: implications for public health initiatives

Pre-cessation reduction is associated with quitting smoking. However, many smokers reduce the amount consumed but may not quit altogether. Using a representative sample of adult current daily smokers, this project explored future intentions of smokers regarding cigarette consumption. This information is important because it can provide a framework within which to plan tobacco cessation initiatives. A random digit dialing telephone survey was conducted of 889 Canadian current daily smokers, 18 years and older. The response rate was 65% (of households with a smoker in residence, 65% agreed to participate). Analyses focused on the 825 respondents who smoked at least 10 cigarettes per day at some point in their lives. As part of this survey, respondents were asked their future plans about their smoking (maintain, increase, reduce, quit). Of these 825 respondents, the majority of respondents had plans to change their cigarette use, with 55% planning to quit, 18.8% to reduce and 22.5% to maintain the amount they smoked (3.4% did not know and 2 respondents planned to increase). Most smokers who planned to reduce their smoking saw it as a step towards quitting smoking completely. These results present a picture of smokers, the majority of whom appear to be in some form of transition. Many smokers planned to reduce, of which the overwhelming majority saw their reduction as a step towards quitting. Opportunities exist to capitalize on these intentions to change in efforts to promote tobacco cessation.

Treatment of tobacco dependence in mental health and addictive disorders

People with mental health and addictive (MHA) disorders smoke at high rates and require tobacco treatment as a part of their comprehensive psychiatric care. Psychiatric care providers often do not address tobacco use among people with mental illness, possibly owing to the belief that their patients will not be able to quit successfully or that even short-term abstinence will adversely influence psychiatric status. Progress in the development of treatments has been slow in part because smokers with current MHA disorders have been excluded from most smoking cessation trials. There are several smoking cessation treatment options, including psychological and pharmacological interventions, that should be offered to people with an MHA disorder who smoke. Building motivation and readiness to quit smoking is a major challenge, and therefore motivational interventions are essential. We review the treatment options for people with tobacco dependence and MHA disorders, offer recommendations on tobacco assessment and tailored treatment strategies, and provide suggestions for future research. Treatment efficacy could be enhanced through promoting smoking reduction as an initial treatment goal, extending duration of treatment, and delivering it within an integrated care model that also aims to reduce the availability of tobacco in MHA treatment settings and in the community.

A test of motivational plus nicotine replacement interventions for HIV positive smokers

The purpose of this study was to test two combination motivational plus pharmacological interventions for smoking cessation among HIV positive smokers. Participants were 40 adults receiving HIV care who smoked daily reporting interest in smoking reduction. Measures were administered at baseline, 1-month, and 3-month follow-ups. Participants were randomly assigned to self-guided reading plus nicotine patch (n = 18) or motivational interviewing plus nicotine patch (n = 22). Groups did not differ at 3 months on biochemically-verified abstinence. The sample reduced cigarettes per day by half a pack and the percent of smoking days by 41%, and 22% were abstinent at 3-month follow-up. Compliance with the nicotine patch was poor and declined over time, but patch use was unrelated to carbon monoxide level at 3-month follow-up. Smoking cessation interventions for people with HIV can be helpful and should include components that encourage some smoke-free days, increase self-efficacy, and attend to adherence to nicotine replacement treatment.

Combination treatment for nicotine dependence: state of the science

Both nicotine replacement and sustained-release buproprion double the odds of achieving short- and moderate-term abstinence from nicotine. However, questions remain about the efficacy of combining pharmacotherapies. Our purposes were to review the evidence for (1) combined pharmacotherapy and (2) multimodal treatment combining pharmacotherapy and behavioral treatment and to recommend combinations of treatments to reduce nicotine dependence. Combining first-line pharmacotherapies with each other or with investigational drugs shows little benefit. In contrast, trials combining specific behavioral treatments with first-line pharmacotherapies show enhanced smoking cessation rates, but benefits are not seen in all populations. We recommend future directions for research, including better specification of behavioral components and further examination of the length and timing of treatment.