Cognitive behavioral therapy for challenges to quitting tobacco smoking among social science and religion students

BACKGROUND

Tobacco smoking is a public health issue. The aim of this investigation was to determine the effect of cognitive behavioral therapy (CBT) on the disputation of challenges to quitting tobacco smoking among students enrolled in the Social Science and religious Education programmes.

METHODS

The study adopted a pretest-posttest randomized controlled group design with follow-up. The population comprised of 76 tobacco smokers (randomized into 1 of 2 groups: n = 38 for the treatment group, n = 38 for the waitlist control group) completed the study. A self-report scale measuring dependence on cigarettes was used as the outcome measure. The treatment group was exposed to a 12-weeks CBT intervention. The treatment and waitlisted groups were evaluated at 3 time points: pretest, post-test, and follow-up. Statistical analyses were achieved using ANOVA.

RESULTS

The result showed that CBT had a significant effect in reducing the challenges to quitting tobacco smoking among the student smokers in the treatment group in comparison with the waitlist control group. The positive behavioral gains after the CBT program also persisted at follow-up in the treatment group compared with the waitlist control group.

CONCLUSION

Therefore, this study suggests that CBT intervention is a time-effective treatment method for disputation of challenges to quitting tobacco smoking among students enrolled in the Social Science and Religious Education Programmes.

The Role of Tobacco Smoking in the Efficacy of Brief Alcohol Intervention: Results from a Randomized Controlled Trial

This study investigated whether tobacco smoking affected outcomes of brief alcohol interventions (BAIs) in at-risk alcohol-drinking general hospital patients. Between 2011 and 2012 among patients aged 18−64 years, 961 patients were allocated to in-person counseling (PE), computer-based BAI containing computer-generated individual feedback letters (CO), and assessment only. PE and CO included contacts at baseline, 1, and 3 months. After 6, 12, 18, and 24 months, self-reported reduction of alcohol use per day was assessed as an outcome. By using latent growth curve models, self-reported smoking status, and number of cigarettes per day were tested as moderators. In PE and CO, alcohol use was reduced independently of smoking status (IRRs ≤ 0.61, ps < 0.005). At month 24, neither smoking status nor number of cigarettes per day moderated the efficacy of PE (IRR = 0.69, ps > 0.05) and CO (IRR = 0.85, ps > 0.05). Up to month 12, among persons smoking ≤ 19 cigarettes per day, the efficacy of CO increased with an increasing number of cigarettes (ps < 0.05). After 24 months, the efficacy of PE and CO that have been shown to reduce drinking did not differ by smoking status or number of cigarettes per day. Findings indicate that efficacy may differ by the number of cigarettes in the short term.

Treatment of Tobacco Smoking: A Review

IMPORTANCE

More deaths in the US are attributed to cigarette smoking each year than to any other preventable cause. Approximately 34 million people and an estimated 14% of adults in the US smoke cigarettes. If they stopped smoking, they could reduce their risk of tobacco-related morbidity and mortality and potentially gain up to 10 years of life.

OBSERVATIONS

Tobacco smoking is a chronic disorder maintained by physical nicotine dependence and learned behaviors. Approximately 70% of people who smoke cigarettes want to quit smoking. However, individuals who attempt to quit smoking make an average of approximately 6 quit attempts before achieving long-term abstinence. Both behavioral counseling and pharmacotherapy while using nicotine replacement therapy (NRT) products, varenicline, or bupropion are effective treatments when used individually, but they are most effective when combined. In a meta-analysis including 19 488 people who smoked cigarettes, the combination of medication and behavioral counseling was associated with a quit rate of 15.2% over 6 months compared with a quit rate of 8.6% with brief advice or usual care. The EAGLES trial, a randomized double-blind clinical trial of 8144 people who smoked, directly compared the efficacy and safety of varenicline, bupropion, nicotine patch, and placebo and found a significantly higher 6-month quit rate for varenicline (21.8%) than for bupropion (16.2%) and the nicotine patch (15.7%). Each therapy was more effective than placebo (9.4%). Combining a nicotine patch with other NRT products is more effective than use of a single NRT product. Combining drugs with different mechanisms of action, such as varenicline and NRT, has increased quit rates in some studies compared with use of a single product. Brief or intensive behavioral support can be delivered effectively in person or by telephone, text messages, or the internet. The combination of a clinician's brief advice to quit and assistance to obtain tobacco cessation treatment is effective when routinely administered to tobacco users in virtually all health care settings.

CONCLUSIONS AND RELEVANCE

Approximately 34 million people in the US smoke cigarettes and could potentially gain up to a decade of life expectancy by stopping smoking. First-line therapy should include both pharmacotherapy and behavioral support, with varenicline or combination NRT as preferred initial interventions.

Balancing Consideration of the Risks and Benefits of E-Cigarettes

The topic of e-cigarettes is controversial. Opponents focus on e-cigarettes' risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking. Most US health organizations, media coverage, and policymakers have focused primarily on risks to youths. Because of their messaging, much of the public-including most smokers-now consider e-cigarette use as dangerous as or more dangerous than smoking. By contrast, the National Academies of Science, Engineering, and Medicine concluded that e-cigarette use is likely far less hazardous than smoking. Policies intended to reduce adolescent vaping may also reduce adult smokers' use of e-cigarettes in quit attempts. Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, many scientists, including this essay's authors, encourage the health community, media, and policymakers to more carefully weigh vaping's potential to reduce adult smoking-attributable mortality. We review the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation, concerns about youth vaping, and the need to balance valid concerns about risks to youths with the potential benefits of increasing adult smoking cessation.

The Impact of Surgeon Adherence to Preoperative Optimization of Hernia Repairs

BACKGROUND

At the patient level, optimizing risk factors before surgery is a proven approach to improve patient outcomes after hernia repair. However, nearly 25% of patients are not adequately optimized before surgery. It is currently unknown how surgeon-level adherence to preoperative optimization impacts postoperative outcomes. In this context, we evaluated the association between surgeon adherence to optimization practices and surgeon-level postoperative outcomes.

MATERIALS AND METHODS

Michigan Surgical Quality Collaborative data from 2014 to 2018 was analyzed to examine rates of surgeon adherence to preoperative optimization when performing elective ventral and incisional hernia repair. Adherence was defined as operating on patients who were nontobacco users with a body mass index >18.5 kg/m2 and <40 kg/m2. Surgeons were assigned a risk- and reliability-adjusted adherence rate which was used to divide surgeons into tertiles. Outcomes were compared between adherence tertiles.

RESULTS

Across 70 hospitals in Michigan, 15,016 patients underwent ventral and incisional hernia repair, cared for by 454 surgeons. Surgeon adherence to preoperative optimization ranged from 51% to 76%. Surgeons in the lowest optimization tertile had higher rates of emergency department visits (8.78% versus 7.05% versus 7.03%, P < 0.001), serious complications (2.12% versus 1.56% versus 1.84%, P = 0.041), and any complication (4.08% versus 3.37% versus 4.04%, P = 0.043), than middle and high optimization tertiles.

CONCLUSIONS

Surgeons' clinical outcomes, including complication rates, are affected by the proportion of their patients who are preoperatively optimized with regard to obesity and tobacco use. These results suggest that surgeons can improve their postoperative outcomes by addressing these issues before surgery.

Healthcare Professionals' Beliefs, Attitudes, Knowledge, and Behavior Around Vaping in Pregnancy and Postpartum: A Qualitative Study

INTRODUCTION

Finding effective ways to help pregnant women quit smoking and maintain long-term abstinence is a public health priority. Electronic cigarettes (ie, vaping) could be a suitable cessation tool in pregnancy for those who struggle to quit; however, healthcare professionals (HCP) must be informed about these devices to offer appropriate advice. This study used the Capability, Opportunity, Motivation, and Behavior (COM-B) model and Theoretical Domains Framework (TDF) to explore HCP attitudes towards vaping in pregnancy and postpartum; beliefs about the health risks of vaping; perceived barriers and facilitators of vaping in pregnancy; knowledge of current guidelines and policies; and training needs.

METHODS

Interviews (n = 60) were conducted with midwives (n = 17), health visitors (n = 10), general practitioners (n = 15) and stop smoking specialists (n = 18) across the United Kingdom. Interview transcriptions were analyzed thematically using the framework approach and the COM-B.

RESULTS

Discussing vaping as a tool for quitting smoking in pregnancy was prevented by a lack of capability (limited knowledge of vaping, lack of training in smoking cessation); lack of opportunity (restricted by organizational policies and guidelines, lack of time and financial issues impacting on training), and negative social influences (sensationalist media and stigma associated with vaping in pregnancy); and lack of motivation (fear of future litigation and comebacks should adverse effects from vaping arise).

CONCLUSIONS

Factors related to capability, opportunity, and motivation were identified that influence HCPs attitudes and behaviors towards vaping in pregnancy. Gaps in knowledge and training needs were identified, which could inform the development of targeted vaping training.

IMPLICATIONS

Vaping could be suitable in pregnancy for those struggling to quit smoking. However, HCPs must be informed about these devices to offer appropriate advice. These data extend our knowledge of factors influencing HCP attitudes and behaviors towards vaping in pregnancy. Generally, vaping was perceived as safer than cigarettes, but a perceived lack of evidence, health and safety risks, dependency, and regulation issues were concerning. Considering our findings, greater efforts are needed to ensure HCPs are sufficiently informed about vaping and guidelines available. More importance should be placed on training for all HCPs who have contact with pregnant women.

Negative affect and the utilization of tobacco treatment among adult smokers with cancer

OBJECTIVE

We investigated the patterns of tobacco treatment utilization among US adult smokers with cancer and the role of negative affect as potential individual-level psychosocial barriers and facilitators influencing quit attempts and tobacco treatment utilization.

METHODS

We analyzed data from the adult sample in Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) Study. Using structural equation modeling, we examined (1) the association between cancer diagnosis and negative affect (e.g., depressive mood, anxiety, and distress) and (2) the associations between negative affect and smoking cessation behaviors (i.e., quit attempts and tobacco treatment utilization).

RESULTS

Compared to adults without cancer, cancer survivors were more likely to have attempted to quit tobacco use in the past 12 months (p < 0.05) and experienced increased negative affect (p < 0.01). However, negative affect appeared to be a psychological barrier to quit attempts, as it was associated with lower likelihood of attempting to quit (p < 0.05). On the other hand, among past-12-month quit attempters, negative affect was related to higher likelihood of using any type of tobacco treatment (p < 0.001).

CONCLUSIONS

Negative affect may be a potential underlying mechanism in the relationship between cancer diagnosis status and quit attempts and tobacco treatment utilization, influencing the utilization of tobacco treatment among smokers with cancer. Research is needed to investigate whether integrating emotional management in the oncology setting may effectively aid smoking cessation among patients with cancer.

Acceptability of real-time video counselling compared to other behavioural interventions for smoking cessation in rural and remote areas

BACKGROUND

This study evaluated the acceptability of real-time video counselling compared to a) telephone counselling and b) written materials in assisting rural and remote residents to quit smoking.

METHODS

Participants were recruited into a three-arm, parallel group randomised trial and randomly allocated to either: a) real-time video counselling; b) telephone counselling; or c) written materials. At 4-months post-baseline participants completed an online survey that examined self-reported acceptability and helpfulness of the support.

RESULTS

Overall, 93.5 % of video counselling participants and 96.2 % of telephone counselling participants who received support thought it was acceptable for a smoking cessation advisor to contact them via video software or telephone respectively. There were significant differences between video counselling and telephone counselling groups on three of 10 acceptability or helpfulness measures. Video counselling participants had significantly lower odds of reporting the number of calls were about right (OR 0.50, 95 % CI 0.27-0.93), recommending the support to family and friends (OR 0.18, 95 % CI 0.04-0.85) and reporting the support helped with motivation to try quitting (OR 0.24, 95 % CI 0.07-0.76) compared to telephone counselling participants. Video counselling participants had significantly greater odds than written materials participants of rating the support favourably on all seven acceptability and helpfulness items compared.

CONCLUSIONS

Real-time video counselling for smoking cessation is acceptable and well-received by those living in rural and remote locations. Further research is required to enhance the three attributes that were less acceptable for video counselling than telephone counselling.

Inequalities, harm reduction and non-combustible nicotine products: a meta-ethnography of qualitative evidence

BACKGROUND

We sought to review qualitative evidence on how smokers in different socioeconomic groups engage with non-combustible nicotine products (NCNP), including electronic cigarettes and nicotine replacement therapies, in order to provide insight into how these products might impact on smoking inequalities.

METHODS

We searched ten electronic databases in February 2017 using terms relating to NCNP and socioeconomic status. We included qualitative studies that were published since 1980 and were available in English. We used guidelines adapted from the Critical Appraisal Skills Programme for appraising qualitative research.

RESULTS

The review only identified studies exploring the attitudes of socioeconomically disadvantaged smokers towards NCNP for harm reduction or cessation purposes (i.e. we did not identify any relevant studies of more advantaged socioeconomic groups). Using a lines-of-argument meta-ethnographic approach, we identified a predominantly pessimistic attitude to NCNP for harm reduction or cessation of smoking due to: wider circumstances of socioeconomic disadvantage; lack of a perceived advantage of alternative products over smoking; and a perceived lack of information about relative harms of NCNP compared to smoking. Optimistic findings, although fewer, suggested the potential of NCNP being taken up among smokers experiencing socioeconomic disadvantage.

CONCLUSIONS

Overall, our review highlights the importance of considering the social, cultural and economic circumstances that influence experiences of smoking and of alternative product use.

Heterogeneous treatment effects of a text messaging smoking cessation intervention among university students

Introduction

Despite tobacco being an important preventable factor with respect to ill health and death, it is a legal substance that harms and kills many of those who use it. Text messaging smoking cessation interventions have been evaluated in a variety of contexts, and are generally considered to have a positive effect on smoking cessation success. In order for text messaging interventions to continue to be useful as prevalence of smoking decreases, it may be necessary to tailor the interventions to specific individuals. However, little is known with regard to who benefits the most and least from existing interventions.

Methods

In order to identify heterogenous treatment effects, we analyzed data from a randomized controlled trial of a text messaging smoking cessation intervention targeting university students in Sweden. We used a Bayesian hierarchical model where the outcome was modelled using logistic regression, and so-called horseshoe priors were used for coefficients. Predictive performance of the model, and heterogeneous treatment effects, were calculated using cross-validation over the trial data.

Results

Findings from the study of heterogenous treatment effects identified less effect of the intervention among university students with stronger dependence of nicotine and students who smoke a greater quantity of cigarettes per week. No heterogeneity was found with respect to sex, number of years smoking, or the use of snuff.

Discussion

Results emphasize that individuals with a more developed dependence of nicotine may have a harder time quitting smoking even with support. This questions the dissemination and development of text messaging interventions to university students in the future, as they may not be the optimal choice of intervention for those with a more developed dependence. On the other hand, text messaging interventions may be useful to disseminate among university students that are at risk of developing a strong dependence.

Trial registration

International Standard Randomized Controlled Trial Number (ISRCTN): 75766527; http://www.controlled-trials.com/ISRCTN75766527.

2018 Langley Award for Basic Research on Nicotine and Tobacco: Bringing Precision Medicine to Smoking Cessation

INTRODUCTION

Large segments of the world population use combustible cigarettes, and our society pays a high price for smoking, through increased healthcare expenditures, morbidity and mortality. The development of combustible cigarette smoking requires the initiation of smoking and a subsequent chain of behavioral transitions from experimental use, to established regular use, to the conversion to addiction. Each transition is influenced by both environmental and genetic factors, and our increasing knowledge about genetic contributions to smoking behaviors opens new potential interventions.

METHODS

This review describes the journey from genetic discovery to the potential implementation of genetic knowledge for the treatment of tobacco use disorder.

RESULTS AND CONCLUSIONS

The field of genetics applied to smoking behaviors has rapidly progressed with the identification of highly validated genetic variants that are associated with different smoking behaviors. The large scale implementation of this genetic knowledge to accelerate smoking cessation represents an important clinical challenge in precision medicine.

Smoking and Tobacco-Free Policies in Women's Residential Substance Use Disorder Treatment Facilities: A Community-Engaged Approach

Introduction

The purpose of this study was to (1) describe the role of smoking in the lives of women in residential substance use disorder (SUD) treatment and (2) explore perceptions of the facilitators and barriers to tobacco-free policy among women in residential SUD treatment.

Methods

This was a community-engaged study using qualitative descriptive methods. We first recruited women in a residential SUD treatment facility to participate on a community research team. Interviews with staff (N = 10) and focus groups with clients (N = 42) were conducted using guides informed by the community research team. Interviews and focus groups were analyzed using content analysis.

Results

There were two themes related to the role of smoking in the women's lives: (1) smoking facilitates socialization and (2) smoking as a coping mechanism. There were three themes related to the benefits of tobacco-free policy: (1) improved health, (2) support for continued abstinence from a previous tobacco-free placement (eg, prison), and (3) less grounds up-keep. Barriers to tobacco-free policy included (1) lack of an alternative coping mechanism to smoking, (2) fear that a tobacco-free policy would drive clients away, and (3) anticipation of implementation challenges.

Conclusions

Many women in residential SUD treatment smoke, which they attribute to the fact that smoking is used to facilitate socialization and cope with stress. Future research is needed to develop and test messages to counter the misperception that smoking is an effective method to cope with stress. Ultimately, evidence-based tobacco-free policies are needed to reduce tobacco-related disease among women with SUDs.

Implications

To promote smoking cessation among women with substance use disorders through evidence-based tobacco policy, it is necessary to first understand the role of smoking in their lives as well as facilitators and barriers to tobacco-free policy in residential treatment facilities. Participants reported that smoking facilitated socialization and served as a coping mechanism. Tobacco-free policies have many benefits, including improved health, support for continued abstinence from a previous tobacco-free placement (eg, prison), and less grounds up-keep. Barriers include the lack of an alternative coping mechanism, fear that a tobacco-free policy would drive away clients and anticipation of implementation challenges. To reduce the burden of tobacco-related morbidity and mortality among women and their children, it is necessary to catalyze a culture change in behavioral health settings to prioritize the treatment of tobacco alongside treatment of other addictions.

Socioeconomic patterns of smoking cessation behavior in low and middle-income countries: Emerging evidence from the Global Adult Tobacco Surveys and International Tobacco Control Surveys

INTRODUCTION

Tobacco smoking is often more prevalent among those with lower socio-economic status (SES) in high-income countries, which can be driven by the inequalities in initiation and cessation of smoking. Smoking is a leading contributor to socio-economic disparities in health. To date, the evidence for any socio-economic inequality in smoking cessation is lacking, especially in low- and middle-income countries (LMICs). This study examined the association between cessation behaviours and SES of smokers from eight LMICs.

METHODS

Data among former and current adult smokers aged 18 and older came from contemporaneous Global Adult Tobacco Surveys (2008-2011) and the International Tobacco Control Surveys (2009-2013) conducted in eight LMICs (Bangladesh, Brazil, China, India, Mexico, Malaysia, Thailand and Uruguay). Adjusted odds ratios (AORs) of successful quitting in the past year by SES indicators (household income/wealth, education, employment status, and rural-urban residence) were estimated using multivariable logistic regression controlling for socio-demographics and average tobacco product prices. A random effects meta-analysis was used to combine the estimates of AORs pooled across countries and two concurrent surveys for each country.

RESULTS

Estimated quit rates among smokers (both daily and occasional) varied widely across countries. Meta-analysis of pooled AORs across countries and data sources indicated that there was no clear evidence of an association between SES indicators and successful quitting. The only exception was employed smokers, who were less likely to quit than their non-employed counterparts, which included students, homemakers, retirees, and the unemployed (pooled AOR≈0.8, p<0.10).

CONCLUSION

Lack of clear evidence of the impact of lower SES on adult cessation behaviour in LMICs suggests that lower-SES smokers are not less successful in their attempts to quit than their higher-SES counterparts. Specifically, lack of employment, which is indicative of younger age and lower nicotine dependence for students, or lower personal disposable income and lower affordability for the unemployed and the retirees, may be associated with quitting. Raising taxes and prices of tobacco products that lowers affordability of tobacco products might be a key strategy for inducing cessation behaviour among current smokers and reducing overall tobacco consumption. Because low-SES smokers are more sensitive to price increases, tobacco taxation policy can induce disproportionately larger decreases in tobacco consumption among them and help reduce socio-economic disparities in smoking and consequent health outcomes.

Racial/Ethnic Differences in Physiological Stress and Relapse among Treatment Seeking Tobacco Smokers

Stress is robustly associated with tobacco smoking and relapse. African Americans experience greater difficulty quitting compared to whites, yet no studies have examined race differences in physiological stress biomarkers during a quit attempt. This pilot study compared cortisol levels among treatment-seeking African American and white smokers, and relapse rates. Adult smokers (N = 115; n = 72 African American, n = 43 White) received eight sessions of group cognitive behavioral therapy plus transdermal nicotine patches. Assessments included demographics, salivary cortisol (collected at session 1, the end-of-therapy [EOT], and one-month post-therapy), and carbon monoxide-verified smoking relapse. Overall, cortisol levels declined over the course of the day at baseline, the EOT, and the one-month follow-up. African Americans exhibited lower cortisol levels compared to Whites at baseline and the EOT, but not at the one-month follow-up. In addition, African American smokers exhibited flatter slopes compared to Whites at each time point. Relapse rates were greater among African Americans at the EOT and one-month follow-up. The attenuated cortisol pattern observed in African Americans may indicate hypothalamic-pituitary-adrenal axis (HPA) exhaustion and aid our understanding of tobacco-related disparities. There is a need to focus on stress mechanisms and specific intervention approaches in order to eliminate racial/ethnic differences.

Are Electronic Cigarettes an Effective Aid to Smoking Cessation or Reduction Among Vulnerable Groups? A Systematic Review of Quantitative and Qualitative Evidence

INTRODUCTION

Smoking prevalence remains high in some vulnerable groups, including those who misuse substances, have a mental illness, are homeless, or are involved with the criminal justice system. E-cigarette use is increasing and may support smoking cessation/reduction.

METHODS

Systematic review of quantitative and qualitative data on the effectiveness of e-cigarettes for smoking cessation/reduction among vulnerable groups. Databases searched were MEDLINE, EMBASE, PsychINFO, CINAHL, ASSIA, ProQuest Dissertations and Theses, and Open Grey. Narrative synthesis of quantitative data and thematic synthesis of qualitative data.

RESULTS

2628 records and 46 full texts were screened; 9 studies were identified for inclusion. Due to low quality of evidence, it is uncertain whether e-cigarettes are effective for smoking cessation in vulnerable populations. A moderate quality study suggested that e-cigarettes were as effective as nicotine replacement therapy. Four studies suggested significant smoking reduction; however, three were uncontrolled and had sample sizes below 30. A prospective cohort study found no differences between e-cigarette users and nonusers. No significant adverse events and minimal side effects were identified. Qualitative thematic synthesis revealed barriers and facilitators associated with each component of the COM-B (capability, opportunity, motivation, and behavior) model, including practical barriers; perceptions of effectiveness for cessation/reduction; design features contributing to automatic and reflective motivation; smoking bans facilitating practical opportunity; and social connectedness increasing social opportunity.

CONCLUSION

Further research is needed to identify the most appropriate device types for practicality and safety, level of support required in e-cigarette interventions, and to compare e-cigarettes with current best practice smoking cessation support among vulnerable groups.

IMPLICATIONS

Smoking prevalence among people with mental illness, substance misuse, homelessness, or criminal justice system involvement remains high. E-cigarettes could support cessation. This systematic review found limited quantitative evidence assessing effectiveness. No serious adverse events were identified. Qualitative thematic synthesis revealed barriers and facilitators mapping to each component of the COM-B (capability, opportunity, motivation, and behavior) model, including practical barriers; perceived effectiveness; design features contributing to automatic and reflective motivation; smoking bans facilitating practical opportunity; and social connectedness increasing social opportunity. Further research should consider appropriate devices for practicality and safety, concurrent support, and comparison with best practice smoking cessation support.

Perceived addiction to smoking and associations with motivation to stop, quit attempts and quitting success: A prospective study of English smokers

AIMS

Some argue that perceived addiction to smoking (PAS) might undermine motivation to stop. We examined the association of PAS with motivation to stop in a population sample and assessed its association with past and future quit attempts and future quit success.

METHOD

12,700 smokers in England were surveyed between September 2009-March 2012 as part of the Smoking Toolkit Study. 2796 smokers were followed up after 6 months. PAS was assessed at baseline by a single self-report item. The outcome variables were ratings of motivation to stop and reports of past-year quit attempts at baseline, and quit attempts in the past 6 months and smoking status at follow-up. Baseline covariates were sex, age, social grade and daily cigarette consumption.

RESULTS

In adjusted analyses, PAS was positively associated with at least some degree of motivation to stop versus no motivation (ORs = 1.97-2.96, all p's < 0.001). PAS was also positively associated with past-year quit attempts (OR = 1.43, 95% CI = 1.32-1.55, p < 0.001), but not with future quit attempts (OR = 1.17, 95% CI = 0.99-1.39, p = 0.064) or quit success (OR = 1.04, 95% CI = 0.73-1.47, p = 0.83).

CONCLUSION

In smokers in England, perceived addiction to smoking is positively associated with motivation to stop and having recently made a quit attempt but is not clearly associated with future quit attempts or success. These findings provide no grounds for believing that increasing smokers' perceived addiction through promotion of stop-smoking support has undermined motivation to stop.

Health Care Provider Intervention and Utilization of Cessation Assistance in 12 Low- and Middle-Income Countries

Background and Aim

There is a need to improve utilization of cessation assistance in low- and middle-income countries (LMICs), and tobacco cessation research has been identified as priority in LMICs. This study evaluates the relationship between health care provider intervention and cessation assistance utilization in LMICs.

Methods

Data from 13 967 participants (aged ≥15 years, 90.3% males) of the Global Adults Tobacco Survey conducted in 12 LMICs (74.3%-97.3% response rates) were analyzed with utilization of counseling/cessation clinic, WHO-recommended medications, and quitline as outcome variables. Health care provider intervention ("no intervention," only "tobacco screening," "quit advice") was the exposure variable. Weighted multiple logistic regression models were used to examine the relationship between each outcome variable and the exposure variable, adjusting for other covariates. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) are reported.

Results

Approximately 52%, 8%, and 40% of participants received no intervention, only tobacco screening, and advice to quit, respectively. Overall, 0.4%, 1.9%, 3.0%, and 4.5% used quitline, WHO-recommended medications, counseling/cessation clinic, and any cessation assistance, respectively. Compared with no intervention, quit advice was associated with increased utilization of quitline (OR = 2.24, 95% CI = 1.2 to 4.4), WHO-recommended medications (OR = 1.67, 95% CI = 1.2 to 2.3), counseling/cessation clinic (OR = 4.41, 95% CI = 3.2 to 6.1), and any assistance (any of the three types) (OR = 2.80, 95% CI = 2.2 to 3.6).

Conclusion

The findings of this study suggest that the incorporation of quit advice by health care providers in tobacco control programs and health care systems in LMICs could potentially improve utilization of cessation assistance to improve smoking cessation in LMICs.

Implications

This first study of association between health care provider intervention and the utilization of cessation assistance in LMICs reports that there was a missed opportunity to provide quit advice to about 60% of smokers who visited a health care provider in the past year. The odds of utilization of counseling/cessation clinic, WHO-recommended medications, and quitline were significantly increased in participants who were advised to quit smoking. The results suggest that effective integration and implementation of advice to quit in tobacco control programs and the national health care systems may increase the use of cessation assistance to quit smoking.

Combined Smoking Cues Enhance Reactivity and Predict Immediate Subsequent Smoking

Introduction

Cue reactivity (CR) research has reliably demonstrated robust cue-induced responding among smokers exposed to common proximal smoking cues (eg, cigarettes, lighter). More recent work demonstrates that distal stimuli, most notably the actual environments in which smoking previously occurred, can also gain associative control over craving. In the real world, proximal cues always occur within an environment; thus, a more informative test of how cues affect smokers might be to present these two cue types simultaneously.

Methods

Using a combined-cue counterbalanced CR paradigm, the present study tested the impact of proximal (smoking and neutral) + personal environment (smoking and nonsmoking places) pictorial cues, on smokers' subjective and behavioral CR; as well as the extent to which cue-induced craving predicts immediate subsequent smoking in a within-subjects design.

Results

As anticipated, the dual smoking cue combination (ProxS + EnvS) led to the greatest cue-induced craving relative to the other three cue combinations (ProxS + EnvN, ProxN + EnvS, and ProxN ± EnvN), ps < .004. Dual smoking cues also led to significantly shorter post-trial latencies to smoke, ps < .01. Overall CR difference score (post-trial craving minus baseline craving) was predictive of subsequent immediate smoking indexed by: post-trial latency to smoke [B = -2.69, SE = 9.02; t(143) = -2.98, p = .003]; total puff volume [B = 2.99, SE = 1.13; t(143) = 2.65, p = .009]; and total number of puffs [B = .053, SE = .027; t(143) = 1.95, p = .05].

Conclusions

The implications of these findings for better understanding the impact of cues on smoking behavior and cessation are discussed.

Implications

This novel cue reactivity study examined smokers' reactivity to combined proximal and distal smoking cues. Exposure to a combination of two smoking cues (proximal and environment) led to the greatest increases in cue-induced craving and smoking behavior compared to all other cue combinations. Further, the overall magnitude of cue-induced craving was found to significantly predict immediate subsequent smoking. This work provides new insight on how exposure to various cues and cue combinations directly affect smokers' craving and actual smoking behavior, as well as the relationship between those two indices of reactivity.

Effects of time-varying changes in tobacco and alcohol use on depressive symptoms following pharmaco-behavioral treatment for smoking and heavy drinking

BACKGROUND

Complete abstinence from alcohol as well as smoking cessation have been shown to predict reductions in depressive symptoms over time. However, whether reducing alcohol use or smoking positively affect depressive symptoms has yet to be examined. The current study examined depressive symptoms as a function of time-varying changes in alcohol use and smoking status following a pharmaco-behavioral treatment addressing smoking cessation and alcohol reduction.

METHODS

Participants were heavy-drinking smokers (n = 150) followed for 26 weeks after their quit smoking date, with assessments of smoking, alcohol use, and depressive symptoms at baseline and 2, 8, 16, and 26 weeks.

RESULTS

Abstinence from smoking was associated with significantly lower depressive symptoms, as compared to little to no reduction in smoking (B = -6.1) as well as significant reductions in smoking (B = 4.01). Exploratory analyses, which excluded observations in which a participant was abstinent, revealed a significant effect of percent change in cigarettes smoked, modeled continuously, on depressive symptoms, (B = 4.39). By contrast, no differences were observed in depressive symptoms in relation to changes in alcohol use.

CONCLUSION

It appears that smoking abstinence is associated with improvements in depression as compared to any level of sustained or reduced use and that the magnitude of smoking reduction may be associated with lower depressive symptoms among those who did not quit successfully. If replicated, these findings may inform treatment for individuals for whom depression is a major barrier to cessation and who have been unable or are unwilling to be completely abstinent from smoking.

"They're thinking, well it's not as bad, I probably won't get addicted to that. But it's still got the nicotine in it, so…": Maturity, Control, and Socializing: Negotiating Identities in Relation to Smoking and Vaping-A Qualitative Study of Young Adults in Scotland

Objective

To explore the understandings of and engagement with e-cigarettes, of young adults from disadvantaged backgrounds, and how these may have an impact on existing smoking identities.

Methods

Twenty-two small group and 11 individual qualitative interviews were conducted in Central Scotland with 72 16-24 year olds between September 2015 and April 2016. Participants were mostly smokers and ex-smokers from socioeconomically disadvantaged backgrounds.

Results

Although most participants had tried e-cigarettes, they generally held ambivalent views about e-cigarettes and vaping. Two overarching themes were identified which helped in understanding this. Firstly, e-cigarettes were understood by the participants in relation to their existing smoking identities. Vaping was viewed as less controllable and more addictive than smoking, which did not fit with their self-identity as controlled smokers. Secondly, they felt that vaping could not replace the social and cultural importance that smoking had in their lives.

Conclusion

This study suggests that though young adults from disadvantaged areas are trying e-cigarettes for various reasons, vaping is rarely sustained. Through their own experiences of vaping and their observations of others vaping, the participants perceive the behavior as endangering an existing acceptable and controlled smoking identity. Additionally, e-cigarettes were considered to be a jarring presence in existing social situations where smoking was valued. This study, therefore, provides insights into how young adults may be rationalizing their continued smoking in the face of potentially less harmful alternatives.

Implications

As new and novel nicotine delivery devices, and due to their similarity to smoking, e-cigarettes have the potential to help smokers in their quit attempts. However, the findings from this study raise questions about whether e-cigarettes are regarded as having this potential by young adult smokers from disadvantaged socioeconomic environments where smoking is more commonplace and acceptable.

Contingency Management Versus Psychotherapy for Prenatal Smoking Cessation: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Prenatal smoking is the leading preventable cause of poor obstetric outcomes, yet treatment options are limited. Past reviews of prenatal smoking cessation have often grouped all counseling into a single category, which ignores the fact that psychotherapy is distinct from brief counseling. The objective of this study was to compare the effect sizes of two intensive interventions for prenatal smoking cessation: contingency management (i.e., financial incentives for abstinence) and psychotherapy.

METHODS

A systematic search for randomized controlled trials testing the efficacy of contingency management or psychotherapy was completed using PubMed, PsycINFO, Web of Science, the Cochrane Library, and EMBASE. Independent raters extracted data and assessed trials for risk of bias. Treatment effects were analyzed for three times points: late pregnancy, early postpartum, and late postpartum.

RESULTS

The search yielded 22 studies, and meta-analytic results indicated that interventions (compared with control groups) generally increased the odds of abstinence. Moderator analyses indicated that intervention type (contingency management vs. psychotherapy) accounted for variability in effect sizes. When comparing treatment type, effects of contingency management interventions were significantly greater than those of psychotherapeutic interventions. Although psychotherapy did not affect smoking abstinence, contingency management interventions had significant treatment effects at all three time points.

CONCLUSIONS

Contingency management seems to be a safe and efficacious prenatal smoking cessation treatment. Although psychotherapy alone did not show an effect on prenatal smoking abstinence, future research may seek to combine this approach with contingency management to promote prenatal smoking cessation.

A randomised trial of real-time video counselling for smoking cessation in regional and remote locations: study protocol

BACKGROUND

Real-time video communication technology (e.g. Skype) may be an effective mode for delivering smoking cessation treatment to regional and remote residents. This randomised trial examines the effectiveness of real-time video counselling compared to: 1) telephone counselling; and 2) written materials (control) in achieving smoking abstinence in regional and remote residents.

DESIGN

A three-arm, parallel group, randomised trial will be conducted with smokers residing in regional and remote areas of New South Wales, Australia. Potential participants will complete an online screening survey and if eligible an online baseline survey. Participants will be randomly allocated into: 1) real-time video counselling; 2) telephone counselling; or 3) written materials (control). In the video counselling intervention an advisor will deliver up to six video sessions (e.g. via Skype) to participants. Those who nominate a quit date within a month during the initial video session will be offered sessions on the quit date, 3-, 7-, 14- and 30-days after the quit date. Those not ready to set a quit date within a month during the initial video session will be offered sessions 2-, 4- and 6-weeks later. Other than delivery mode, the video counselling and telephone counselling will be identical in content and callback schedules. Control group participants will be mailed one-off written materials. Follow-up surveys will occur at 4-months, 7-months and 13-months post-baseline. The primary outcome will be 7-day point prevalence abstinence at 13-months post-baseline.

DISCUSSION

Real-time video counselling may be an effective strategy for smoking cessation that could be integrated into quitlines globally.

Role of smoking intention in tobacco use reduction: A mediation analysis of an effective classroom-based prevention/cessation intervention for adolescents

INTRODUCTION

Although some school-based tobacco cessation and prevention programs have been proven to be effective, there remains a lack of understanding of how these programs succeed.

METHODS

This longitudinal study aimed to test smoking intention as a mediator of Project EX's intervention efficacy to reduce tobacco use. Using a computerized random number generator, six high schools located in the Mediterranean coast were randomly selected to participate in the program condition (Spanish version of Project EX) or the waiting-list control group with baseline, immediate-posttest, and 12-month follow-up assessments. At baseline, 685 adolescents aged 14-20 years (mean age: 14.87; SD = 0.92; 47.4% were females) were evaluated using self-administered tests of tobacco, and smoking intention. A biomarker of smoke inhalation, a measurement of exhaled carbon monoxide (ECM), was used. Mediation analyses were conducted using the PROCESS v2.12 macro for Windows.

RESULTS

Project EX had a significant effect on smoking intention. Indirect effects indicated that Project EX reduced the ECM level, and number of cigarettes used.

CONCLUSIONS

This is the first Spanish study that explored intention as a mediator of the long-term efficacy of Project EX to reduce tobacco use in adolescents. Results suggested that interventions that reduce consumption intention at short-term are more likely to be successful in decreasing tobacco use in the long-term.

Sex differences in smoking constructs and abstinence: The explanatory role of smoking outcome expectancies

Scientific evidence suggests women experience more severe problems when attempting to quit smoking relative to men. Yet, little work has examined potential explanatory variables that maintain sex differences in clinically relevant smoking processes. Smoking outcome expectancies have demonstrated sex differences and associative relations with the smoking processes and behavior, including problems when attempting to quit, smoking-specific experiential avoidance, perceived barriers to quitting, and smoking abstinence. Thus, expectancies about the consequences of smoking may explain sex differences across these variables. Accordingly, the current study examined the explanatory role of smoking-outcome expectancies (e.g., long-term negative consequences, immediate negative consequences, sensory satisfaction, negative affect reduction, and appetite weight control) in models of sex differences across cessation-related problems, smoking-specific experiential avoidance, perceived barriers to quitting, and smoking abstinence. Participants included 450 (48.4% female; Mage = 37.45, SD = 13.50) treatment-seeking adult smokers. Results indicated that sex had an indirect effect on problems when attempting to quit smoking through immediate negative consequences and negative affect reduction expectancies; on smoking-specific experiential avoidance through long-term negative consequences, immediate negative consequences, and negative affect reduction expectancies; on barriers to quitting through negative affect reduction expectancies; and on abstinence through appetite weight control expectancies. The current findings suggest that sex differences in negative affect reduction expectancies and negative consequences expectancies may serve to maintain maladaptive smoking processes, whereas appetite weight control expectancies may promote short-term abstinence. These findings provide initial evidence for the conceptual role of smoking expectancies as potential "linking variables" for sex differences in smoking variables. (PsycINFO Database Record

Smokers' Understandings of Addiction to Nicotine and Tobacco: A Systematic Review and Interpretive Synthesis of Quantitative and Qualitative Research

Background

Despite the centrality of addiction in academic accounts of smoking, there is little research on smokers' beliefs about addiction to smoking, and the role of nicotine in tobacco dependence. Smokers' perspectives on nicotine's role in addiction are important given the increasing prevalence of nontobacco nicotine products such as e-cigarettes. We conducted a systematic review of studies investigating smokers' understandings and lay beliefs about addiction to smoking and nicotine.

Method

We searched PubMed, Embase, CINAHL, and PsycINFO for studies investigating lay beliefs about addiction to smoking. Twenty-two quantitative and 24 qualitative studies met inclusion criteria. Critical interpretive synthesis was used to analyze the results.

Results

Very few studies asked about addiction to nicotine. Quantitative studies that asked about addiction to smoking showed that most smokers believe that cigarettes are an addictive product, and that they are addicted to smoking. Across qualitative studies, nicotine was not often mentioned by participants. Addiction to smoking was most often characterized as a feeling of "need" for cigarettes resulting from an interplay between physical, mental, and social processes. Overall, we found that understandings of smoking were more consistent with the biopsychosocial model of addiction than with more recent models that emphasize the biological aspects of addiction.

Conclusion

Researchers should not treat perceptions of addiction to smoking interchangeably with perceptions of addiction to nicotine. More research on lay beliefs about nicotine is required, particularly considering the increasing use of e-cigarettes and their potential for long-term nicotine maintenance for harm reduction.

Implications

Quantitative studies show that most smokers believe that smoking is addictive and that they are addicted. A feeling of "need" for cigarettes was central to qualitative accounts of addiction, but nicotine was not often discussed. Overall, smokers' understandings of addiction reflect a biopsychosocial model rather than a neurobiological one. Given the growing market for e-cigarettes and therapeutic nicotine, more research is required on lay beliefs about nicotine and addiction.

Construct and Predictive Validity of Three Measures of Intention to Quit Smoking: Findings From the International Tobacco Control (ITC) Netherlands Survey

Introduction

The aim of the study was to compare the construct validity and the predictive validity of three instruments to measure intention to quit smoking: a Stages of Change measure, the Motivation To Stop Scale (MTSS), and a Likert scale. We used the Theory of Planned Behavior as theoretical framework.

Methods

We used data from the International Tobacco Control Netherlands Survey. We included smokers who participated in three consecutive survey waves (n = 980). We measured attitude, subjective norm, and perceived behavioral control in 2012, intention to quit with three instruments in 2013, and having made a quit attempt in the last year in 2014. We conducted Structural Equation Modeling with three models for the instruments of intention separately and with one model that included the three instruments simultaneously.

Results

All three instruments of intention were significantly and positively related to attitude and perceived behavioral control but none was related to subjective norm. All three instruments were significantly and positively related to making a quit attempt. The relation of the Likert scale with making a quit attempt (β = 0.38) was somewhat stronger than that of the Stages of Change measure (β = 0.35) and the MTSS (β = 0.22). When entering the three instruments together into one model, only the Likert scale was significantly related to making a quit attempt.

Conclusions

All three instruments showed reasonable construct validity and comparable predictive validity. Under the studied conditions, the Likert scale performed slightly better than the Stages of Change measure and the MTSS.

Implications

An assessment of the Stages of Change, the Motivation To Stop Scale, and a Likert scale showed comparable predictive and construct validity as measures for intention to quit smoking. All three instruments can be used in future research; however, under the studied theoretical framework, that is, the Theory of Planned Behavior, the Likert scale performed slightly better than the other two instruments.

[How does vaping products work]

To maximize the chances of replacing smoking with vaping, it is necessary to know the different types of existing devices, their characteristics and their most important settings as well as their influence on sensations. To support a user it is also important to understand the nature of the inhaled and exhaled vapor, as well as the possible mistakes that can lead to a less enjoyable experience. Highlighting e-liquids formulations and emissions can help understanding how a minimum of 95 % risk reduction compared to tobacco smoking is achieved and the influence of compounds on the user's experience. At last, a proper care, especially to refill the device and to change the resistance is the key to an effective use over time.

Management and Point-of-Care for Tobacco Dependence (PROMPT): a feasibility mixed methods community-based participatory action research project in Ottawa, Canada

OBJECTIVE

To determine the feasibility of a Community-Based Participatory Tobacco Dependence Strategy (PROMPT) in the inner city population of Ottawa (Canada).

DESIGN

A feasibility mixed methods prospective cohort study following principles of community-based participatory action research.

INTERVENTION

Recruited 80 people whouse drugs, followed them for 6 months while providing access to counselling, nicotine replacement therapy and peer-support in a community setting.

SETTING

Community research office in downtown Ottawa, adjacent to low-income housing, shelter services and street-based drug consumption.

PRIMARY OUTCOME

Retention rate at 6-month follow-up.

SECONDARY OUTCOME

Biochemically validated 7-day point prevalence smoking abstinence at 26 weeks, self-reported abstinence in the past 7 days with exhaled carbon monoxide ≤10 ppm.

RESULTS

The average age of participants was 43.8 years. The 6-month follow-up rate was 42.5%. The mean number of smoking years reported was 27.3 years. The participants were 70% male, 33.7% reported less than a high-school education, 21% identified as indigenous and 43.8% reported an income between US$1000 and US$1999 per month. The baseline mean daily cigarette use was 20.5 and 9.3 cigarettes at study end, with mean reduction of 11.2 cigarettes at 6 months (P=0.0001). There was a considerable reduction in self-reported illicit substance use (18.8%), including a reduction in the opioids heroin (6.3%), fentanyl (2.6%) and Oxycontin (3.8%). The study findings also reveal psycho-socioeconomic benefits such as improved health, return to work and greater community engagement.

CONCLUSIONS

The PROMPT project describes socioeconomic variables associated with tobacco and polysubstance use. A programme focused on tobacco dependence, easily accessible in the community and led by community peers with lived experience is feasible to implement and has the potential to support positive life changes. PROMPT's patient engagement model is an effective harm-reduction strategy for the growing opioid use crisis and can improve the health outcomes of marginalised at-risk populations worldwide.

Respiratory problems and anxiety sensitivity in smoking lapse among treatment seeking smokers

PURPOSE

The current study examined whether the interaction of lower respiratory symptoms and anxiety sensitivity is related to smoking lapse in the context of smoking cessation.

METHOD

Participants were adult daily smokers (N=60) exposed to the World Trade Center (WTC) disaster who were in a smoking cessation treatment program (75.0% male, 50.6years old [SD=9.2], and current smoking rate was 17.6 cigarettes per day (SD=10.6).

RESULTS

Results indicated that the interaction between lower respiratory symptoms and anxiety sensitivity was a significant predictor of greater risk for lapse (i.e., lower survival time; B=0.005, OR=1.01, p=0.039). Follow-up analysis showed that greater respiratory symptoms were a significant predictor of lapse risk among those with high (B=0.116, OR=1.12, p=0.025), but not those with low (B=-0.048, OR=0.95, p=0.322), levels of anxiety sensitivity.

DISCUSSION

The findings from the current study suggest that smokers with greater respiratory symptoms and higher levels of anxiety sensitivity may be associated with early lapse to smoking following smoking cessation treatment. Future work has the potential to inform the development of tailored cessation interventions for smokers who experience varying levels of lower respiratory symptoms and anxiety sensitivity.

Predictors of smoking cessation group treatment engagement among veterans with serious mental illness

High prevalence rates of tobacco use, particularly cigarettes, pose a serious health threat for individuals with serious mental illness (SMI), and research has demonstrated the effectiveness of pharmacotherapy and psychosocial interventions to reduce tobacco use in this group. However, few studies have considered predictors of tobacco cessation treatment engagement among individuals with SMI. The current study examined predictors of engagement in smoking cessation groups among veterans with SMI engaged in mental health services at three VA medical centers. All veterans were participating in a smoking cessation treatment study. Of 178 veterans who completed baseline assessments, 127 (83.6%) engaged in treatment, defined as attending at least three group sessions. Forty-one (N=41) predictors across five domains (demographics, psychiatric concerns, medical concerns, smoking history, and self-efficacy to quit smoking) were identified based on previous research and clinical expertise. Using backward elimination to determine a final multivariable logistic regression model, three predictors were found to be significantly related to treatment engagement: marital status (never-married individuals more likely to engage); previous engagement in group smoking cessation services; and greater severity of positive symptoms on the Brief Psychiatric Rating Scale. When included in the multivariable logistic regression model, the full model discriminates between engagers and non-engagers reasonably well (c statistic=0.73). Major considerations based on these findings are: individuals with SMI appear to be interested in smoking cessation services; and serious psychiatric symptomatology should not discourage treatment providers from encouraging engagement in smoking cessation services.

Contingency management interventions for tobacco and other substance use disorders in pregnancy

Contingency management (CM) is an effective intervention for reducing use of licit and illicit substances in a variety of populations. Pregnant women are a vulnerable population with much to gain from effective interventions for substance use disorders, and for whom CM interventions may be especially well-suited. We reviewed the literature on CM interventions among pregnant women with tobacco and other substance use disorders with 3 aims: (a) describe the effectiveness of CM for reducing use of tobacco and other substances during pregnancy, (b) describe the effects of CM interventions on infant outcomes, and (c) identify needs for future research on CM in pregnancy. Our search strategy revealed 27 primary studies of CM in pregnancy. CM was effective in the majority of studies targeting nicotine abstinence, and results were mixed in studies targeting illicit substances. A variety of methodologies were used within the relatively small number of studies making it difficult to identify underlying mechanisms. Also, very few studies reported maternal and infant outcomes, and significant effects of CM were only apparent when secondary analyses pooled data from multiple studies. Furthermore, there is extremely limited data on the cost effectiveness of CM interventions in pregnancy. Future research should address these 3 areas to better determine the ultimate value of CM as an efficacious treatment for pregnant women with substance use disorders. (PsycINFO Database Record

Online Vape Shop Customers Who Use E-Cigarettes Report Abstinence from Smoking and Improved Quality of Life, But a Substantial Minority Still Have Vaping-Related Health Concerns

(1) Background: Characteristics and usage patterns of vapers (e-cigarette users) have mainly been studied in web-based convenience samples or in visitors of brick-and-mortar vape shops. We extended this by targeting customers of one particular online vape shop in the Netherlands; (2) Methods: Customers were questioned on their smoking history, current smoking and vaping status, reasons for vaping, perceived harmfulness, and potential health changes due to vaping; (3) Results: Almost everyone (99%, 95% CI 0.96, 1.00) smoked before they started vaping. A great majority agreed that unlike with other smoking-cessation aids, they could quit smoking (81%, 95% CI 0.79, 0.90) due to vaping. Almost all customers were regular vapers (93.6%, 95% CI 0.89, 0.96) who used state-of-the-art open system devices without modifications and e-liquid with 10 mg/mL nicotine on average. Vapers reported using e-cigs to quit smoking, because e-cigs are healthier, and for financial reasons. The majority (52.6%, 95% CI 0.46, 0.60) perceived vaping as not that harmful to not harmful at all, but one fifth (21.8%, 95% CI 0.16, 0.28) believed vaping to be harmful. More than half (57.8%, 95% CI 0.50, 0.65) reported gaining more pleasure from vaping than from smoking. A substantial majority (84.2%, 95% CI 0.78, 0.89) agreed that their health had improved since they started vaping; (4) Conclusions: Findings are similar to those obtained in other vape shop studies, but also to the results of convenience samples of less-well-defined populations.

Tobacco control environment: cross-sectional survey of policy implementation, social unacceptability, knowledge of tobacco health harms and relationship to quit ratio in 17 low-income, middle-income and high-income countries

OBJECTIVES

This study examines in a cross-sectional study 'the tobacco control environment' including tobacco policy implementation and its association with quit ratio.

SETTING

545 communities from 17 high-income, upper-middle, low-middle and low-income countries (HIC, UMIC, LMIC, LIC) involved in the Environmental Profile of a Community's Health (EPOCH) study from 2009 to 2014.

PARTICIPANTS

Community audits and surveys of adults (35-70 years, n=12 953).

PRIMARY AND SECONDARY OUTCOME MEASURES

Summary scores of tobacco policy implementation (cost and availability of cigarettes, tobacco advertising, antismoking signage), social unacceptability and knowledge were associated with quit ratios (former vs ever smokers) using multilevel logistic regression models.

RESULTS

Average tobacco control policy score was greater in communities from HIC. Overall 56.1% (306/545) of communities had >2 outlets selling cigarettes and in 28.6% (154/539) there was access to cheap cigarettes (<5cents/cigarette) (3.2% (3/93) in HIC, 0% UMIC, 52.6% (90/171) LMIC and 40.4% (61/151) in LIC). Effective bans (no tobacco advertisements) were in 63.0% (341/541) of communities (81.7% HIC, 52.8% UMIC, 65.1% LMIC and 57.6% LIC). In 70.4% (379/538) of communities, >80% of participants disapproved youth smoking (95.7% HIC, 57.6% UMIC, 76.3% LMIC and 58.9% LIC). The average knowledge score was >80% in 48.4% of communities (94.6% HIC, 53.6% UMIC, 31.8% LMIC and 35.1% LIC). Summary scores of policy implementation, social unacceptability and knowledge were positively and significantly associated with quit ratio and the associations varied by gender, for example, communities in the highest quintile of the combined scores had 5.0 times the quit ratio in men (Odds ratio (OR) 5·0, 95% CI 3.4 to 7.4) and 4.1 times the quit ratio in women (OR 4.1, 95% CI 2.4 to 7.1).

CONCLUSIONS

This study suggests that more focus is needed on ensuring the tobacco control policy is actually implemented, particularly in LMICs. The gender-related differences in associations of policy, social unacceptability and knowledge suggest that different strategies to promoting quitting may need to be implemented in men compared to women.

Study protocol for a pragmatic randomised controlled trial evaluating efficacy of a smoking cessation e-'Tabac Info Service': ee-TIS trial

INTRODUCTION

A French national smoking cessation service, Tabac Info Service, has been developed to provide an adapted quitline and a web and mobile application involving personalised contacts (eg, questionnaires, advice, activities, messages) to support smoking cessation. This paper presents the study protocol of the evaluation of the application (e-intervention Tabac Info Service (e-TIS)). The primary objective is to assess the efficacy of e-TIS. The secondary objectives are to (1) describe efficacy variations with regard to users' characteristics, (2) analyse mechanisms and contextual conditions of e-TIS efficacy.

METHODS AND ANALYSES

The study design is a two-arm pragmatic randomised controlled trial including a process evaluation with at least 3000 participants randomised to the intervention or to the control arm (current practices). Inclusion criteria are: aged 18 years or over, current smoker, having completed the online consent forms, possessing a mobile phone with android or apple systems and using mobile applications, wanting to stop smoking sooner or later. The primary outcome is the point prevalence abstinence of 7 days at 6 months later. Data will be analysed in intention to treat (primary) and per protocol analyses. A logistic regression will be carried out to estimate an OR (95% CI) for efficacy. A multivariate multilevel analysis will explore the influence on results of patients' characteristics (sex, age, education and socioprofessional levels, dependency, motivation, quit experiences) and contextual factors, conditions of use, behaviour change techniques.

ETHICS AND DISSEMINATION

The study protocol was reviewed by the ethical and deontological institutional review board of the French Institute for Public Health Surveillance on 18 April 2016. The findings of this study will allow us to characterise the efficacy of e-TIS and conditions of its efficacy. These findings will be disseminated through peer-reviewed articles.

TRIAL REGISTRATION NUMBER

NCT02841683; Pre-results.

Electronic nicotine delivery systems and/or electronic non-nicotine delivery systems for tobacco smoking cessation or reduction: a systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis to investigate the impact of electronic nicotine delivery systems (ENDS) and/or electronic non-nicotine delivery systems (ENNDS) versus no smoking cessation aid, or alternative smoking cessation aids, in cigarette smokers on long-term tobacco use.

DATA SOURCES

Searches of MEDLINE, EMBASE, PsycInfo, CINAHL, CENTRAL and Web of Science up to December 2015.

STUDY SELECTION

Randomised controlled trials (RCTs) and prospective cohort studies.

DATA EXTRACTION

Three pairs of reviewers independently screened potentially eligible articles, extracted data from included studies on populations, interventions and outcomes and assessed their risk of bias. We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate overall certainty of the evidence by outcome.

DATA SYNTHESIS

Three randomised trials including 1007 participants and nine cohorts including 13 115 participants proved eligible. Results provided by only two RCTs suggest a possible increase in tobacco smoking cessation with ENDS in comparison with ENNDS (RR 2.03, 95% CI 0.94 to 4.38; p=0.07; I²=0%, risk difference (RD) 64/1000 over 6 to 12 months, low-certainty evidence). Results from cohort studies suggested a possible reduction in quit rates with use of ENDS compared with no use of ENDS (OR 0.74, 95% CI 0.55 to 1.00; p=0.051; I²=56%, very low certainty).

CONCLUSIONS

There is very limited evidence regarding the impact of ENDS or ENNDS on tobacco smoking cessation, reduction or adverse effects: data from RCTs are of low certainty and observational studies of very low certainty. The limitations of the cohort studies led us to a rating of very low-certainty evidence from which no credible inferences can be drawn. Lack of usefulness with regard to address the question of e-cigarettes' efficacy on smoking reduction and cessation was largely due to poor reporting. This review underlines the need to conduct well-designed trials measuring biochemically validated outcomes and adverse effects.

Impact of quitting smoking and smoking cessation treatment on substance use outcomes: An updated and narrative review

BACKGROUND

Historically, smoking cessation was thought to negatively impact substance use outcomes among smokers who use other substances. We sought to synthesize recent reports on this association.

METHODS

Google Scholar, PubMed, and Cinahl were searched for studies published from 2006 to March 29, 2016 that reported impact of smoking cessation treatment or quitting smoking on substance use or substance use disorder treatment outcomes in the general population and among those in substance abuse treatment. Studies were grouped by reported impact as follows: "positive" (i.e. improved), "null" (i.e. no change), or "negative" (i.e. worsened).

RESULTS

Twenty-four studies were included. Eighteen reported the impact of quitting smoking and six reported the impact of smoking cessation treatment intervention, independent of quitting, on substance use outcomes. Eleven studies (46%) reported solely positive impact; four (17%) reported solely null impact; eight (33%) reported mixed positive and null impact by analysis (combined and subgroup, n=1); substance (n=4); length of follow-up (n=2); and comparison group (n=1). One study (4%) reported mixed negative and null impact by ethnic group. No studies reported increased substance use.

CONCLUSION

Smoking cessation does not appear to have a negative effect, and often has a positive effect on substance use outcomes. Smoking cessation advice should be offered, without hesitation, to smokers who report substance use and those in treatment for substance use disorder.

National guidelines for smoking cessation in primary care: a literature review and evidence analysis

National guidelines for smoking cessation in primary care can be effective in improving clinical practice. This study assessed which parties are involved in the development of such guidelines worldwide, which national guidelines address primary care, what recommendations are made for primary care settings, and how these recommendations correlate with each other and with current evidence. We identified national guidelines using an online resource. Only the most recent version of a guideline was included. If an English version was not available, we requested a translation or summary of the recommendations from the authors. Two researchers independently extracted data on funding sources, development methodologies, involved parties, and recommendations made within the guidelines. These recommendations were categorised using the pile-sort method. Each recommendation was cross-checked with the latest evidence and was awarded an evidence-rating. We identified 43 guidelines from 39 countries and after exclusion, we analysed 26 guidelines (22 targeting general population, 4 targeted subpopulations). Twelve categories of recommendations for primary care were identified. There was almost universal agreement regarding the need to identify smokers, advice them to quit and offer behavioural and pharmacological quit smoking support. Discrepancies were greatest for specific recommendations regarding behavioural and pharmacological support, which are likely to be due to different interpretations of evidence and/or differences in contextual health environments. Based on these findings, we developed a universal checklist of guideline recommendations as a practice tool for primary care professionals and future guideline developers.

SMOKING CESSATION SUPPORT IN PRIMARY CARE

UNIVERSAL GUIDELINES SOUGHT: An international team call for a universal guideline for primary-care practitioners who help patients to stop smoking. Although many nations have such guidelines, no studies have examined whether these guidelines are consistent with the current evidence. Marjolein Verbiest at the National Institute for Health Innovation, The University of Auckland, New Zealand, and co-workers of the International Primary Care Respiratory Group and the National Centre for Smoking Cessation and Training reviewed, evaluated and compared 26 national guidelines. Almost all guidelines place importance on identifying smokers, advising them to quit and providing behavioural and medication-based support. However, there were discrepancies in the support offered, which could be due to different interpretations of evidence, costs of medication and cultural differences. The authors offer a checklist for primary care that can inform future universal guidelines suitable for primary care.

Relative reinforcing efficacy of cigarettes as a predictor of smoking abstinence among treatment-seeking smokers

RATIONALE

Relative reinforcing efficacy (RRE) is a core feature of behavioral economic theories of addiction. A measure of RRE in smokers is the cigarette purchase task (CPT). Only one previous study has assessed whether CPT indices predict treatment outcomes among smokers with substance use disorders (SUDs) who were not motivated to quit smoking, limiting the generalizability of the results.

OBJECTIVES

This study was aimed at exploring demand indices as predictors of smoking abstinence among participants receiving a cognitive behavioral treatment (CBT) combined with contingency management (CM) versus CBT alone. It also sought to validate the CPT as a measure of RRE.

METHODS

Participants were 159 (62.3 % women) smokers aged 44.8 (SD 12.6) years randomized to CBT alone or combined with CM. They smoked an average of 21.1 (SD 8.5) cigarettes per day, and their mean score on the Fagerström Test for Nicotine Dependence (FTND) was 5.5 (SD 1.9). Demand indices were generated from a hypothetical CPT assessed at baseline.

RESULTS

Smoking levels were high (≥20 cigarettes) at prices of up to €0.10 per cigarette. Elasticity was the only index that predicted smoking abstinence at the end of treatment, but only in the CBT + CM condition. The variance explained by elasticity was 6.8 % in the independent model and 4.6 % in the covariate model. Cigarette demand indices and smoking-related measures were significantly associated.

CONCLUSION

This is the first research showing that CPT is a valid measure of CM outcome among treatment-seeking smokers. This study also provides evidence of convergent validity for the CPT.

The Harmfulness of Alcohol and Tobacco Smoking in Cardiovascular Pathology and the Perspective of Spiritual Therapy

A holistic approach to the human person, from a somatic, psychological and spiritual point of view, with reference to the harmfulness of alcoholism and smoking in cardiovascular pathology, highlights several therapeutic variants over time. Among them are: the current somatic therapy, which could not offer optimal solution in eradicating this vice, and psychiatry which, using will power, could not solve man’s contradiction with himself, caused by a tempting and treacherous irrationality of senses, instinctive-affective desires, turned into vices, as a “Quasi altera natura”, devoid of any bright and creative horizon. As such we propose an alternative that entails changing one’s lifestyle to eliminate the harmful effect of alcoholism and smoking on cardiovascular pathology, through the perspective of spiritual therapy, accessible to contemporary society, at no cost and with no adverse events.

Re-starting smoking in the postpartum period after receiving a smoking cessation intervention: a systematic review

AIMS

In pregnant smoking cessation trial participants, to estimate (1) among women abstinent at the end of pregnancy, the proportion who re-start smoking at time-points afterwards (primary analysis) and (2) among all trial participants, the proportion smoking at the end of pregnancy and at selected time-points during the postpartum period (secondary analysis).

METHODS

Trials identified from two Cochrane reviews plus searches of Medline and EMBASE. Twenty-seven trials were included. The included trials were randomized or quasi-randomized trials of within-pregnancy cessation interventions given to smokers who reported abstinence both at end of pregnancy and at one or more defined time-points after birth. Outcomes were validated biochemically and self-reported continuous abstinence from smoking and 7-day point prevalence abstinence. The primary random-effects meta-analysis used longitudinal data to estimate mean pooled proportions of re-starting smoking; a secondary analysis used cross-sectional data to estimate the mean proportions smoking at different postpartum time-points. Subgroup analyses were performed on biochemically validated abstinence.

RESULTS

The pooled mean proportion re-starting at 6 months postpartum was 43% [95% confidence interval (CI) = 16-72%, I(2)  = 96.7%] (11 trials, 571 abstinent women). The pooled mean proportion smoking at the end of pregnancy was 87% (95% CI = 84-90%, I(2)  = 93.2%) and 94% (95% CI = 92-96%, I(2)  = 88%) at 6 months postpartum (23 trials, 9262 trial participants). Findings were similar when using biochemically validated abstinence.

CONCLUSIONS

In clinical trials of smoking cessation interventions during pregnancy only 13% are abstinent at term. Of these, 43% re-start by 6 months postpartum.