Managing smoking cessation

Healthcare financing systems for increasing the use of tobacco dependence treatment

BACKGROUND

We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts.

OBJECTIVES

The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment through healthcare financing interventions on abstinence from smoking. The secondary objectives were to examine the effects of different levels of financial support on the use and/or prescription of smoking cessation treatment and on the number of smokers making a quit attempt.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2012.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), controlled trials and interrupted time series studies involving financial benefit interventions to smokers or their healthcare providers or both.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed the quality of the included studies. Risk ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random-effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives.

MAIN RESULTS

We found eleven trials involving financial interventions directed at smokers and healthcare providers.Full financial interventions directed at smokers had a statistically significant favourable effect on abstinence at six months or greater when compared to no intervention (RR 2.45, 95% CI 1.17 to 5.12, I² = 59%, 4 studies). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.11, 95% CI 1.04 to 1.32, I² = 15%) and use of smoking cessation treatment (NRT: RR 1.83, 95% CI 1.55 to 2.15, I² = 43%; bupropion: RR 3.22, 95% CI 1.41 to 7.34, I² = 71%; behavioural therapy: RR 1.77, 95% CI 1.19 to 2.65). There was no evidence of an effect on smoking cessation when we pooled two trials of financial incentives directed at healthcare providers (RR 1.16, CI 0.98 to 1.37, I² = 0%). Comparisons of full coverage with partial coverage, partial coverage with no coverage, and partial coverage with another partial coverage intervention did not detect significant effects. Comparison of full coverage with partial or no coverage resulted in costs per additional quitter ranging from $119 to $6450.

AUTHORS' CONCLUSIONS

Full financial interventions directed at smokers when compared to no financial interventions increase the proportion of smokers who attempt to quit, use smoking cessation treatments, and succeed in quitting.  The absolute differences are small but the costs per additional quitter are low to moderate. We did not detect an effect on smoking cessation from financial incentives directed at healthcare providers. The methodological qualities of the included studies need to be taken into consideration when interpreting the results.

Tabagismo materno durante a gestação e medidas antropométricas do recém-nascido: um estudo de base populacional no extremo sul do Brasil

Este estudo transversal de base populacional teve por objetivo investigar a prevalência de tabagismo materno durante a gestação e seu impacto sobre as medidas antropométricas do recém-nascido. Aplicou-se questionário padronizado a todas as parturientes nas maternidades do Município de Rio Grande, Rio Grande do Sul, Brasil, em 2007. Foram obtidas medidas de peso, comprimento e perímetros cefálico dos recém-nascidos. A prevalência do tabagismo materno na gestação foi de 23%, enquanto a prevalência da exposição passiva ao fumo foi de 29%. Após ajuste para possíveis fatores de confusão, comparados aos recém-nascidos de mães que nunca fumaram, aqueles nascidos de mães fumantes durante toda a gestação tiveram ao nascer, em média, redução de 223,4g (IC95%: 156,7; 290,0) no peso, de 0,94cm (IC95%: 0,60; 1,28) no comprimento e de 0,69cm (IC95%: 0,42; 0,95) no perímetro cefálico. Concluiu-se que a prevalência de tabagismo materno na gestação é alta no Município de Rio Grande. Tabagismo materno durante toda a gestação teve impacto negativo nas medidas antropométricas do recém-nascido.

Self-reported exposure to policy and environmental influences on smoking cessation and relapse: a 2-year longitudinal population-based study

Although most smokers want to quit, the long-term success rate of quit attempts remains low; research is needed to understand the policy and environmental influences that can increase the success of cessation efforts. This paper uses regression methods to investigate self-reported exposure to policy and environmental influences on quit attempts, maintenance of a quit attempt for at least 6 months, and relapse in a longitudinal population-based sample, the New York Adult Cohort Survey, followed for 12 months (N = 3,261) and 24 months (N = 1,142). When policy or environmental influence variables were assessed independently of other policy or environmental influence variables, many were significant for at least some of the cessation outcomes. In the full models that included a full set of policy or environmental influence variables, many significant associations became nonsignificant. A number of policies may have an influence on multiple cessation outcomes. However, the effect varies by cessation outcome, and statistical significance is influenced by model specification.

"I did not intend to stop. I just could not stand cigarettes any more." A qualitative interview study of smoking cessation among the elderly

Background

Every year, more than 650,000 Europeans die because they smoke. Smoking is considered to be the single most preventable factor influencing health. General practitioners (GP) are encouraged to advise on smoking cessation at all suitable consultations. Unsolicited advice from GPs results in one of 40-60 smokers stopping smoking. Smoking cessation advice has traditionally been given on an individual basis. Our aim was to gain insights that may help general practitioners understand why people smoke, and why smokers stop and then remain quitting and, from this, to find fruitful approaches to the dialogue about stopping smoking.

Methods

Interviews with 18 elderly smokers and ex-smokers about their smoking and decisions to smoke or quit were analysed with qualitative content analysis across narratives. A narrative perspective was applied.

Results

Six stages in the smoking story emerged, from the start of smoking, where friends had a huge influence, until maintenance of the possible cessation. The informants were influenced by "all the others" at all stages. Spouses had vital influence in stopping, relapses and continued smoking. The majority of quitters had stopped by themselves without medication, and had kept the tobacco handy for 3-6 months. Often smoking cessation seemed to happen unplanned, though sometimes it was planned. With an increasingly negative social attitude towards smoking, the informants became more aware of the risks of smoking.

Conclusion

"All the others" is a clue in the smoking story. For smoking cessation, it is essential to be aware of the influence of friends and family members, especially a spouse. People may stop smoking unplanned, even when motivation is not obvious. Information from the community and from doctors on the negative aspects of smoking should continue. Eliciting life-long smoking narratives may open up for a fruitful dialogue, as well as prompting reflection about smoking and adding to the motivation to stop.

A real-life study of the effectiveness of different pharmacological approaches to the treatment of smoking cessation: re-discussing the predictors of success

OBJECTIVE

To evaluate the effectiveness of nicotine replacement therapy (NRT), bupropion, nortriptyline and combination therapy and describe factors associated with treatment success.

INTRODUCTION

Clinical trials clearly demonstrate the efficacy of pharmacotherapy in smoking cessation. However, it is only after its use in real-life settings that clinical effectiveness and limitations of a treatment are fully known.

METHODS

Patients attended a four-session cognitive-behavioral program and received medicines free of charge. Abstinence from smoking was assessed at each visit.

RESULTS

A total of 868 smokers (68.8% women) were included. Their mean age was 49.6 years; the amount smoked was 25 cigarettes/day and the Fagerströ m Score was 6.6. Abstinence rates after 6 months and 1 year were 36.5% and 33.6%. In univariate analysis, male gender, age (>50), higher number of cigarettes smoked, cardiovascular comorbidities, longer interval from the last cigarette and combined treatment of nortriptyline plus NRT were predictive of abstinence, while neuropsychiatric comorbidities and the answer ''yes'' to the question ''Do you smoke more often during the first hours after waking'' were correlated with failure. In a multivariate model, predictors of abstinence were neuropsychiatric comorbidities, the answer ''yes'' to the question ''Do you smoke more often during the first hours after waking'' and combined treatment of nortriptyline plus NRT. Male gender and a longer period from the last cigarette were correlated with lower abstinence rate.

CONCLUSION

Satisfactory success rates were obtained in a teaching hospital. Factors such as age, daily cigarette consumption, number of pack-years and dependency score were not reliable markers of abstinence. The combination nortriptyline+NRT was independently associated with higher abstinence rates.

Trial Protocol: Using genotype to tailor prescribing of nicotine replacement therapy: a randomised controlled trial assessing impact of communication upon adherence

Background

The behavioural impact of pharmacogenomics is untested; informing smokers of genetic test results for responsiveness to smoking cessation medication may increase adherence to this medication. The objective of this trial is to estimate the impact upon adherence to nicotine replacement therapy (NRT) of informing smokers that their oral dose of NRT has been tailored to a DNA analysis. Hypotheses to be tested are as follows:

I Adherence to NRT is greater among smokers informed that their oral dose of NRT is tailored to an analysis of DNA (genotype), compared to one tailored to nicotine dependence questionnaire score (phenotype).

II Amongst smokers who fail to quit at six months, motivation to make another quit attempt is lower when informed that their oral dose of NRT was tailored to genotype rather than phenotype.

Methods/Design

An open label, parallel groups randomised trial in which 630 adult smokers (smoking 10 or more cigarettes daily) using National Health Service (NHS) stop smoking services in primary care are randomly allocated to one of two groups:

i. NRT oral dose tailored by DNA analysis (OPRM1 gene) (genotype), or

ii. NRT oral dose tailored by nicotine dependence questionnaire score (phenotype)

The primary outcome is proportion of prescribed NRT consumed in the first 28 days following an initial quit attempt, with the secondary outcome being motivation to make another quit attempt, amongst smokers not abstinent at six months. Other outcomes include adherence to NRT in the first seven days and biochemically validated smoking abstinence at six months. The primary outcome will be collected on 630 smokers allowing sufficient power to detect a 7.5% difference in mean proportion of NRT consumed using a two-tailed test at the 5% level of significance between groups. The proportion of all NRT consumed in the first four weeks of quitting will be compared between arms using an independent samples t-test and by estimating the 95% confidence interval for observed between-arm difference in mean NRT consumption (Hypothesis I). Motivation to make another quit attempt will be compared between arms in those failing to quit by six months (Hypothesis II).

Discussion

This is the first clinical trial evaluating the behavioural impact on adherence of prescribing medication using genetic rather than phenotypic information. Specific issues regarding the choice of design for trials of interventions of this kind are discussed.

Trial details

Funder: Medical Research Council (MRC)

Grant number: G0500274

ISRCTN: 14352545

Date trial stated: June 2007

Expected end date: December 2009

Expected reporting date: December 2010

Using theories of behaviour change to inform interventions for addictive behaviours

AIMS

This paper reviews a set of theories of behaviour change that are used outside the field of addiction and considers their relevance for this field.

METHODS

Ten theories are reviewed in terms of (i) the main tenets of each theory, (ii) the implications of the theory for promoting change in addictive behaviours and (iii) studies in the field of addiction that have used the theory. An augmented feedback loop model based on Control Theory is used to organize the theories and to show how different interventions might achieve behaviour change.

RESULTS

Briefly, each theory provided the following recommendations for intervention: Control Theory: prompt behavioural monitoring, Goal-Setting Theory: set specific and challenging goals, Model of Action Phases: form 'implementation intentions', Strength Model of Self-Control: bolster self-control resources, Social Cognition Models (Protection Motivation Theory, Theory of Planned Behaviour, Health Belief Model): modify relevant cognitions, Elaboration Likelihood Model: consider targets' motivation and ability to process information, Prototype Willingness Model: change perceptions of the prototypical person who engages in behaviour and Social Cognitive Theory: modify self-efficacy.

CONCLUSIONS

There are a range of theories in the field of behaviour change that can be applied usefully to addiction, each one pointing to a different set of modifiable determinants and/or behaviour change techniques. Studies reporting interventions should describe theoretical basis, behaviour change techniques and mode of delivery accurately so that effective interventions can be understood and replicated.

Long-term smoking relapse: a study using the british household panel survey

BACKGROUND

There is limited population-based evidence on long-term smoking relapse rates after 1 year of abstinence. We estimate the incidence of relapse and evaluate demographic, health, socioeconomic characteristics, and episodic events associated with an increased probability of relapse.

METHODS

Smoking relapse is studied using a subsample of individuals in the annual British Household Panel Survey, between 1991 and 2006, who reported not being a smoker for at least 1 year (two consecutive surveys) after previously reporting smoking (n = 1,578). A random-effects panel logit regression was used to examine the association between smoking relapse and length of abstinence, demographic, socioeconomic, and health variables.

RESULTS

Data were available on individuals for a mean of 5.2 years after the initial 1-year smoking abstinence. We estimated that 37.1% (34.0%-40.5%; 95% CI) of the sample would relapse within 10 years. Increased length of abstinence, increased age, being married, being educated to degree level, and a high frequency of General Practitioner (GP) visits were significantly associated with a lower risk of relapse. Conversely, higher relapse rates were significantly associated with mental health problems and having a partner who started smoking.

CONCLUSIONS

A significant proportion of smokers relapse after more than 1 year of abstinence. This study sheds light on factors associated with long-term relapse. This can form the basis for designing public health interventions to prolong abstinence and targeting interventions at former smokers at the highest risk of relapse.

The 'quit' smoker and stillbirth risk: a review of contemporary literature in the light of findings from a case-control study

OBJECTIVE

to identify existing literature which addresses the topic of detecting, assessing and intervening when a pregnant woman who has quit smoking relapses. This literature review was conducted in the light of findings of a case-control study which suggest that a quit smoking status is associated with increased risk of late stillbirth (odds ratio 3.03, 95% confidence interval 1.27-7.24, p = 0.01).

METHOD

a structured review was conducted to identify literature related to quitting smoking in early pregnancy, prevalence and likelihood of relapse, possible methods for detecting smoking resumption, potential intervention strategies for the relapsed smoker and the societal burden of continuing to smoke in pregnancy.

FINDINGS

there is a wide variety of evidence for the effectiveness of intervention strategies aimed at assisting women to quit smoking during pregnancy. However, few studies have specifically aimed to identify strategies to assist those women who report quitting in early pregnancy to maintain that status throughout pregnancy.

CONCLUSIONS

in light of the results of the case-control study and this literature review, it is important that changes are made to prenatal care in order to enable midwives to better identify women who are struggling with abstinence or who resume smoking during pregnancy.

IMPLICATIONS FOR PRACTICE

midwives should discuss and monitor smoking status with women at every prenatal visit. If a midwife finds that a woman has relapsed into smoking, they can be offered a range of quit smoking intervention strategies, including referral to a dedicated cessation service, counselling support, alternative therapies and, perhaps, nicotine replacement therapy. Further research aimed at identifying the extent of relapse among these women and the impact this may have on pregnancy outcome is warranted. Research to ascertain the most appropriate interventions to prevent relapse is also needed.

Smoking cessation in severe mental illness: what works?

AIMS

The physical health of people with severe mental illness (SMI) is poor. Smoking-related illnesses are a major contributor to excess mortality and morbidity. An up-to-date review of the evidence for smoking cessation interventions in SMI is needed to inform clinical guidelines.

METHODS

We searched bibliographic databases for relevant studies and independently extracted data. Included studies were randomized controlled trials (RCTs) of smoking cessation or reduction conducted in adult smokers with SMI. Interventions were compared to usual care or placebo. The primary outcome was smoking cessation and secondary outcomes were smoking reduction, change in weight, change in psychiatric symptoms and adverse events.

RESULTS

We included eight RCTs of pharmacological and/or psychological interventions. Most cessation interventions showed moderate positive results, some reaching statistical significance. One study compared behavioural support and nicotine replacement therapy (NRT) to usual care and showed a risk ratio (RR) of 2.74 (95% CI 1.10-6.81) for short-term smoking cessation, which was not significant at longer follow-up. We pooled five trials that effectively compared bupropion to placebo giving an RR of 2.77 (95% CI 1.48-5.16), which was comparable to Hughes et al.'s 2009 figures for general population data; RR = 1.69 (95% CI 1.53-1.85). Smoking reduction data were too heterogeneous for meta-analysis, but results were generally positive. Trials suggest few adverse events. All trials recorded psychiatric symptoms and the most significant changes favoured the intervention groups over the control groups.

CONCLUSIONS

Treating tobacco dependence is effective in patients with SMI. Treatments that work in the general population work for those with severe mental illness and appear approximately equally effective. Treating tobacco dependence in patients with stable psychiatric conditions does not worsen mental state.

Scolders, carers or friends: South African midwives' contrasting styles of communication when discussing smoking cessation with pregnant women

OBJECTIVE

to investigate how midwives are currently communicating with women about smoking during pregnancy with a view to involving them in a smoking cessation intervention in antenatal clinics.

DESIGN

a qualitative study using individual, in-depth interviews for data collection.

SETTING AND PARTICIPANTS

24 nurses providing antenatal care to pregnant smokers attending public sector clinics in five major cities in South Africa.

FINDINGS

three archetypes of midwives, characterised by different styles of communication and approaches to smoking cessation, emerged from the analysis of the interview data. These were described as the 'Angry Scolders', the 'Benign Carers' and the 'Enthusiastic Friends'. The first type conformed to the traditional, authoritarian style of communication, where the midwife assumed a dominant, expert role. When women failed to comply with their advice, these midwives typically became angry and confrontational. The second type of midwife used a paternalistic communication style and emphasised the role of education in changing behaviour. However, these midwives had little confidence that they could influence women to quit. The third type embraced a patient-centred approach, consciously encouraging more interaction with their patients and attempting to understand change from their point of view. These midwives were optimistic of women's capacity to change and more satisfied with their current health education efforts than the first two types. The Benign Carers and Enthusiastic Friends were more open to participation in the potential intervention than the Angry Scolders.

KEY CONCLUSIONS

the prevailing traditional, authoritarian style of communication is inappropriate for smoking cessation education and counselling as it provokes resistance and avoidance on the part of pregnant smokers. The paternalistic approach appears to be largely ineffectual, whereas the patient-centred approach elicits the most positive response from pregnant women and enhances the possibility of a trusting and cooperative relationship with the midwife. Midwives using this style are more open to fulfilling their role in smoking cessation.

IMPLICATIONS FOR PRACTICE

smoking cessation interventions need to attend to not only what midwives say to pregnant women about smoking, but also how they communicate about the issue. The use of a patient-centred approach, such as brief motivational interviewing, is recommended as a means of improving counselling outcomes among pregnant smokers.

Clinical utility of varenicline for smokers with medical and psychiatric comorbidity

Chronic obstructive pulmonary disease (COPD) is a costly and deadly disease afflicting an estimated 210 million people and accounting for 5% of all global deaths. Exposure to cigarette smoke is the greatest risk factor for COPD in the developed world. Smoking cessation improves respiratory symptoms and lung function and reduces mortality among patients with COPD. Cigarette smokers with COPD and other co-morbid conditions such as cardiovascular disease and psychiatric illnesses should receive comprehensive tobacco treatment interventions incorporating efficacious pharmacotherapies. Varenicline, an α₄β₂ nicotinic acetylcholine receptor partial agonist, is the newest and most effective drug currently available to promote smoking cessation. In conjunction with behavioral interventions and clinical monitoring for potential side effects, varenicline offers great hope for reducing smoking-attributable death and disability.

Interventions for promoting smoking cessation during pregnancy

BACKGROUND

Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, low birthweight, preterm birth and has serious long-term health implications for women and babies. Smoking in pregnancy is decreasing in high-income countries and increasing in low- to middle-income countries and is strongly associated with poverty, low educational attainment, poor social support and psychological illness.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2008), the Cochrane Tobacco Addiction Group's Trials Register (June 2008), EMBASE, PsycLIT, and CINAHL (all from January 2003 to June 2008). We contacted trial authors to locate additional unpublished data.

SELECTION CRITERIA

Randomised controlled trials where smoking cessation during pregnancy was a primary aim of the intervention.

DATA COLLECTION AND ANALYSIS

Trials were identified and data extracted by one person and checked by a second. Subgroup analysis was conducted to assess the effect of risk of trial bias, intensity of the intervention and main intervention strategy used.

MAIN RESULTS

Seventy-two trials are included. Fifty-six randomised controlled trials (over 20,000 pregnant women) and nine cluster-randomised trials (over 5000 pregnant women) provided data on smoking cessation outcomes.There was a significant reduction in smoking in late pregnancy following interventions (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.96), an absolute difference of six in 100 women who stopped smoking during pregnancy. However, there is significant heterogeneity in the combined data (I(2) > 60%). In the trials with the lowest risk of bias, the interventions had less effect (RR 0.97, 95% CI 0.94 to 0.99), and lower heterogeneity (I(2) = 36%). Eight trials of smoking relapse prevention (over 1000 women) showed no statistically significant reduction in relapse.Smoking cessation interventions reduced low birthweight (RR 0.83, 95% CI 0.73 to 0.95) and preterm birth (RR 0.86, 95% CI 0.74 to 0.98), and there was a 53.91g (95% CI 10.44 g to 95.38 g) increase in mean birthweight. There were no statistically significant differences in neonatal intensive care unit admissions, very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power.

AUTHORS' CONCLUSIONS

Smoking cessation interventions in pregnancy reduce the proportion of women who continue to smoke in late pregnancy, and reduce low birthweight and preterm birth. Smoking cessation interventions in pregnancy need to be implemented in all maternity care settings. Given the difficulty many pregnant women addicted to tobacco have quitting during pregnancy, population-based measures to reduce smoking and social inequalities should be supported.

Sex differences in attitudes and experiences concerning smoking and cessation: results from an international survey

OBJECTIVE

Males and females may have different attitudes and experiences concerning smoking and smoking cessation. We examined sex differences in reasons for smoking, motivations for quitting, past quit attempts, and types of cessation support provided by physicians by surveying randomly selected smokers from 16 countries.

METHODS

Current cigarette smokers were surveyed by telephone about their attitudes and experiences regarding smoking and smoking cessation.

RESULTS

Of the 3760 respondents, 1516 (40.3%) were female. Overall, females reported more reasons for smoking, were more likely to be motivated to quit by life changes, and more likely to use medications or counselling for smoking cessation than males. Although 70% of respondents recalled their physician asking about smoking and advising quitting, only 39% of females and 26% of males recalled being offered assistance for cessation. Females recalled more frequent prescription or recommendation of pharmaceutical cessation aids and more assistance in setting a quit date.

CONCLUSION

Males and females have different attitudes and experiences when it comes to smoking and cessation.

PRACTICE IMPLICATIONS

Health care providers can significantly influence smoking-cessation success by offering efficacious treatment to patients. Our data will help physicians to optimally tailor smoking-cessation interventions to patients, according to their sex.

Real world study to evaluate the effectiveness of varenicline and cognitive-behavioural interventions for smoking cessation

A prospective pragmatic interventional study was conducted to evaluate the effectiveness of varenicline for smoking cessation among a cohort of motivated smokers attending two smoking cessation clinics. Smokers between 18 and 65 years who had smoked 10 or more cigarettes per day were included. All participants received cognitive-behavioural varenicline according to approved dose and prescriptions. Continuous abstinence, validated by exhaled CO levels, was assessed in each control. A total of 264 smokers – 155 males (58.7%) and 109 females (41.3%) – were included. Mean age was 43.7, amount smoked was 23 cigarettes per day and 61.4% had at least one prior attempt to quit. The continuous abstinence rate at end of treatment (12 wks) was 58.3%. Conclusions: varenicline and cognitive-behavioural intervention are effective for smoking cessation with high continuous abstinence rates when are used in a clinical setting.

Healthcare financing systems for increasing the use of tobacco dependence treatment

BACKGROUND

We hypothesized that provision of financial assistance for smokers trying to quit, or reimbursement of their care providers, could lead to an increased rate of successful quit attempts.

OBJECTIVES

The primary objective of this review was to assess the impact of reducing the costs of providing or using smoking cessation treatment by health care financing interventions on abstinence from smoking and utilization of smoking cessation treatment.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction group specialized register; the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2008; MEDLINE (from January 1966 to August 2008) and EMBASE (from January 1980 to August 2008) to identify trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and controlled trials involving financial benefit interventions to smokers or their health care providers or both.

DATA COLLECTION AND ANALYSIS

Three reviewers independently extracted data and assessed the quality of the included studies. Rate ratios (RR) were calculated for individual studies on an intention-to-treat basis and meta-analysis was performed using a random effects model. We included economic evaluations when a study presented the costs and effects of two or more alternatives.

MAIN RESULTS

We found nine trials involving financial interventions directed at smokers and two studies directed at health care providers.There was a statistically significant favourable effect of full financial interventions directed at smokers on continuous abstinence compared to no interventions with a risk ratio (RR) of 4.38 (95% CI 1.94 to 9.87). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.19; 95% CI 1.07 to 1.32; N = 3). There was a significant effect of financial interventions directed at health care providers in increasing the utilization of behavioural interventions for smoking cessation (RR 1.33; 95% CI 1.01 to 1.77). Comparison of full benefit with partial or no benefit resulted in costs per additional quitter ranging from $260 to $1453.

AUTHORS' CONCLUSIONS

Full financial interventions directed at smokers when compared to no financial interventions could increase the proportion quitting, quit attempts and utilization of pharmacotherapy by smokers. Although the absolute differences were small the costs per additional quitter were low. The methodological qualities of the included studies need to be taken into consideration in interpreting the conclusions.

Update on smoking cessation therapies

As a reflection of an exponential increase in smoking rates throughout the world during the last century, the economic and human burden of mortality and morbidity related to smoking is now clearly defined. Smoking cessation is associated with health benefits for people of all ages. In this paper we provide a comprehensive review of current licensed pharmacological smoking cessation agents including efficacy and safety profiles, with comparisons of individual therapies available. Furthermore, we offer a prospective on the need for further testing of other agents including novel avenues of therapy.

Smoking cessation in pregnancy

BACKGROUND

Pregnant women who continue to smoke expose their developing fetus to a wide range of risks. Assisting these patients to stop smoking can be an important intervention for the health of the baby and the mother. The management of pregnant smokers can be challenging, due to the potential risks of pharmacotherapy. There are a number of options available to the clinician to aid smoking cessation in non pregnant women. These include nicotine replacement therapy (NRT), bupropion, varenicline, and a range of non-drug therapies.

OBJECTIVE

To provide guidance to prescribers on the best way to manage smoking cessation in the pregnant patient, reviewing the risks and efficacy of the different approaches.

METHODS

An extensive literature search was carried out to find original studies which examined issues surrounding the safety and efficacy of methods of smoking cessation in pregnancy.

RESULTS/CONCLUSION

NRT is the agent of choice for smoking cessation in pregnancy as the safety of other therapies in pregnancy have not yet been proved.

A randomized trial of short psychotherapy versus sustained-release bupropion for smoking cessation

AIMS

To compare the efficacy and safety of a novel psychological intervention for smoking cessation called psychodynamic model (PDM) training to an active control condition of sustained-release bupropion.

DESIGN

Randomized controlled clinical trial with allocation concealment.

SETTING

Private psychiatric practice.

PARTICIPANTS

Seven hundred and seventy-nine adult smokers recruited by advertising.

INTERVENTIONS

PDM training (n = 366 participants) consisted of a very brief (1.5 days) psychoeducation and a supervised training in autosuggestion techniques (guided imageries) aimed at enhancing self-management, decidedness, assertiveness, security and competence in relationships, natural functions of organs and awareness of bodily functions. Bupropion SR (n = 413) was increased to 150 mg twice daily over 1 week and given over a 8-week period.

MEASUREMENTS

Twelve-month continuous abstinence confirmed by exhaled carbon monoxide (CO) of 9 parts per million (p.p.m.) or less at all interviews conducted at 3, 6 and 12 months.

FINDINGS

Intention-to-treat analysis revealed Russell standard 12-month continuous abstinence rates of 39.1% in the psychotherapy group versus 12.3% in the bupropion SR group (P < 0.001) with a relative benefit (RB) of 3.16 (2.38-4.26). Completer analysis revealed 12-month continuous abstinence rates of 39.9% in the psychotherapy group versus 22.5% in the bupropion group [P < 0.001; RB 1.78 (1.35-2.34)]. Of note, bupropion abstinence rates were comparable to previous medications/placebo-only comparisons in geographically different samples.

CONCLUSIONS

The 1.5-day psychotherapy exceeded bupropion's efficacy, presenting an alternative to pharmacological smoking cessation aids, especially for smokers who reject drugs to treat their substance dependence, at a similar cost (Euro 350) as the bupropion treatment (Euro 355).

Work-place social capital and smoking cessation: the Finnish Public Sector Study

AIMS

To examine whether high social capital at work is associated with an increased likelihood of smoking cessation in baseline smokers.

DESIGN

Prospective cohort study.

SETTING

Finland.

PARTICIPANTS

A total of 4853 employees who reported to be smokers in the baseline survey in 2000-2002 (response rate 68%) and responded to a follow-up survey on smoking status in 2004-2005 (response rate 77%).

MEASUREMENTS

Work-place social capital was assessed using a validated and psychometrically tested eight-item measure. Control variables included sex, age, socio-economic position, marital status, place of work, heavy drinking, physical activity, body mass index and physician-diagnosed depression.

FINDINGS

In multi-level logistic regression models adjusted for all the covariates, the odds for being a non-smoker at follow-up were 1.26 [95% confidence interval (CI)=1.03-1.55] times higher for baseline smokers who reported high individual-level social capital than for their counterparts with low social capital. In an analysis stratified by socio-economic position, a significant association between individual-level social capital and smoking cessation was observed in the high socio-economic group [odds ratio (OR) (95% CI)=1.63 (1.01-2.63)], but not in intermediate [(OR=1.10 (0.83-1.47)] or low socio-economic groups [(OR=1.28 (0.86-1.91)]. Work unit-level social capital was not associated with smoking cessation.

CONCLUSIONS

If the observed associations are causal, these findings suggest that high perceived social capital at work may facilitate smoking cessation among smokers in higher-status jobs.

A pilot randomised controlled trial of the feasibility of using body scan and isometric exercises for reducing urge to smoke in a smoking cessation clinic

BACKGROUND

The main cause of relapse in smokers attempting to quit is inability to resist urges to smoke. Pharmacotherapy ameliorates but does not entirely prevent urges to smoke when abstinent, so other methods to resist urges to smoke might be helpful. Exercise is effective, but aerobic exercise is often impractical when urges strike. Two techniques, body scan and isometric exercise, have been shown to reduce urge intensity and nicotine withdrawal symptoms in temporarily abstinent smokers. It is unclear whether they would be used or effective in typical smokers attempting to quit.

METHODS

In a pilot trial set in a UK smoking cessation clinic, 20 smokers were randomised to receive emails containing .mp3 files and .pdf illustrations of the instructions for doing the body scan and isometric exercises. Twenty smokers received no other intervention, although all 40 were receiving weekly behavioural support and nicotine replacement therapy. Carbon monoxide confirmed abstinence, nicotine withdrawal symptoms, urges to smoke, and use of the techniques to resist urges were recorded weekly for four weeks after quit day.

RESULTS

60-80% of quitters reported using the isometric exercises each week and 40-70% reported using the body scan to deal with urges. On average, these techniques were rated as 'slightly helpful' for controlling the urges. There were no large or significant differences in withdrawal symptoms or urge intensity between the two groups. The risk ratio and 95% confidence interval for exercises compared with controls for prolonged confirmed abstinence at four weeks was 0.82 (0.44-1.53). 81% of quitters intended to continue using isometric exercises and 25% body scan, while 81% and 50% respectively would recommend using these techniques to others trying to stop.

CONCLUSION

Isometric exercises, and to a lesser extent body scan, were popular and perceived as somewhat helpful by quitters. The trial showed that these techniques were used and a larger trial could now be developed to examine the influence of the methods on reducing urges to smoke and increasing abstinence.

[In-patient smoker? - Providing appropriate intervention]

Tobacco use is the most avoidable cause of death. Other than provoking multiple diseases requiring hospitalisation, Tobacco Use is also a disease requiring management in the hospital setting, not only in terms of controlling the withdrawal symptoms of the patient, who has been abruptly prohibited from smoking, but also for fulfilling legislation which prohibits tobacco use in the health services, the only efficient way of preventing exposure of non-smokers to environmental tobacco smoke. Treating the in-patient smoker in an appropriate way also provides a window of opportunity for promoting not just a temporary but a complete smoking cessation.