ABSTRACT
Aim To examine the efficacy and acceptability of online, interactive interventions for smoking cessation and to identify treatment effect moderators and mediators.
Methods A systematic ...review and meta‐analysis of the literature (1990–2008) was conducted, finding 11 relevant randomized controlled trials. Data were extracted and risk ratios and risk differences estimated with a random effects model.
Results There was no evidence of publication bias. Included trials were of variable methodological quality. Web‐based, tailored, interactive smoking cessation interventions were effective compared with untailored booklet or e‐mail interventions rate ratio (RR) 1.8; 95% confidence interval (CI) 1.4–2.3 increasing 6‐month abstinence by 17% (95% CI 12–21%). No overall effect of interactive compared with static web‐based interventions was detected but there was significant heterogeneity, with one study obtaining a clear effect and another failing to find one. Few moderating or mediating factors were evaluated in studies and those that were had little effect. Pooled results suggest that only interventions aimed at smokers motivated to quit were effective (RR 1.3, 95% CI 1.0–1.7). Fully automated interventions increased smoking cessation rates (RR 1.4, 95% CI 1.0–2.0), but evidence was less clear‐cut for non‐automated interventions. Overall, the web‐based interventions evaluated were considered to be acceptable and user satisfaction was generally high.
Conclusion Interactive, web‐based interventions for smoking cessation can be effective in aiding cessation. More research is needed to evaluate the relative efficacy of interactive web‐based interventions compared with static websites.
Rates of smoking and smoking cessation vary with socio-economic status. The objectives were to assess the association between neighbourhood deprivation, completion of treatment to support quit ...attempts and success of quit attempts-while taking into account other predictors of outcome.
555,744 quit attempts supported by English Stop Smoking Services in 2009-2012 were linked to the Index of Multiple Deprivation (IMD) 2010 ranks for the clients' neighbourhood and split into deciles relative to the national IMD. Logistic regressions tested the association between neighbourhood deprivation and completion (4-week follow-up) of treatment and biochemically validated success (expired-air carbon monoxide <10 ppm) while adjusting for demographics and intervention characteristics. Sensitivity analyses assessed subsamples: first supported attempts (n = 364,397), those with recorded cigarette dependence (n = 98,659) and completed treatment (n = 416,436).
Higher neighbourhood deprivation was associated with reduced completion (OR(adj) = 0.949, 95% CI: 0.947 to 0.951) and success (OR(adj) = 0.957, 95% CI: 0.955 to 0.959). Results of sensitivity analyses were consistent with those of the main analysis.
Neighbourhood deprivation was associated with small but consistent reductions in completion and success of evidence-based interventions. These associations were not explained by intervention characteristics, demographics or dependence and reduced completion did not fully account for reduced success.
Up-to-date data tracking of national smoking patterns and cessation-related behaviour is required to evaluate and inform tobacco control strategies. The Smoking Toolkit Study (STS) was designed for ...this role. This paper describes the methodology of the STS and examines as far as possible the representativeness of the samples.
The STS consists of monthly, cross sectional household interviews of adults aged 16 and over in England with smokers and recent ex-smokers in each monthly wave followed up by postal questionnaires three and six months later. Between November 2006 and December 2010 the baseline survey was completed by 90,568 participants. STS demographic, prevalence and cigarette consumption estimates are compared with those from the Health Survey for England (HSE) and the General Lifestyle Survey (GLF) for 2007-2009.
Smoking prevalence estimates of all the surveys were similar from 2008 onwards (e.g 2008 STS=22.0%, 95% C.I.=21.4% to 22.6%, HSE=21.7%, 95% C.I.=20.9% to 22.6%, GLF=20.8%, 95% C.I.=19.7% to 21.9%), although there was heterogeneity in 2007 (chi-square=50.30, p<0.001). Some differences were observed across surveys within sociodemographic sub-groups, although largely in 2007. Cigarette consumption was virtually identical in all surveys and years.
There is reason to believe that the STS findings (see http://www.smokinginengland.info) are generalisable to the adult population of England.
ObjectivesTo determine whether England's smoke-free legislation, introduced on 1 July 2007, influenced intentions and attempts to stop smoking.Design and settingNational household surveys conducted ...in England between January 2007 and December 2008. The sample was weighted to match census data on demographics and included 10 560 adults aged 16 or over who reported having smoked within the past year.ResultsA greater percentage of smokers reported making a quit attempt in July and August 2007 (8.6%, n=82) compared with July and August 2008 (5.7%, n=48) (Fisher's exact=0.022); there was no significant difference in the number of quit attempts made at other times in 2007 compared with 2008. In the 5 months following the introduction of the legislation 19% (n=75) of smokers making a quit attempt reported that they had done so in response to the legislation. There were no significant differences in these quit attempts with regard to gender, social grade or cigarette consumption; there was however a significant linear trend with increasing age (χ2=7.755, df=1, p<0.005). The prevalence of respondents planning to quit before the ban came into force decreased over time, while those who planned to quit when the ban came into force increased as the ban drew closer.ConclusionEngland's smoke-free legislation was associated with a significant temporary increase in the percentage of smokers attempting to stop, equivalent to over 300 000 additional smokers trying to quit. As a prompt to quitting the ban appears to have been equally effective across all social grades.
Following the recommendation of lung cancer screening in the US, screening committees in several European countries are reviewing the evidence for implementing national programmes. However, ...inadequate participation from high-risk groups poses a potential barrier to its effectiveness. The present study examined interest in a national lung cancer screening programme and modifiable attitudinal factors that may affect participation by smokers.
A population-based survey of English adults (n = 1464; aged 50-70 years) investigated screening intentions in different invitation scenarios, beliefs about lung cancer, early detection and treatment, worry about lung cancer risk, and stigma. Data on smoking status and perceived chances of quitting were also collected, but eligibility for lung screening in the event of a national programme was unknown.
Intentions to be screened were high in all three invitation scenarios for both current (≥ 89%) and former (≥ 94%) smokers. However, smokers were less likely to agree that early-stage survival is good (43% vs. 53%; OR: 0.64, 0.46-0.88) or be willing to have surgery for an early stage, screen-detected cancer (84% vs. 94%; OR: 0.38, 0.21-0.68), compared with former smokers. Willingness to have surgery was positively associated with screening intentions; with absolute differences of 25% and 29%. Worry about lung cancer risk was also most common among smokers (48%), and one fifth of respondents thought screening smokers was a waste of NHS money.
A national lung cancer screening programme would be well-received in principle. To improve smokers' participation, care should be taken to communicate the survival benefits of early-stage diagnosis, address concerns about surgery, and minimise anxiety and stigma related to lung cancer risk.
Despite cigarette-like adverse health outcomes associated with waterpipe tobacco smoking and increase in its use among youth, it is a much underexplored research area. We aimed to measure the ...prevalence and patterns of waterpipe tobacco use and evaluate tobacco control policy with respect to waterpipe tobacco, in several universities across the UK. We also aimed to measure stop smoking practitioners' encounter of waterpipe tobacco smoking.
We distributed an online survey to six UK universities, asking detailed questions on waterpipe tobacco. Multivariable logistic regression models, adjusted for age, gender, ethnicity, graduate status, university and socioeconomic status (SES) assessed associations between waterpipe tobacco smoking (single use and dual use with cigarettes) and sociodemographic variables. SES was ascertained by average weekly self-spend on non-essentials. We also descriptively analysed data from a 2012 survey of stop smoking practitioners to assess the proportion of clients that used waterpipe regularly.
f 2217 student responses, 66.0% (95% CI 63.9-68.0%) had tried waterpipe tobacco smoking; 14.3% (95% CI 12.8-15.8%) reported past-30 day use, and 8.7% (95% CI 7.6-9.9%) reported at least monthly users. Past-30 day waterpipe-only use was associated with being younger (AOR 0.95, 95% CI 0.91-0.99), male (AOR 1.44, 95% CI 1.08-1.94), higher SES (AOR 1.16, 95% CI 1.06-1.28) and belonging to non-white ethnicities (vs. white, AOR 2.24, 95% CI 1.66-3.04). Compared to less than monthly users, monthly users were significantly more likely to have urges to smoke waterpipe (28.1% vs. 3.1%, p<0.001) report difficulty in quitting (15.5% vs. 0.8%, p<0.001), report feeling guilty, and annoyed when criticised about waterpipe smoking (19.2% vs. 9.2%, p<0.001). Nearly a third (32.5%) of respondents who had tried waterpipe had violated the UK smokefree law and a quarter (24.5%) reporting seeing health warnings on waterpipe tobacco packaging or apparatuses. Of 1,282 smoking cessation practitioners, a quarter (23.4%, 95% CI 21.5-26.1%) reported having some clients who regularly use waterpipes, but 69.5% (95% CI 67.0-72.0%) never ask clients about waterpipe use. Three quarters (74.8%, 95% CI 72.4-77.1%) want more information about waterpipe tobacco smoking.
While two thirds of university students have ever tried waterpipe tobacco, at least monthly use is less common. Regular users display features of waterpipe tobacco dependence, and a substantial minority of SSS practitioners encounter clients who regularly use waterpipe. The lack of training on waterpipe for SSS practitioners and reported violations of smokefree laws for waterpipe highlight the need for regular surveillance of and a coordinated tobacco control strategy for waterpipe use.
NHS Stop Smoking Services (SSSs) provide free at the point of use treatment for smokers who would like to stop. Since their inception in 1999 they have evolved to offer a variety of support options. ...Given the changes that have happened in the provision of services and the ongoing need for evidence on effectiveness, the Evaluating Long-term Outcomes for NHS Stop Smoking Services (ELONS) study was commissioned.
The main aim of the study was to explore the factors that determine longer-term abstinence from smoking following intervention by SSSs. There were also a number of additional objectives.
The ELONS study was an observational study with two main stages: secondary analysis of routine data collected by SSSs and a prospective cohort study of service clients. The prospective study had additional elements on client satisfaction, well-being and longer-term nicotine replacement therapy (NRT) use.
The setting for the study was SSSs in England. For the secondary analysis, routine data from 49 services were obtained. For the prospective study and its added elements, nine services were involved. The target population was clients of these services.
There were 202,804 cases included in secondary analysis and 3075 in the prospective study.
A combination of behavioural support and stop smoking medication delivered by SSS practitioners.
Abstinence from smoking at 4 and 52 weeks after setting a quit date, validated by a carbon monoxide (CO) breath test.
Just over 4 in 10 smokers (41%) recruited to the prospective study were biochemically validated as abstinent from smoking at 4 weeks (which was broadly comparable with findings from the secondary analysis of routine service data, where self-reported 4-week quit rates were 48%, falling to 34% when biochemical validation had occurred). At the 1-year follow-up, 8% of prospective study clients were CO validated as abstinent from smoking. Clients who received specialist one-to-one behavioural support were twice as likely to have remained abstinent than those who were seen by a general practitioner (GP) practice and pharmacy providers odds ratio (OR) 2.3, 95% confidence interval (CI) 1.2 to 4.6. Clients who received group behavioural support (either closed or rolling groups) were three times more likely to stop smoking than those who were seen by a GP practice or pharmacy providers (OR 3.4, 95% CI 1.7 to 6.7). Satisfaction with services was high and well-being at baseline was found to be a predictor of abstinence from smoking at longer-term follow-up. Continued use of NRT at 1 year was rare, but no evidence of harm from longer-term use was identified from the data collected.
Stop Smoking Services in England are effective in helping smokers to move away from tobacco use. Using the 52-week CO-validated quit rate of 8% found in this study, we estimate that in the year 2012-13 the services supported 36,249 clients to become non-smokers for the remainder of their lives. This is a substantial figure and provides one indicator of the ongoing value of the treatment that the services provide. The study raises a number of issues for future research including (1) examining the role of electronic cigarettes (e-cigarettes) in smoking cessation for service clients this study did not look at e-cigarette use (except briefly in the longer-term NRT study) but this is a priority for future studies; (2) more detailed comparisons of rolling groups with other forms of behavioural support; (3) further exploration of the role of practitioner knowledge, skills and use of effective behaviour change techniques in supporting service clients to stop smoking; (4) surveillance of the impact of structural and funding changes on the future development and sustainability of SSSs; and (5) more detailed analysis of well-being over time between those who successfully stop smoking and those who relapse. Further research on longer-term use of non-combustible nicotine products that measures a wider array of biomarkers of smoking-related harm such as lung function tests or carcinogen metabolites.
The National Institute for Health Research Health Technology Assessment programme. The UK Centre for Tobacco and Alcohol Studies provided funding for the longer-term NRT study.
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.
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.
Physician adherence to guideline recommendations regarding the provision of counseling and support for smokers willing to quit is low. A lack of training during undergraduate medical education has ...been identified as a potential cause. This prospective intervention study evaluated a novel teaching module for medical students.
As part of a 6-week cardiovascular course, 125 fourth-year undergraduate medical students received a multimodal and interactive teaching module on smoking cessation, including online learning material, lectures, seminars, and practical skills training. Short- and medium-term effects on knowledge, skills, attitudes, and self-reported practice were measured using written examinations and an objective structured clinical examination at the end of the module and 6 months later. Results were compared to data obtained from a historical control cohort (n = 70) unexposed to the intervention.
At the 6-month follow-up, scores in the knowledge test were significantly higher in the intervention than the control group (61.1% vs. 51.7%; p < .001). A similar pattern was observed in the objective structured clinical examination (71.5% vs. 60.5%; p < .001). More students in the intervention than control group agreed that smoking was a chronic disease (83.1% vs. 68.1%; p = .045). The control group was more likely to report recording smoking status (p = .018), but no group difference was detected regarding the report of advising to quit (p = .154).
A novel teaching module for undergraduate medical students produced a sustained learning outcome in terms of knowledge, skills, and attitudes but not self-reported practice.
Studies across the world have identified considerable knowledge gaps and deficits in practical training with regard to smoking cessation counseling in undergraduate medical students. This paper describes a teaching intervention informed by current recommendations for the design of educational activities aimed at enabling medical students to deliver adequate behavior change counseling. The teaching module was tailored to the needs of a specific healthcare system. Given its effectiveness as demonstrated in this prospective study, a rollout of this intervention in medical schools might have the potential to substantially improve medical students' knowledge, skills, and attitudes in relation to smoking cessation counseling.
Rationale
It is widely believed that nicotine withdrawal symptoms appear within a few hours of stopping smoking, but few data exist documenting their emergence in naturalistic settings. In several ...countries, nicotine replacement products are licensed for relief of withdrawal symptoms during temporary abstinence, but again, there are no data supporting this from naturalistic settings.
Objectives
To examine the emergence of cigarette craving and withdrawal symptoms during temporary abstinence in a naturalistic setting while using either nicotine or placebo gum.
Methods
Double-blind, randomised, placebo-controlled study in which 132 dependent smokers abstained for 6 h with the assistance of either nicotine (2 mg,
n
= 42 or 4 mg,
n
= 24) or placebo (
n
= 66) gum while travelling on a non-smoking train. Outcome measures were ratings of craving and mood withdrawal symptoms prior to treatment and at regular intervals during abstinence.
Results
In a multivariate analysis of all symptoms, there was no interaction between treatment and time
F
(21,110) = 1.28,
p
= 0.20,
= 0.20 nor an effect of treatment
F
(7,124) = 0.45,
p
= 0.87,
= 0.03. There was an effect of time
F
(21,110) = 11.59,
p
< 0.001,
= 0.69) and univariate analyses revealed that the majority of symptoms increased linearly throughout the period of abstinence with detectable onsets typically between the first 60 and 180 min of abstinence.
Conclusions
Smokers who temporarily abstain in naturalistic settings experience craving and withdrawal symptoms that emerge linearly over the first 6 h of abstinence. Changes in craving and several mood withdrawal symptoms can be detected within the first 3 h. Nicotine gum may not have an acute effect on the development of these symptoms.
PDF
