Are predictors of making a quit attempt the same as predictors of 3-month abstinence from smoking? Findings from a sample of smokers recruited for a study of computer-tailored smoking cessation advice in primary care

Social smoker identity and associations with smoking and quitting behaviour: A cross-sectional study in England

BACKGROUND

'Social smoking' typically occurs predominantly or exclusively in the presence of others who are smoking. Relatively little is known about changes in the prevalence of 'social smoking identity' over time and its association with other smoking-related correlates.

METHODS

Data were from the Smoking Toolkit Study, a nationally-representative cross-sectional survey in England. Participants were 26,774 adults who currently smoked or had quit in the past year, surveyed between February-2014 and April-2021. We estimated the proportion identifying as having a social smoking identity, changes over time, and associations with smoking in social situations, cigarette dependence, motivation to stop, quit attempts and success.

RESULTS

Of adults who currently smoked or had quit in the past year, 34.0% (95% Confidence Interval (CI)=33.5-34.6) identified as having a social smoking identity. There was a near linear increase in this proportion from 31.9% (95%CI=29.7-34.2) in February-2014 to 36.5% (95%CI=34.1-38.9) in April-2021. Adults who currenty smoked identifying as having a social smoking identity were less cigarette dependent (adjusted B=0.34, 95%CI=0.31-0.37) and more motivated to stop (aOR=1.20, 95%CI=1.15-1.26) than those who did not. Adults who currently smoked or had quit in the past year identifying as having a social smoking identity reported more smoking in social situations (aOR=6.45, 95%CI=6.13-6.80) and past-year quit attempts (aOR=1.22, 95%CI=1.14-1.30) than those who did not. Quit success was not associated with having a social smoking identity among adults who currently smoked or had quit in the past year and who had attempted to quit (aOR=0.90, 95%CI=0.79-1.02).

CONCLUSIONS

An increasing proportion, over a third, of adults who currently smoked or had quit in the past year in England identify as having a social smoking identity. Despite being associated with lower dependence, greater motivation to quit and more quit attempts, social smoking identity is not associated with greater quit success, suggesting a complex interplay between identity and smoking-related behaviours.

Factors Associated With Abstinence Among Young Adult Smokers Enrolled in a Real-world Social Media Smoking Cessation Program

OBJECTIVE

Social media platforms are promising to provide smoking cessation support. This study aimed to identify baseline factors associated with cigarette smoking abstinence among young adult smokers enrolled in a real-world social media-based smoking cessation program.

AIMS AND METHODS

We analyzed data from young adult smokers (aged 18-30 years) participating in a publicly available Facebook-based smoking cessation program serving the San Francisco Bay Area. The analytic sample consisted of 248 participants who completed both the baseline and follow-up surveys at 3 months. Multivariable logistic regression analysis determined baseline factors significantly associated with self-reported 7-day cigarette smoking abstinence at 3 months.

RESULTS

Participants were race/ethnically diverse, well-educated, and 47.6% reported LGB + sexual identity. Those who reported dual use of cigarettes and e-cigarettes in the past 30 days (vs. cigarette use only), current alcohol users (vs. non-users), and those aged 25-30 years (vs. 18-24 years) were significantly less likely to report 7-day abstinence at 3 months. Non-daily smokers (vs. daily smokers) and those with high desire to quit smoking (vs. low to moderate desire) were more likely to report abstinence. Results also showed reduction in the percentage of e-cigarette and other tobacco product use among participants.

CONCLUSIONS

Social media interventions may be more effective for young adult non-daily smokers and those with high desire to quit smoking. Smoking cessation programs may help reduce use of other tobacco products among treatment-seeking smokers. Smoking cessation interventions for young adults need to explicitly address dual use of cigarettes and e-cigarettes and use of alcohol.

IMPLICATIONS

Findings of this study highlight the need for future interventions to address dual use of cigarettes and e-cigarettes and use of alcohol to improve cigarette smoking abstinence outcomes. The reduction in the use of other tobacco products among program participants indicates that social media smoking cessation programs may exert a broader positive influence on overall tobacco consumption. The large number of LGB+ smokers participating in the program suggests social media is a promising cessation channel for this hard-to-reach group, warranting further study.

Covariates of success in quitting smoking: a systematic review of studies from 2008 to 2021 conducted to inform the statistical analyses of quitting outcomes of a hospital-based tobacco dependence treatment service in the United Kingdom

Background

Smoking cessation interventions are being introduced into routine secondary care in the United Kingdom (UK), but there are person and setting-related factors that could moderate their success in quitting smoking. This review was conducted as part of an evaluation of the QUIT hospital-based tobacco dependence treatment service ( https://sybics-quit.co.uk). The aim of the review was to identify a comprehensive set of variables associated with quitting success among tobacco smokers contacting secondary healthcare services in the UK who are offered support to quit smoking and subsequently set a quit date. The results would then be used to inform the development of a statistical analysis plan to investigate quitting outcomes.

Methods

Systematic literature review of five electronic databases. Studies eligible for inclusion investigated quitting success in one of three contexts: (a) the general population in the UK; (b) people with a mental health condition; (c) quit attempts initiated within a secondary care setting. The outcome measures were parameters from statistical analysis showing the effects of covariates on quitting success with a statistically significant (i.e., p-value <0.05) association.

Results

The review identified 29 relevant studies and 14 covariates of quitting success, which we grouped into four categories: demographics (age; sex; ethnicity; socio-economic conditions; relationship status, cohabitation and social network), individual health status and healthcare setting (physical health, mental health), tobacco smoking variables (current tobacco consumption, smoking history, nicotine dependence; motivation to quit; quitting history), and intervention characteristics (reduction in amount smoked prior to quitting, the nature of behavioural support, tobacco dependence treatment duration, pharmacological aids).

Conclusions

In total, 14 data fields were identified that should be considered for inclusion in datasets and statistical analysis plans for evaluating the quitting outcomes of smoking cessation interventions initiated in secondary care contexts in the UK.

PROSPERO registration

CRD42021254551 (13/05/2021).

Smoking cessation strategies for women: An analysis of smoking cessation determinants among Korean female smokers participating in a smoking cessation outreach program

Background: Although there is strong evidence that behavioral counseling improves quit rates, limited data are available on individualized smoking cessation counseling provided to female smokers because they often are hesitant to identify as smokers. This study aimed to elucidate factors related to smoking cessation among Korean women who participated in the smoking cessation outreach program. Methods: This retrospective descriptive study used data retrieved from the Korea Health Promotion Institute. The data included individual participant characteristics, supportive services received, and self-reported smoking cessation outcomes from June 1, 2015, to December 31, 2017. Results: Data from 709 women were analyzed. We found cessation rates of 43.3% (confidence interval [CI]=0.40, 0.47) at four weeks, 28.6% (CI=0.25, 0.32) at 12 weeks, and 21.6% (CI=0.19, 0.25) at six months. Significant determinants of quitting at six months were regular exercise (odds ratio [OR]=3.02; 95% CI=1.28, 3.29; P=0.009) and the number of counseling sessions during the first four weeks of the program (OR=1.26; 95% CI=1.04, 1.82; P=0.041). Conclusion: Providing intensive counseling during initial phase of smoking cessation program and regular exercise would be effective strategies for smoking cessation programs for women smokers to promote their health.

Predictors of electronic nicotine product quit attempts and cessation: Analysis of waves 3 and 4 of the PATH study

INTRODUCTION

Identifying theory-based predictors of electronic nicotine product (ENP) quit attempts and cessation can guide the development of effective vaping cessation interventions, which are currently limited. This study examined predictors of ENP quit attempts and cessation among adult ENP users.

METHODS

Using data from wave 3 (W3; 2015-2016) current established ENP users in the Population Assessment of Tobacco and Health study, we used multivariable logistic regression to identify predictors of (i) wave 4 (W4; 2016-2018) quit attempts (unweighted n = 1,135); and (ii) W4 cessation among those who made a quit attempt (unweighted n = 610). Predictors included Social Cognitive Theory (SCT)-based cognitive (interest in quitting, self-efficacy to quit, outcome expectancies, risk perception), behavioral (smoking status, and use of combustibles, non-combustibles, cannabis, and alcohol), and socio-environmental (perceived disapproval, household rules, exposure to advertising) factors.

RESULTS

Between W3 and W4, 51.7% of W3 ENP users made a quit attempt. Among those who tried quitting, 68.4% stopped using ENPs. SCT-based predictors of ENP quit attempts included higher interest in quitting ENPs (aOR = 1.18), greater self-efficacy to quit ENPs (aOR = 1.31), and currently using cigarettes (vs non-smoker; aOR = 1.71), non-combustibles (aOR = 2.25), and cannabis (aOR = 1.80). Predictors of ENP cessation included greater self-efficacy to quit ENPs (aOR = 1.33), greater perceived risk of ENPs (aOR = 1.35), and being a current smoker (vs non-smoker; aOR = 3.28).

CONCLUSIONS

ENP cessation interventions should address cognitive factors, particularly self-efficacy, as it predicted quit attempts and cessation. Cigarette smoking among dual users should be monitored and addressed to ensure that those who quit using ENPs do not maintain cigarette use.

Receipt of Tobacco Treatment and One-Year Smoking Cessation Rates Following Lung Cancer Screening in the Veterans Health Administration

BACKGROUND

Implementation of effective smoking cessation interventions in lung cancer screening has been identified as a high-priority research gap, but knowledge of current practices to guide process improvement is limited due to the slow uptake of screening and dearth of data to assess cessation-related practices and outcomes under real-world conditions.

OBJECTIVE

To evaluate cessation treatment receipt and 1-year post-screening cessation outcomes within the largest integrated healthcare system in the USA-the Veterans Health Administration (VHA). Design Observational study using administrative data from electronic medical records (EMR). Patients Currently smoking Veterans who received a first lung cancer screening test using low-dose CT (LDCT) between January 2014 and June 2018. Main Outcomes Tobacco treatment received within the window of 30 days before and 30 days after LDCT; 1-year quit rates based on EMR Smoking Health Factors data 6-18 months after LDCT. Key Results Of the 47,609 current smokers screened (95.3% male), 8702 (18.3%) received pharmacotherapy and/or behavioral treatment for smoking cessation; 531 (1.1%) received both. Of those receiving pharmacotherapy, only one in four received one of the most effective medications: varenicline (12.1%) or combination nicotine replacement therapy (14.3%). Overall, 5400 Veterans quit smoking-a rate of 11.3% (missing=smoking) or 13.5% (complete case analysis). Treatment receipt and cessation were associated with numerous sociodemographic, clinical, and screening-related factors.

CONCLUSIONS

One-year quit rates for Veterans receiving lung cancer screening in VHA are similar to those reported in LDCT clinical trials and cohort studies (i.e., 10-17%). Only 1% of Veterans received the recommended combination of pharmacotherapy and counseling, and the most effective pharmacotherapies were not the most commonly received ones. The value of screening within VHA could be improved by addressing these treatment gaps, as well as the observed disparities in treatment receipt or cessation by race, rurality, and psychiatric conditions.

Changes in Cigarette Smoking and Vaping in Response to the COVID-19 Pandemic in the UK: Findings from Baseline and 12-Month Follow up of HEBECO Study

This study investigated UK adults' changes in cigarette smoking and vaping during the COVID-19 pandemic and factors associated with any changes. Data were from an online longitudinal study. A self-selected sample (n = 332) of 228 smokers and 155 vapers (51 participants were both smokers and vapers) completed 5 surveys between April 2020 and June 2021. Participants self-reported data on sociodemographics, COVID-19-related, and smoking/vaping characteristics. During the 12 months of observations, among smokers, 45% self-reported a quit attempt (27.5% due to COVID-19-related reasons) since the onset of COVID-19 pandemic and the quit rate was 17.5%. At 12 months, 35.1% of continuing smokers (n = 174) reported smoking less and 37.9% the same, while 27.0% reported an increase in the number of cigarettes smoked/day. Among vapers, 25.0% self-reported a quit attempt (16.1% due to COVID-19-related reasons) and the quit rate was 18.1%. At 12 months, 47.7% of continuing vapers (n = 109) reported no change in the frequency of vaping/hour, while a similar proportion reported vaping less (27.5%) and more (24.8%). Motivation to quit smoking and being younger were associated with making a smoking quit attempt and smoking cessation. Being a cigarette smoker was associated with vaping cessation. Among a self-selected sample, COVID-19 stimulated more interest in reducing or quitting cigarette smoking than vaping.

Strict and Comprehensive Tobacco Control Policy is Needed: A Qualitative Study Exploring How People Responding a New Policy of Pictorial Health Warning on Cigarette Package in Indonesia

BACKGROUND: Little is known about the process on how smoker and nonsmoker responses to a Pictorial Health Warning (PHW) which is important for policy improvement. AIM: We aim to explore the nature of the reaction and the extent of impact of the PHW implementation on smoking habit in Indonesia. METHODS: We collected the data among adult aged 18+ years in Sleman District, Yogyakarta, Indonesia, involving 45 informants in in-depth interviews and 22 informants in four Focus Group Discussions, selected using the maximum variation sampling according to smoking status and area of residence. We discussed with respondents about the meaning of the PHWs, how they felt when seeing the PHWs, how those feelings emerged when seeing the PHWs, and the impact of seeing the PHWs. We analyzed the data using the content analysis. RESULTS: PHWs raised the intended negative emotional response, that wearing out over time. However, for smokers, the disease threat in the message was less obvious than to defeat smoking addiction. Smokers tried to manage their risk of illness themselves. Among non-smokers, they were more confident in being non-smokers. Both smokers and non-smokers thought that Government is half-hearted in controlling the smoking problem. Smokers were grateful, but non-smokers were sorry for this. CONCLUSIONS: The application of PHW threatens smokers but does not make them quit smoking because of the fear of defeating cigarette dependence. For non-smokers, they feel more confident to be a smoker-free. Respondents claim the government is not serious about controlling smoking.

Is the motivation to quit smoking a predictor of abstinence maintenance?

INTRODUCTION

The aim of this study was to explore the utility of measuring motivation to quit smoking as a predictor of abstinence maintenance among smokers who wanted to quit and who were included in a multicenter study conducted in daily clinical practice.

METHODS

This observational, longitudinal (prospective cohort), multicenter study was conducted in smoking clinics in Spain and the Argentine Republic in daily clinical practice. Motivation was assessed using three quantitative motivation tests and a Visual Analogue Scale. Statistical analysis included descriptive, association measures and logistic regression models.

RESULTS

Of a total of 404 subjects, 273 were ultimately included for analysis (147 women; 53.8%), mean age 51±11 years). In one year, 53.5% (36.13% by intention to treat) of subjects (146) were successful in quitting smoking [men: 45.2% (66) and women: 54.8% (80)], with no differences between sexes. None of the scales utilized was associated, in an unquestionable or direct way, with long-term abstinence, although three of them, in a very complex model, with additional variables and added interactions, were associated with the ‘result’ variable, when other variables intervened in certain circumstances.

CONCLUSIONS

None of the analyzed motivational scales alone demonstrated an association with success or failure in quitting smoking; thus, their use in isolation is of no value. Some of the scales analyzed might be related to the maintenance of abstinence but in complex models where other variables intervene, which makes interpretation considerably difficult. Therefore, the predictive capacity of the tests analyzed, based on the models, was low.

Gender Differences in Prevalence and Risk Factors for Hypertension among Adult Populations: A Cross-Sectional Study in Indonesia

Although hypertension is among the main public health concerns in Indonesia, due to the scarcity of data, few studies have investigated the factors associated with hypertension in men and women. This study aimed to examine the prevalence of and factors associated with hypertension among adult men and women in Indonesia. The 2018 Survey of the Sleman Health Demographic and Surveillance System was utilized, consisting of 4328 individuals aged 18+ years. Multivariable logistic regression analysis was performed to determine the sociodemographic and health behavior factors of hypertension. Overall, the prevalence of hypertension was 40% (42% in men and 38% in women). Age, abdominal obesity and chronic non-communicable diseases were the common predictors of hypertension in men and women (p < 0.05). The odds ratio of hypertension among men with low education was lower than among those with high education (OR = 0.52, 95% CI: 0.29–0.94). For women, being in the poorest socioeconomic condition increased the risk of hypertension by 1.67 times compared to the richest (95% CI: 1.21–2.32). Gender differences in the prevalence of and factors associated with hypertension were observed among adult populations in Sleman District, Yogyakarta, Indonesia. Therefore, a gender-based approach in the health prevention strategy to control hypertension for men and women is needed.

The effects of community participation program on smoke-free homes in a suburban community of Thailand

INTRODUCTION

Smoking inside the home affects the health of both the smoker and family members via secondhand exposure. This research examined the impact of a community participation program on creating smoke-free homes in a suburban community in Thanyaburi district, Pathumthani province in Thailand.

METHODS

The study involved families, with a smoker in the home, that were randomly assigned to intervention and control groups each containing 27 families. The intervention group was administered with the community participation program for smoke-free homes for 5 sessions during the 6-month period of study. The program included providing information on secondhand smoking and harms, knowledge about quitting smoking and healthcare support, practice skills, campaigns in the community, visiting and encouraging, and reflecting and evaluation. The control group was normally treated by the community committee and health volunteers. Data collection was undertaken at baseline and at 6 months after implementation by an interview with questionnaires.

RESULTS

Our results show that after the implementation, the intervention group reported significantly higher mean score on skills in negotiating with smokers for a smoking-ban inside home and mean score on emotional support for non-smoking inside the home than those at baseline and those of the control group. The proportion having smoking ban home rules in the intervention group was significantly higher than at baseline and that of the control group (92.6% vs 18.5%). The proportion of smoke-free homes was higher in the intervention than in the control group (75% vs 0%).

CONCLUSIONS

These findings suggest that community participation programs for smoke-free home may be effective in raising awareness on the impact of secondhand smoke among family members and in working together to manage smoke-free home environments. The program may be applicable for further development within communities to achieve smoke-free homes.

Durability of Abstinence After Completing a Comprehensive Digital Smoking Cessation Program Incorporating a Mobile App, Breath Sensor, and Coaching: Cohort Study

Background

Despite decreasing prevalence over the last several decades, cigarette smoking remains the leading cause of preventable death and disease, underscoring the need for innovative, effective solutions. Pivot is a novel, inclusive smoking cessation program designed for smokers along the entire spectrum of readiness to quit. Pivot leverages proven methods and technological advancements, including a personal portable breath carbon monoxide sensor, smartphone app, and in-app text-based coaching. We previously reported outcomes from the end of active Pivot program participation in 319 adult smokers. Herein, we report longer-term follow up in this cohort.

Objective

The aim of this study was to assess and report participant outcomes 3 months after completion of Pivot, including smoking behavior, quit rates, continuous abstinence rates and durability, and predictors of abstinence.

Methods

This prospective remote cohort study included US-based cigarette smokers aged 18 to 65 years who smoked ≥5 cigarettes per day (CPD). Three months after completion of active participation in Pivot, final follow-up data were collected via an online questionnaire. Outcomes included smoking behavior (CPD and quit attempts), self-reported quit rates (7- and 30-day point prevalence abstinence [PPA]), and continuous abstinence rates (proportion who achieved uninterrupted abstinence) and duration. Exploratory regression analyses were performed to identify baseline characteristics associated with achievement of 7-day PPA, 30-day PPA, and continuous abstinence.

Results

A total of 319 participants completed onboarding (intention-to-treat [ITT]); 288/319 participants (90.3%) completed follow up (completers) at a mean of 7.2 (SD 1.2) months after onboarding. At final follow up, CPD were reduced by 52.6% (SE 2.1; P<.001) among all 319 participants, and most completers (152/288, 52.8%) reduced their CPD by at least 50%. Overall, most completers (232/288, 80.6%) made at least one quit attempt. Quit rates increased after the end of Pivot; using ITT analyses, 35.4% (113/319) achieved 7-day PPA and 31.3% (100/319) achieved 30-day PPA at final follow up compared with 32.0% (102/319) and 27.6% (88/319), respectively, at the end of the Pivot program. Continuous abstinence was achieved in about a quarter of those who onboarded (76/319, 23.8%) and in most who reported 30-day PPA at the end of Pivot (76/88, 86.4%), with a mean abstinence duration of 5.8 (SD 0.6) months. In exploratory regression analyses, lower baseline CPD, more positive baseline attitudes reflecting higher self-efficacy (higher confidence to quit and lower perceived difficulty of quitting), and higher education were associated with achieving abstinence.

Conclusions

This study provides the first longer-term outcomes of the Pivot smoking cessation program. At final follow up, quit rates increased and continuous abstinence was favorable; the majority who achieved abstinence at the end of Pivot sustained abstinence throughout follow up. Decreases in CPD persisted and most participants made a quit attempt. Overall, final follow-up outcomes were stable or improved when compared to previous outcomes from the end of the program. These findings validate earlier results, and suggest that Pivot is an effective and durable solution for smoking cessation.

Trial Registration

ClinicalTrials.gov NCT03295643; https://clinicaltrials.gov/ct2/show/NCT03295643

Population-Level Assessment of Smoking-Related Beliefs and Behaviors Among Survivors of Genitourinary Cancers: An Application of the Theory of Planned Behavior

OBJECTIVE

To describe attitudes, perceptions, and beliefs related to smoking and smoking cessation among survivors of genitourinary cancers using a theory-based framework.

METHODS

We performed a cross-sectional analysis of Wave III of the PATH study, a prospective cohort survey study assessing tobacco-use patterns and attitudes among a representative population-based sample of US adults. All adult current smokers with a history of urologic cancer were included. Primary outcomes were mapped to components of the Theory of Planned Behavior (TPB) and included: attempts to quit, readiness to quit, plan to quit, being told to quit, peers views toward smoking, regret about smoking, the perceived relationship between smoking and cancer/overall health. Secondary outcomes include: time to first cigarette, utilization of smoking cessation aids. Population weighted percentages with 95% confidence intervals were estimated.

RESULTS

Our cohort represents a population estimate of 461,182 adult current smokers with a history of genitourinary cancer. The majority of respondents (90%) perceived smoking to be harmful to one's health and 83% were regretful about having started smoking. An equal proportion of respondents indicated that they were "very ready to quit," "somewhat ready to quit," or "not ready to quit." Among all respondents, 73% had been told by a physician to quit in the past year but only 7% indicated that they had used prescription medication and only 21% had used nicotine replacement therapy to help with smoking cessation.

CONCLUSION

There is significant variation in attitudes, behaviors, and perceptions related to smoking and smoking cessation among survivors of genitourinary malignancy. Patient-level smoking cessation interventions may need to be highly personalized for optimal success.

Perceptions, Predictors of and Motivation for Quitting among Smokers from Six European Countries from 2016 to 2018: Findings from EUREST-PLUS ITC Europe Surveys

The European Tobacco Products Directive (TPD) was introduced in 2016 in an effort to decrease prevalence of smoking and increase cessation in the European Union (EU). This study aimed to explore quitting behaviours, motivation, reasons and perceptions about quitting, as well as predictors (reported before the TPD implementation) associated with post-TPD quit status. A cohort study was conducted involving adult smokers from six EU countries (n = 3195). Data collection occurred pre-(Wave 1; 2016) and post-(Wave 2; 2018) TPD implementation. Bivariate and logistic regression analyses of weighted data were conducted. Within this cohort sample, 415 (13.0%) respondents reported quitting at Wave 2. Predictors of quitting were moderate or high education, fewer cigarettes smoked per day at baseline, a past quit attempt, lower level of perceived addiction, plans for quitting and the presence of a smoking-related comorbidity. Health concerns, price of cigarettes and being a good example for children were among the most important reasons that predicted being a quitter at Wave 2. Our findings show that the factors influencing decisions about quitting may be shared among European countries. European policy and the revised version of TPD could emphasise these factors through health warnings and/or campaigns and other policies.

Differential changes in quitting smoking by daily cigarette consumption and intention to quit after the introduction of a tobacco tax increase and pictorial cigarette pack warnings in Korea, 2013-2017

BACKGROUND

This study examined whether changes in quitting smoking differed according to smokers' cigarettes consumed per day (CPD) and intention to quit (ITQ) after the introduction of two tobacco control measures in Korea, a tobacco tax increase in 2015 and pictorial cigarette pack warnings (PCW) in 2016.

METHODS

We utilized data from the Korea Welfare Panel Study from 2013 to 2017, an interval that was divided into four periods (2013-2014, 2014-2015, 2015-2016, and 2016-2017). We examined differential changes in quitting smoking by smokers' CPD and ITQ using a generalized estimating equation model.

RESULTS

Smokers with 1-14 CPD or an ITQ were more likely to quit smoking in each period. However, when compared to the pre-policy period (2013-2014), smokers with 15 or more CPD and those with an ITQ had a higher risk ratio of quitting smoking in all study periods. In stratified analyses, when the tobacco excise tax was increased, the risk ratios of quitting smoking increased in most subgroups, especially smokers with 15 or more CPD or an ITQ. The increased risk ratio of 15 or more CPD smokers subgroup sustained afterward. However, after the introduction of PCW, there were no significant changes from the previous period in most subgroups.

CONCLUSIONS

The addictive nature of tobacco and the type of tobacco control policies jointly contributed to changes in quitting smoking among Korean smokers. Tobacco control policies, particularly substantial tobacco tax increase, acted as a cue-to-action for quitting smoking among more dependent smokers.

Impact of tobacco tax increases and industry pricing on smoking behaviours and inequalities: a mixed-methods study

Background

Increasing tobacco prices through taxation is very effective for reducing smoking prevalence and inequalities. For optimum effect, understanding how the tobacco industry and smokers respond is essential. Tobacco taxation changes occurred in the UK over the study period, including annual increases, a shift in structure from ad valorem to specific taxation and relatively higher increases on roll-your-own tobacco than on factory-made cigarettes.

Objectives

Understanding tobacco industry pricing strategies in response to tax changes and the impact of tax on smokers’ behaviour, including tax evasion and avoidance, as well as the effect on smoking inequalities. Synthesising findings to inform how taxation can be improved as a public health intervention.

Design

Qualitative analysis and evidence synthesis (commercial and Nielsen data) and longitudinal and aggregate cross-sectional analyses (International Tobacco Control Policy Evaluation Project data).

Setting

The UK, from 2002 to 2016.

Data sources and participants

Data were from the tobacco industry commercial literature and retail tobacco sales data (Nielsen, New York, NY, USA). Participants were a longitudinal cohort (with replenishment) of smokers and ex-smokers from 10 surveys of the International Tobacco Control Policy Evaluation Project (around 1500 participants per survey).

Main outcome measures

(1) Tobacco industry pricing strategies, (2) sales volumes and prices by segments over time and (3) smokers’ behaviours, including products purchased, sources, brands, consumption, quit attempts, success and sociodemographic differences.

Review methods

Tobacco industry commercial literature was searched for mentions of tobacco products and price segments, with 517 articles extracted.

Results

The tobacco industry increased prices on top of tax increases (overshifting), particularly on premium products, and, recently, the tobacco industry overshifted more on cheap roll-your-own tobacco than on factory-made cigarettes. Increasingly, price rises were from industry revenue generation rather than tax. The tobacco industry raised prices gradually to soften impact; this was less possible with larger tax increases. Budget measures to reduce cheap product availability failed due to new cheap factory-made products, price marking and small packs. In 2014, smokers could buy factory-made (roll-your-own tobacco) cigarettes at real prices similar to 2002. Exclusive roll-your-own tobacco and mixed factory-made cigarettes and roll-your-own tobacco use increased, whereas exclusive factory-made cigarette use decreased, alongside increased cheap product use, rather than quitting. Quitting behaviours were associated with higher taxes. Smokers consumed fewer factory-made cigarettes and reduced roll-your-own tobacco weight over time. Apparent illicit purchasing did not increase. Disadvantaged and dependent smokers struggled with tobacco affordability and were more likely to smoke cheaper products, but disadvantage did not affect quit success.

Limitations

Different for each data set; triangulation increased confidence.

Conclusions

The tobacco industry overshifted taxes and increased revenues, even when tax increases were high. Therefore, tobacco taxes can be further increased to reduce price differentials and recoup public health costs. Government strategies on illicit tobacco appear effective. Large, sudden tax increases would reduce the industry’s ability to manipulate prices, decrease affordability and increase quitting behaviours. More disadvantaged, and dependent, smokers need more help with quitting.

Future work

Assessing the impact of tax changes made since 2014; changing how tax changes are introduced (e.g. sudden intermittent or smaller continuous); and tax changes on tobacco initiation.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

Factors associated with abstinence after a recent smoking cessation attempt across 28 European Union member states

INTRODUCTION

There is a lack of information regarding factors associated with successful smoking cessation on a population and European Union (EU)-wide level. Our study seeks to explore individual and country-level factors associated with abstinence after a recent smoking cessation attempt across the EU.

METHODS

We obtained data from the March 2017 Special Eurobarometer 87.1 (n=27901). Regression analysis was performed on a subset of 1472 individuals who made quit attempts in the past 12 months. Sociodemographic, policy and country-level factors were assessed using logistic regression among smokers and ex-smokers who attempted to quit approximately 12 months before the survey date. We defined and examined the Cessation Ratio (ratio of number of recent quitters to those who did not succeed) across 28 EU Member States.

RESULTS

In all, 14.9% (n=1018) of current smokers and 8.80% (n=454) of ex-smokers attempted to quit in approximately the last 12 months (n=1472). Cessation Ratios ranged from 0.182 (95% CI: 0.045–0.319) in Estonia to 1.060 (95% CI: 0.262–1.860) in Sweden. There is a quadratic, U-shaped relationship between odds of quitting and smoking prevalence. The lowest odds of cessation were observed at a prevalence of 26.3%, with higher odds of cessation observed above and below this point. Respondents who reported financial difficulties were less likely to quit (AOR=0.66; 95% CI: 0.52–0.83). There was no association of likelihood of success with other sociodemographic factors or the Tobacco Control Scale treatment score.

CONCLUSIONS

These findings highlight a need for exploring reasons behind the variation in likelihood of abstinence following a recent quit attempt, in order to design policies targeted at population groups or countries that need greater support.

Factors associated with quit attempts and smoking cessation in Brazil: findings from the International Tobacco Control Brazil Survey

OBJECTIVES

This study aimed to identify factors associated with attempting to quit and successful smoking cessation in a population-based sample of Brazilian smokers.

STUDY DESIGN

This is a prospective cohort study.

METHODS

Data came from the first two waves of the International Tobacco Control Brazil Survey, conducted in 2009 and 2012/2013 in three cities: Rio de Janeiro, São Paulo, and Porto Alegre. Data were collected from 488 adults (aged ≥18 years) who smoked at Wave 1 and who were resurveyed at Wave 2. Crude and adjusted relative risks for two outcomes (making a quit attempt between Wave 1 and Wave 2 and successfully quitting by Wave 2) were estimated. Multivariable multilevel logistic regression models were used, whereby variables were added to the models in a series of blocks.

RESULTS

Nearly two-thirds (65.6%) of smokers attempted to quit between waves, and 23.4% had quit at Wave 2. Intention to quit smoking at Wave 1 was the only variable associated with attempt to quit by Wave 2 (odds ratio [OR] = 2.85; 95% confidence interval [CI] 1.64-4.94; P < 0.001). Smokers of higher socio-economic status (OR high versus low = 1.80; 95% CI 1.05-3.10; P = 0.03) and lower nicotine dependence (OR low Heaviness of Smoking Index [HSI] versus high HSI = 1.94; 95% CI 1.10-3.43; P = 0.02) were more likely to successfully quit. The presence of another adult smoker at home was negatively related to successful quitting (OR = 0.50; 95% CI 0.26-0.94; P = 0.03).

CONCLUSIONS

These results are generally consistent with prior research and have potential to inform governmental interventions to promote tobacco cessation, particularly among disadvantaged groups.

Dynamic, data-driven typologies of long-term smoking, cessation, and their correlates: Findings from the International Tobacco Control (ITC) Netherlands Survey

RATIONALE

Efforts towards tobacco control are numerous, but relapse rates for smoking cessations remain high. Behavioral changes necessary for continuous cessation appear complex, variable and subject to social, biological, psychological and environmental determinants. Currently, most cessation studies concentrate on short-to midterm behavioral changes. Besides, they use fixed typologies, thereby failing to capture the temporal changes in smoking/cessation behaviors, and its determinants.

OBJECTIVE

To obtain long-term, data-driven longitudinal patterns or profiles of smoking, cessation, and related determinants in a cohort of adult smokers, and to investigate their dynamic links.

METHODS

The dataset originated from the International Tobacco Control (ITC) Netherlands Project, waves 2008 to 2016. Temporal dynamics of smoking/cessation, psychosocial constructs, and time-varying determinants of smoking were extracted with Group-Based Trajectory Modeling technique. Their associations were investigated via multiple regression models.

RESULTS

Substantial heterogeneity of smoking and cessation behaviors was unveiled. Most respondents were classified as persistent smokers, albeit with distinct levels of consumption. For a minority, cessation could be sustained between 1 and 8 years, while others showed relapsing or fluctuating smoking behavior. Links between smoking/cessation trajectories with those of psychosocial and sociodemographic variables were diverse. Notably, changes in two variables were aligned to behavioral changes towards cessation: decreasing number of smoking peers and attaining a higher self-perceived control.

CONCLUSION

The unveiled heterogeneity of smoking behavior over time and the varied cross-dependencies between smoking data-driven typologies and those of underlying risk factors underscore the need of individually tailored approaches for motivational quitting.

A text message delivered smoking cessation intervention: Design and rationale of the Text My Quit Study

INTRODUCTION

Smoking cessation interventions delivered through mobile technologies offer promise as an effective intervention tool. However, most existing programs have not been empirically tested, were not developed with end-user participation, and/or do not address evidence-based cognitive and behavioral variables shown to enhance smoking cessation in clinical trials. In addition, many programs tested in research trials have required users to access the internet and/or a smartphone app to access all program features, limiting the potential reach of those programs.

METHODS/DESIGN

This study is a randomized controlled trial testing the efficacy of the TMQ intervention for smoking cessation. All participants are randomly assigned to receive 12 weeks of either; (1) a tailored smoking-cessation intervention delivered 100% through text messaging (TMQ), or (2) non-smoking-related text messages serving as a control for contact and subject burden (Mojo). Assessments are conducted at baseline, 3- and 6-month follow-up. The primary outcome is prolonged abstinence using an intent-to-treat approach. To understand why TMQ may be more effective than Mojo, we will test several posited mechanisms of action (i.e., mediators) that may underlie intervention efficacy and will examine use of the TMQ integrated social support (ISS) network. At the end of treatment, semi-structured interviews will be conducted with TMQ participants.

CONCLUSIONS

This study will provide a rigorous test of an innovative smoking cessation program delivered 100% through text messages. Use of mixed methodologies will provide the opportunity to enhance our understanding of the user's experience with TMQ and identify areas for future enhancement and/or expansion.

Secondary analysis of an RCT on Emergency Department-Initiated Tobacco Control: Repeatedly assessed point-prevalence abstinence up to 12 months and extension of results through a 10-year follow-up

INTRODUCTION

Emergency departments (EDs) are opportune places for tobacco control interventions. The ‘Tobacco Control in an Urban Emergency Department’ (TED) study, ISRCTN41527831, originally evaluated the effect of motivational interviewing on-site plus up to four booster telephone calls on 12-month abstinence. This study’s aim was to evaluate the effect of the intervention on 7-day point-prevalence abstinence at 10 years follow-up (primary outcome) as well as on repeated point-prevalence abstinence at 1, 3, 6, 12 months and at 10 years (continual smoking abstinence, secondary outcome).

METHODS

At the 10 years follow-up and after informed consent, study participants responded to a mailed questionnaire. The primary outcome was analyzed in observed-only and in all-cases analyses. The secondary outcomes were analyzed using a multiple adjusted GLMM for binary outcomes.

RESULTS

Out of 1012 TED-study participants, 986 (97.4%) were alive and 231 (23.4% of 986) responded to the follow-up at 10 years. For observed-only and all-cases analyses, the effect of the baseline intervention on 7-day point-prevalence abstinence at the 10 years follow-up was statistically non-significant. However, when taking into account all repeated measures, the intervention significantly influenced continual abstinence with odds ratio 1.32 (95% CI: 1.01–1.73; p=0.042). Baseline motivation, perceived self-efficacy to stop smoking, and nicotine dependency were independently associated with long-term continual smoking abstinence (all p<0.05).

CONCLUSIONS

A conventional analysis failed to confirm a significant effect of the ED-initiated tobacco control intervention on the point-prevalence abstinence at 10 years. Results from a more integrative analysis nonetheless indicated an enduring intervention effect on continual abstinence among smokers first encountered in the emergency department setting 10 years earlier.

Factors associated with Quitline and pharmacotherapy utilisation among low-socioeconomic status smokers

AIMS

To examine factors associated with Quitline and pharmacotherapy utilisation in low socioeconomic status (low-SES) smokers enrolled in a smoking cessation trial.

METHODS

Baseline data was used from a large-scale smoking cessation randomised controlled trial (RCT). Logistic regression models were used to examine predictors of treatment utilisation prior to entering the RCT and perceived effectiveness of past and future use.

RESULTS

A total of 1047 smokers consented and prior to enrolment 92% had previously tried to quit smoking, 86% had ever used quit support, 83% had used pharmacotherapy at least once and 38% had ever utilised Quitline. For those who had used pharmacotherapies, 71% used NRT, of which 21% had used dual NRT products. In the last 12-months, 27% utilised Quitline and 50% utilised NRT. Ever use of Quitline was negatively associated with self-efficacy to quit (OR: 0.80; 95% CI: 0.68, 0.94 p < .01) and positively associated with being diagnosed with a mental health condition (OR: 1.50; 95% CI: 1.01, 2.25 p < .05). Recent use of NRT was positively associated with mental health condition (OR: 1.39; 95% CI: 1.02, 1.90 p < .05) and negatively associated with alcohol consumption (OR: 0.69; 95% CI: 0.52, 0.92 p < .01).

CONCLUSION

Past use of Quitline and pharmacotherapy treatment was associated with self-efficacy to quit, sociodemographic variables, mental health conditions and alcohol consumption. Community-based strategies that target smoking, mental health and drug and alcohol problems may overcome some of the barriers that prevent low-SES populations from engaging with smoking cessation support.

A recommender system to quit smoking with mobile motivational messages: study protocol for a randomized controlled trial

Background

Smoking cessation is the most common preventative for an array of diseases, including lung cancer and chronic obstructive pulmonary disease. Although there are many efforts advocating for smoking cessation, smoking is still highly prevalent. For instance, in the USA in 2015, 50% of all smokers attempted to quit smoking, and only 5–7% of them succeeded – with slight deviation depending on external assistance. Previous studies show that computer-tailored messages which support smoking abstinence are effective. The combination of health recommender systems and behavioral-change theories is becoming increasingly popular in computer-tailoring. The objective of this study is to evaluate patients’s smoking cessation rates by means of two randomized controlled trials using computer-tailored motivational messages. A group of 100 patients will be recruited in medical centers in Taiwan (50 patients in the intervention group, and 50 patients in the control group), and a group of 1000 patients will be recruited on-line (500 patients in the intervention group, and 500 patients in the control group). The collected data will be made available to the public in an open-source data portal.

Methods

Our study will gather data from two sources. The first source is a clinical pilot in which a group of patients from two Taiwanese medical centers will be randomly assigned to either an intervention or a control group. The intervention group will be provided with a mobile app that sends motivational messages selected by a recommender system that takes the user profile (including gender, age, motivations, and social context) and similar users’ opinions. For 6 months, the patients’ smoking activity will be followed up, and confirmed as “smoke-free” by using a test that measures expired carbon monoxide and urinary cotinine levels. The second source will be a public pilot in which Internet users wanting to quit smoking will be able to download the same mobile app as used in the clinical pilot. They will be randomly assigned to a control group that receives basic motivational messages or to an intervention group, that receives personalized messages by the recommender system. For 6 months, patients in the public pilot will be assessed periodically with self-reported questionnaires.

Discussion

This study will be the first to use the I-Change behavioral-change model in combination with a health recommender system and will, therefore, provide relevant insights into computer-tailoring for smoking cessation. If our hypothesis is validated, clinical practice for smoking cessation would benefit from the use of our mobile solution.

Trial registration

ClinicalTrials.gov, ID: NCT03108651. Registered on 11 April 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3000-1) contains supplementary material, which is available to authorized users.

Impact and Effectiveness of a Stand-Alone NRT Starter Kit in a Statewide Tobacco Cessation Program

PURPOSE

To examine 2-week nicotine replacement therapy (NRT) starter kit quit outcomes and predictors and the impact of adding this new service on treatment reach.

DESIGN

Observational study of a 1-year cohort of QUITPLAN Services enrollees using registration and utilization data and follow-up outcome survey data of a subset of enrollees who received NRT starter kits.

SETTING

ClearWay Minnesota's QUITPLAN Services provides a quit line that is available to uninsured and underinsured Minnesotans and NRT starter kits (a free 2-week supply of patches, gum, or lozenges) that are available to all Minnesota tobacco users.

PARTICIPANTS

A total of 15 536 adult QUITPLAN Services enrollees and 818 seven-month follow-up survey NRT starter kit respondents.

MEASURES

Treatment reach for all services and tobacco quit outcomes and predictors for starter kit recipients.

ANALYSIS

Descriptive analyses, χ² analyses, and logistic regression.

RESULTS

Treatment reach increased 3-fold after adding the 2-week NRT starter kit service option to QUITPLAN Services compared to the prior year (1.86% vs 0.59%). Among all participants enrolling in QUITPLAN services during a 1-year period, 83.8% (13 026/15 536) registered for a starter kit. Among starter kit respondents, 25.6% reported being quit for 30 days at the 7-month follow-up. After controlling for other factors, using all NRT and selecting more cessation services predicted quitting.

CONCLUSION

An NRT starter kit brought more tobacco users to QUITPLAN services, demonstrating interest in cessation services separate from phone counseling. The starter kit produced high quit rates, comparable to the quit line in the same time period. Cessation service providers may want to consider introducing starter kits to reach more tobacco users and ultimately improve population health.

Positive Affect as a Predictor of Smoking Cessation and Relapse: Does It Offer Unique Predictive Value among Depressive Symptom Domains?

BACKGROUND

Prior studies have suggested that, among the domains of depressive symptoms, low positive affect (PA) may have a distinct relationship with smoking cessation and relapse. However, the empirical basis for PA-focused interventions cessation is limited, with some mixed findings.

OBJECTIVES

Using a large, diverse sample of treatment-seeking smokers, this study tested the hypothesis that PA adds unique predictive value beyond the effects of the other symptom domains in models of cessation and relapse.

METHODS

Adult smokers participating in a smoking cessation trial (n = 450) were included in this post hoc analysis. Cessation outcomes included smoking abstinence at end of treatment and at 6-month follow-up. Relapse was defined as recurrence of smoking at 6-month follow-up among the end-of-treatment abstainers. Depressive symptoms were assessed at baseline using the Center for Epidemiologic Studies-Depression (CES-D) scale.

RESULTS

With the exception of PA, all of the CES-D domains predicted reduced likelihood of smoking abstinence at end of treatment and cotinine-confirmed (but not self-reported) abstinence at 6 months, as did total CES-D score (all p-values < .05). None of the symptom domains predicted relapse. Conclusions/Importance: Our results provide further evidence that current depressive symptoms predict worse cessation outcomes, but they fail to support recent work suggesting that low PA has incremental predictive value for cessation or relapse beyond the other depressive symptom domains. To improve quit rates for smokers with depressive symptoms, evidence-based mood management interventions should be included in treatment planning.

Cognitive and Behavioral Predictors of Quit Attempts and Biochemically-Validated Abstinence During Pregnancy

Introduction:

Initiating a quit attempt and achieving abstinence are distinct behaviors that have distinct correlates in general smokers. Studies predicting prenatal smoking have not addressed this.

Methods:

Pregnant smokers (N = 207), recruited to a cessation intervention trial, were used as an observational cohort. Women completed measures at baseline and 12-week follow-up (mid-late pregnancy). Outcomes were having made at least one quit attempt since baseline, and cotinine-validated 7-day abstinence at follow-up in attempters. Baseline predictors included demographics (age, deprivation, partner’s smoking), smoking behaviors (nicotine dependence, quit attempt history, previous prenatal smoking), and smoking beliefs (self-efficacy, determination, intention to quit, nonsmoker identity, social support, pregnancy-outcome beliefs). For each outcome, variables reaching p < .1 in logistic regression analyses were entered into a multivariate model controlling for trial arm. A complete case analysis was undertaken, with missing data assumptions tested in sensitivity analyses.

Results:

One hundred seventy-five women (85%) completed follow-up. Intention and determination to quit (p < .001), self-efficacy, nonsmoker identity, and not having previously smoked in pregnancy (p < .05) were univariate predictors of making a quit attempt, with stronger intention to quit the only independent predictor (multivariate odds ratio [OR] = 2.41, 95% confidence interval [CI] 1.19–4.87). Only nicotine dependence predicted validated abstinence among those who made a quit attempt (multivariate OR = 0.25, 95% CI 0.10–0.60).

Conclusions:

Initiating a quit attempt and achieving abstinence during pregnancy were found to have different correlates. For women yet to make a quit attempt in their pregnancy, smoking beliefs may be important intervention targets, but once they are engaged in quitting, nicotine dependence appears of prime importance.

Implications:

This study suggests that cognitive, particularly motivational, variables predict whether pregnant smokers will make a quit attempt, but they do not predict successful abstinence in those who attempt to quit, where nicotine dependence dominates. Interventions should facilitate quit attempts by targeting motivational variables among pregnant women who continue to smoke, but should focus on managing withdrawal once a woman initiates a quit attempt.

Predictors of tobacco abstinence in outpatient smokers with schizophrenia or bipolar disorder treated with varenicline and cognitive behavioral smoking cessation therapy

BACKGROUND

The estimated mortality gap between those with and without serious mental illness (SMI) is increasing, now estimated at 28years, which is largely due to smoking-related diseases.

AIMS

We sought to identify predictors of 14-day continuous abstinence in stable outpatient smokers with SMI.

METHOD

Adult smokers with schizophrenia spectrum (n=130) or bipolar disorder (n=23) were enrolled in a 12-week course of varenicline and cognitive-behavioral therapy for smoking cessation.

RESULTS

Independent predictors of abstinence included reduction in withdrawal symptoms prior to the quit day, fewer cigarettes smoked per day at baseline, better baseline attention, remitted alcohol dependence, and lower expectation of peer support to aid quitting.

CONCLUSIONS

Interventions that consider these targets may improve smoking cessation outcomes in those with SMI.

Abstinence expectancies and quit attempts

INTRODUCTION

Several scales have been developed to measure expectancies about smoking cessation. This secondary analysis tested the reliability and validity of one of the most commonly used expectancy measures - the Perceived Risks and Benefits of Quitting Scale (PRBQ).

METHODS

Smokers (n=143) who planned to quit at some point in the next 3months entered an observational study in which they called an Interactive Voice Response system nightly for 3months to report quit attempts and abstinence. They completed the PRBQ at baseline and the end of 1, 2 and 3months. No treatment was provided.

RESULTS

The Risks scores and Benefit scores of the PRBQ had high internal reliability (alpha=0.88-0.96 across administrations) and high test-retest stability (ICC=0.67-0.80), but poor to moderate concurrent validity (correlation with other cessation measures=0.09-0.52), and poor predictive validity (no significant prediction of quit attempts or duration of abstinence). Results were similar for men and women.

CONCLUSIONS

The PRBQ appears to be reliable but, similar to other scales of cessation expectancies, its validity appears to be poor. The face valid notion that expectations influence quitting requires further testing.

Increasing reach by offering choices: Results from an innovative model for statewide services for smoking cessation

Although state quitlines provide free telephone counseling and often include nicotine replacement therapy (NRT), reach remains limited (1-2% in most states). More needs to be done to engage all smokers in the quitting process. A possible strategy is to offer choices of cessation services through quitlines and to reduce registration barriers. In March 2014, ClearWay Minnesota^SM implemented a new model for QUITPLAN® Services, the state's population-wide cessation services. Tobacco users could choose the QUITPLAN® Helpline or one or more Individual QUITPLAN® Services (NRT starter kit, text messaging, email program, or quit guide). The program website was redesigned, online enrollment was added, and a new advertising campaign was created and launched. In 2014-2015, we evaluated whether these changes increased reach. We also assessed quit attempts, quit outcomes, predictors of 30-day abstinence, and average cost per quit via a seven-month follow-up survey. Between March 2014-February 2015, 15,861 unique tobacco users registered, which was a 169% increase over calendar year 2013. The majority of participants made a quit attempt (83.7%). Thirty-day point prevalence abstinence rates (responder rates) were 26.1% for QUITPLAN Services overall, 29.6% for the QUITPLAN Helpline, and 25.5% for Individual QUITPLAN Services. Several variables predicted quit outcomes, including receiving only one call from the Helpline and using both the Helpline and the NRT starter kit. Providing greater choice of cessation services and reducing registration barriers have the potential to engage more tobacco users, foster more quit attempts, and ultimately lead to long-term cessation and reductions in prevalence.

Commentary on Kale et al. (2015): Further perspectives on the cognitive and demographic variables relevant to smoking cessation and the importance of smoking outcome expectancies

It would be valuable to include expectancies when assessing predictors of smoking cessation attempts and the success of those outcome attempts.