Smoking cessation and severity of disease: the Coronary Artery Smoking Intervention Study

Assessment of a Personal Interactive Carbon Monoxide Breath Sensor in People Who Smoke Cigarettes: Single-Arm Cohort Study

Background

Tobacco use is the leading cause of preventable morbidity and mortality. Existing evidence-based treatments are underutilized and have seen little recent innovation. The success of personal biofeedback interventions in other disease states portends a similar opportunity in smoking cessation. The Pivot Breath Sensor is a personal interactive FDA-cleared (over-the-counter) device that measures carbon monoxide (CO) in exhaled breath, enabling users to link their smoking behavior and CO values, and track their progress in reducing or quitting smoking.

Objective

The objective of this study is to assess the Pivot Breath Sensor in people who smoke cigarettes, evaluating changes in attitudes toward quitting smoking, changes in smoking behavior, and use experience.

Methods

US adults (18-80 years of age, ≥10 cigarettes per day [CPD]) were recruited online for this remote 12-week study. Participants completed a screening call, informed consent, and baseline questionnaire, and then were mailed their sensor. Participants were asked to submit 4 or more breath samples per day and complete questionnaires at 1-4, 8, and 12 weeks. Outcomes included attitudes toward quitting smoking (Stage of Change, success to quit, and perceived difficulty of quitting), smoking behavior (quit attempts, CPD reduction, and 7-, 30-day point prevalence abstinence [PPA]), and use experience (impact and learning).

Results

Participants comprised 234 smokers, mean age 39.9 (SD 11.3) years, 52.6% (123/234) female, mean CPD 20.3 (SD 8.0). The 4- and 12-week questionnaires were completed by 92.3% (216/234) and 91.9% (215/234) of participants, respectively. Concerning attitude outcomes, at baseline, 15.4% (36/234) were seriously thinking of quitting in the next 30 days, increasing to 38.9% (84/216) at 4 weeks and 47.9% (103/215) at 12 weeks (both P<.001). At 12 weeks, motivation to quit was increased in 39.1% (84/215), unchanged in 54.9% (118/215), and decreased in 6.0% (13/215; P<.001). Additional attitudes toward quitting improved from baseline to 12 weeks: success to quit 3.3 versus 5.0 (P<.001) and difficulty of quitting 2.8 versus 4.3 (P<.001). Regarding smoking behavior, at 4 weeks, 28.2% (66/234) had made 1 or more quit attempts (≥1 day of abstinence), increasing to 48.3% (113/234) at 12 weeks. At 4 weeks, 23.1% (54/234) had reduced CPD by 50% or more, increasing to 38.5% (90/234) at 12 weeks. At 12 weeks, CPD decreased by 41.1% from baseline (P<.001), and 7- and 30-day PPA were 12.0% (28/234) and 6.0% (14/234), respectively. Concerning use experience, 75.3% (171/227) reported the sensor increased their motivation to quit. More than 90% (>196/214) indicated the sensor taught them about their CO levels and smoking behavior, and 73.1% (166/227) reported that seeing their CO values made them want to quit smoking.

Conclusions

Use of the Pivot Breath Sensor resulted in a significant increase in motivation to quit, a reduction in CPD, and favorable quit attempt rates. These outcomes confer increased likelihood of quitting smoking. Accordingly, the results support a role for biofeedback via personal CO breath sampling in smoking cessation.

Trial Registration

ClinicalTrials.gov NCT04133064; https://clinicaltrials.gov/ct2/show/NCT04133064

Interaction between a haptoglobin genetic variant and coronary artery disease (CAD) risk factors on CAD severity in Singaporean Chinese population

Background

Haptoglobin (Hp) is a plasma protein with strong anti‐inflammation and antioxidant activities. Its plasma level is known to be inversely associated with many inflammatory diseases, including cardiovascular diseases. However, the association of HP genetic variants with coronary artery disease (CAD) severity/mortality, and how they interact with common CAD risk factors are largely unknown.

Methods

We conducted the analysis in a Singaporean Chinese CAD population with Gensini severity scores (N = 582) and subsequently evaluated the significant findings in an independent cohort with cardiovascular mortality (excluding stroke) as outcome (917 cases and 19,093 controls). CAD risk factors were ascertained from questionnaires, and stenosis information from medical records. Mortality was identified through linkage with the nationwide registry of births and deaths in Singapore. Linear regression analysis between HP genetic variant (rs217181) and disease outcome were performed. Interaction analyses were performed by introducing an interaction term in the same regression models.

Results

Although rs217181 was not significantly associated with CAD severity and cardiovascular mortality (excluding stroke) in all subjects, when stratified by hypertension status, hypertensive individuals with the minor T allele have more severe CAD (β = 0.073, SE = 0.030, p = 0.015) and non‐hypertensive individuals with the T allele have lower risk for mortality (odds ratio = 0.771 (0.607–0.980), p = 0.033).

Conclusion

HP genetic variant is not associated with CAD severity and mortality in the general population. However, hypertensive individuals with the rs217181 T allele associated with higher Hp levels had more severe CAD while non‐hypertensive individuals with the same allele had lower risk for mortality in the Chinese population.

Uptake and efficacy of a systematic intensive smoking cessation intervention using motivational interviewing for smokers hospitalised for an acute coronary syndrome: a multicentre before-after study with parallel group comparisons

OBJECTIVES

To compare the efficacy of a proactive approach with a reactive approach to offer intensive smoking cessation intervention using motivational interviewing (MI).

DESIGN

Before-after comparison in 2 academic hospitals with parallel comparisons in 2 control hospitals.

SETTING

Academic hospitals in Switzerland.

PARTICIPANTS

Smokers hospitalised for an acute coronary syndrome (ACS).

INTERVENTION

In the intervention hospitals during the intervention phase, a resident physician trained in MI systematically offered counselling to all smokers admitted for ACS, followed by 4 telephone counselling sessions over 2 months by a nurse trained in MI. In the observation phase, the in-hospital intervention was offered only to patients whose clinicians requested a smoking cessation intervention. In the control hospitals, no intensive smoking cessation intervention was offered.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was 1 week smoking abstinence (point prevalence) at 12 months. Secondary outcomes were the number of smokers who received the in-hospital smoking cessation intervention and the duration of the intervention.

RESULTS

In the intervention centres during the intervention phase, 87% of smokers (N=193/225) received a smoking cessation intervention compared to 22% in the observational phase (p<0.001). Median duration of counselling was 50 min. During the intervention phase, 78% received a phone follow-up for a median total duration of 42 min in 4 sessions. Prescription of nicotine replacement therapy at discharge increased from 18% to 58% in the intervention phase (risk ratio (RR): 3.3 (95% CI 2.4 to 4.3; p≤0.001). Smoking cessation at 12-month increased from 43% to 51% comparing the observation and intervention phases (RR=1.20, 95% CI 0.98 to 1.46; p=0.08; 97% with outcome assessment). In the control hospitals, the RR for quitting was 1.02 (95% CI 0.84 to 1.25; p=0.8, 92% with outcome assessment).

CONCLUSIONS

A proactive strategy offering intensive smoking cessation intervention based on MI to all smokers hospitalised for ACS significantly increases the uptake of smoking cessation counselling and might increase smoking abstinence at 12 months.

Effect of systems change and use of electronic health records on quit rates among tobacco users in a public hospital system

OBJECTIVES

We examined electronic health records (EHRs) to assess the impact of systems change on tobacco use screening, treatment, and quit rates among low-income primary care patients in Louisiana.

METHODS

We examined EHR data on 79,777 patients with more than 1.2 million adult primary care encounters from January 1, 2009, through January 31, 2012, for evidence of systems change. We adapted a definition of "systems change" to evaluate a tobacco screening and treatment protocol used by medical staff during primary care visits at 7 sites in a public hospital system.

RESULTS

Six of 7 sites met the definition of systems change, with routine screening rates for tobacco use higher than 50%. Within the first year, a 99.7% screening rate was reached. Sites had a 9.5% relative decrease in prevalence over the study period. Patients were 1.03 times more likely to sustain quit with each additional intervention (95% confidence interval = 1.02, 1.04).

CONCLUSIONS

EHRs can be used to demonstrate that routine clinical interventions with low-income primary care patients result in reductions in tobacco use and sustained quits.

Secondary prevention in the intensive care unit: does intensive care unit admission represent a "teachable moment?"

OBJECTIVES

Cigarette smoking and unhealthy alcohol use are common causes of preventable morbidity and mortality that frequently result in admission to an intensive care unit. Understanding how to identify and intervene in these conditions is important because critical illness may provide a "teachable moment." Furthermore, the Joint Commission recently proposed screening and receipt of an intervention for tobacco use and unhealthy alcohol use as candidate performance measures for all hospitalized patients. Understanding the efficacy of these interventions may help drive evidence-based institution of programs, if deemed appropriate.

DATA SOURCES

A summary of the published medical literature on interventions for unhealthy alcohol use and smoking obtained through a PubMed search.

SUMMARY

Interventions focusing on behavioral counseling for cigarette smoking in hospitalized patients have been extensively studied. Several studies include or focus on critically ill patients. The evidence demonstrates that behavioral counseling leads to increased rates of smoking cessation but the effect depends on the intensity of the intervention. The identification of unhealthy alcohol use can lead to brief interventions. These interventions are particularly effective in trauma patients with unhealthy alcohol use. However, the current literature would not support routine delivery of brief interventions for unhealthy alcohol use in the medical intensive care unit population.

CONCLUSIONS

Intensive care unit admission represents a "teachable moment" for smokers and some patients with unhealthy alcohol use. Future studies should assess the efficacy of brief interventions for unhealthy alcohol use in medical intensive care unit patients. In addition, identification of the timing and optimal individual to conduct the intervention will be necessary.

General health screening as part of a periodontal examination

Cardiovascular disease (CVD) and type 2 diabetes are common systemic illnesses with reliable, predictive risk factors. CVD is the number one killer worldwide accounting for nearly 30% of deaths and type 2 diabetes has reached epidemic proportions in many western industrialized countries. Both of these illnesses can go undiagnosed in an alarming number of people for significant periods of time. The relationship between oral health and systemic health has become the focus of much discussion and research in recent times. It is now widely accepted that periodontal disease is associated with systemic illnesses such as CVD and type 2 diabetes. Cigarette smoking and obesity are major risk factors accounting for a large portion of the global disease burden. Many periodontal patients may be at risk of systemic conditions but be asymptomatic and undiagnosed. With an aging population who are mostly retaining their natural dentition, the need for periodontal management will continue to rise in the future. Dental professionals are well placed to perform general health screening for their patients. Therefore, risk assessment during the periodontal examination may facilitate the early identification of the large proportion of people who are unaware of their risk status. As identification and intervention of patients with increased risk factors is key to lowering the systemic disease burden, general health screening during periodontal examinations may present an important opportunity for many patients.

Randomized Trial of a Pharmacist-Delivered Intervention for Improving Lipid-Lowering Medication Adherence among Patients with Coronary Heart Disease

A randomized trial of a pharmacist-delivered intervention (PI) versus usual care (UC) was conducted; 689 subjects with known coronary heart disease were recruited from cardiac catheterization laboratories. Participants in the PI condition received 5 pharmacist-delivered telephone counseling calls post-hospital discharge. At one year, 65% in the PI condition and 60% in the UC condition achieved an LDL-C level <100 mg/dL (P = .29); mean statin adherence was 0.88 in the PI, and 0.90 in the UC (P = .51). The highest percentage of those who reached the LDL-C goal were participants who used statins as opposed to those who did not use statins (67% versus 58%, P = .05). However, only 53% and 56% of the patients in the UC and PI conditions, respectively, were using statins. We conclude that a pharmacist-delivered intervention aimed only at improving patient adherence is unlikely to positively affect outcomes. Efforts must be oriented towards influencing physicians to increase statin prescription rates.

Predictors of success in smoking cessation among hospitalized patients

OBJECTIVE

To determine the predictors of continued smoking abstinence in patients receiving smoking cessation intervention during and following hospital admission.

METHODOLOGY

A prospective cohort study was conducted in a university-affiliated hospital. A total of 248 smokers admitted with primary cardiac and respiratory conditions received verbal advice (lasting about 1 h) and standard booklets on smoking cessation from a dedicated nurse counsellor. After discharge, participants received follow-up telephone counselling calls every 2 weeks from the same smoking counsellor. The main outcome measure was continued abstinence at 2 months after hospital discharge, as determined by self-reporting and carbon monoxide breath testing. The following groups of covariates were analysed to determine the possible factors associated with smoking abstinence: demographics, smoking history, readiness to quit, and medical history.

RESULTS

At 2 months post-discharge, 108 (43.5%) patients remained abstinent. Low nicotine dependence score (odds ratio, 2.30; 95% CI, 1.25-4.26; P = 0.008), decision to quit by sudden cessation as compared to reduction of smoking (odds ratio, 7.19; 95% CI, 1.56-33.06; P = 0.011), and initial hospitalization for their medical condition (odds ratio, 6.37; 95% CI, 1.33-30.44; P = 0.020) were the main independent predictors for positive outcome.

CONCLUSION

Among this cohort of hospitalized patients receiving smoking cessation intervention, low dependence on tobacco, motivation to quit by sudden cessation, and initial hospitalization were the main independent predictors of smoking abstinence after discharge from hospital.

Randomised controlled trial of smoking cessation intervention after admission for coronary heart disease

OBJECTIVE

To determine whether a nurse led smoking cessation intervention affects smoking cessation rates in patients admitted for coronary heart disease.

DESIGN

Randomised controlled trial.

SETTING

Cardiac ward of a general hospital, Norway.

PARTICIPANTS

240 smokers aged under 76 years admitted for myocardial infarction, unstable angina, or cardiac bypass surgery. 118 were randomly assigned to the intervention and 122 to usual care (control group).

INTERVENTION

The intervention was based on a booklet and focused on fear arousal and prevention of relapses. The intervention was delivered by cardiac nurses without special training. The intervention was initiated in hospital, and the participants were contacted regularly for at least five months.

MAIN OUTCOME MEASURE

Smoking cessation rates at 12 months determined by self report and biochemical verification.

RESULTS

12 months after admission to hospital, 57% (n = 57/100) of patients in the intervention group and 37% (n = 44/118) in the control group had quit smoking (absolute risk reduction 20%, 95% confidence interval 6% to 33%). The number needed to treat to get one additional person who would quit was 5 (95% confidence interval, 3 to 16). Assuming all dropouts relapsed at 12 months, the smoking cessation rates were 50% in the intervention group and 37% in the control group (absolute risk reduction 13%, 0% to 26%).

CONCLUSION

A smoking cessation programme delivered by cardiac nurses without special training, significantly reduced smoking rates in patients 12 months after admission to hospital for coronary heart disease.