Smoking cessation: what have we learned over the past decade?

This article discusses developments in understanding smoking and smoking cessation, methodological issues, and intervention approaches over the past 10 years. Although effective multisession clinic interventions have been developed, such programs reach relatively few smokers. This has led to self-help, work site, health care setting, and community interventions aimed at delivering less intensive programs to larger populations. Conceptual and empirical developments and trends within these above delivery contexts are reviewed, and avenues of research are identified. Nicotine replacement strategies have benefited from technological advances (e.g., transdermal patches) and present continuing challenges with respect to integration with behavioral strategies and incorporation into primary care medical settings. Research over the next decade should focus on the development of cost-effective interventions that can reach representative and high-risk smokers.     

Smoking cessation 2: behavioral treatments

The authors' purpose of this portion of a 3-part review of interventions for tobacco dependence is to present evidence regarding the efficacy of behavioral treatments for smoking cessation. The present review includes evidence evaluated in the Treating Tobacco Use and Dependence Clinical Practice Guideline (the Guideline) (MC Fiore, WC Bailey, SJ Cohen, et al, 2000) as well as evidence published subsequent to the Guideline. A wide range of effective behavioral treatments for smoking cessation is available. These interventions come in a variety of formats and intensities, can be used by all types of clinicians in a variety of settings, and are appropriate for different types of smokers. The authors have organized recommendations in 2 broad domains that account for much of the variability across behavioral interventions, treatment content, and structure. Finally, the authors discuss key directions for future research.     

Relapse to smoking

Relapse is by far the most likely outcome of any smoking cessation attempt, even those made with the benefit intensive psychosocial treatment and pharmacotherapy. The present article briefly reviews the epidemiology of smoking and self-quitting, the outcome data for major forms of behavioral and pharmacologic smoking cessation treatments, and what is known about the natural history of relapse and recovery among treated smokers. A recent trend in smoking relapse research has been to study the dynamics of key motivational processes, such as withdrawal symptoms, negative affect, and craving, in the laboratory and in smokers' natural environments. This literature is also briefly reviewed, with an emphasis on how such investigations may reveal the limitations of current cessation treatments. Finally, three significant research themes that are likely to be important in future relapse research are highlighted--the possible "hardening" of the smoking population, the potential for developmental research to deepen our understanding of smoking motivation, and the promise of molecular genetic studies for advancing treatment and our understanding of relapse.     

Smoking cessation 1: pharmacological treatments

In part 1 of this 3-part review of interventions for tobacco dependence, the authors present evidence regarding the efficacy of pharmacological treatments for smoking cessation. They also present evidence and recommendations included in the U.S. Department of Health and Human Services Treating Tobacco Use and Dependence: Clinical Practice Guideline (the Guideline), evidence from studies published after the Guideline, and recommendations of their own. The authors review nicotine replacement therapies, antidepressants, and other pharmacotherapies, followed by pharmacological treatments for special populations. The evidence indicates that a variety of effective smoking cessation medications are available. First-line medications include nicotine replacement therapies and bupropion. Pharmacotherapy is a vital component of smoking cessation interventions and should be offered to all smokers who want to quit unless contraindicated. There is a need for further research on pharmacotherapies for smoking cessation, and the authors discuss key areas for future research.     

Attitudes and practices of African-American women regarding cigarette smoking: implications for interventions.

It has been projected that beyond 1995, African-American women will have the highest prevalence of tobacco smoking. This study, therefore, was undertaken to explore the beliefs, attitudes, and practices among African Americans regarding tobacco smoking so as to design more culturally appropriate smoking cessation interventions. Focus group discussions were conducted with 42 African-American women (31 ever smokers and 11 never smoked) exploring in-depth: 1) knowledge of the health consequences of smoking, 2) attitudes about the acceptability of smoking and personal reasons for smoking, 3) smoking practices, and 4) opinions about the necessary components of smoking cessation programs. Compared with nonsmokers, current smokers have not yet personalized the distant threat of smoking due to the very powerful immediate benefit obtained from the nicotine present in tobacco--the decrease in anxiety, tension, and depression, ie, "stress reduction." There is also a perception of powerful barriers to smoking cessation, ie, no internal mechanisms for stress modulation. Smoking cessation intervention programs must have culturally proficient psychoeducational components to address the cognitive and behavioral dysfunction associated with smoking. For those smokers with evidence of difficulty modulating dysphoria or tension, they also must address the possible underlying biochemical dysregulation.     

Teaching Brief Interventions for Smoking Cessation via an Interactive Computer-based Tutorial

Many current smokers do not plan on quitting any time soon. For these smokers, the immediate treatment goal is not a quit attempt, but an increase in readiness to stop smoking. In the present study we developed an interactive multimedia simulation and tutoring environment that teaches healthcare professionals to provide brief motivational interviewing-based smoking cessation interventions tailored to the patient's current readiness to change. This tutorial utilizes a cognitive science-derived learning approach that provides tailored feedback and lessons based on learners' pre-existing knowledge, is highly interactive and allows learners to practice skills in simulated clinical situations. Results from two pilot studies indicate that healthcare professionals and students found the software easy and enjoyable to use and successfully learned MI-based strategies for smoking cessation.     

A review of smoking cessation interventions for smokers aged 50 and older

Objectives

Cigarette smoking poses substantial health risks at any age, but is particularly dangerous for older smokers, who are already at heightened risk for various health conditions. Studies suggest that older smokers are motivated to quit and succeed, but few of these have been randomized controlled trials. There is a need to systematically evaluate the research on effective interventions in older smokers.

Methods

We followed PRISMA guidelines in the development of this systematic review, which included randomized controlled trials of cessation interventions with smokers aged 50 or older.

Results

We found 740 unique titles matching specified search criteria; 13 met final eligibility criteria. Nearly all the cessation treatments combined counseling with other strategies. Eight studies provided smoking cessation medications. None of the studies used newer forms of technology such as web- or text-based interventions. Nine of the 13 studies reported a significant intervention effect at one or more time points, with three studies reporting sustained treatment effects at 12 mos or longer. In general, more intensive interventions and those with combined approaches including medications and follow-up counseling achieved the best outcomes.

Conclusion

The quit rates from these studies and the relative effectiveness of different intervention approaches are consistent with the general smoking cessation literature. However, in most studies, treatment effects were of short duration, and absolute quit rates were low, leaving the vast majority of older smokers at high risk for smoking-related health conditions. This systematic review suggests a need for additional research to design and test future interventions specifically tailored for older smokers.     

Efficacy of forced smoking cessation and an adjunctive behavioral treatment on long-term smoking rates

This study evaluated the efficacy of a 6-week forced ban on smoking and brief behavioral counseling on long-term smoking rates. Participants were active-duty enrollees in U.S. Air Force basic military training over a 1-year period (N = 25,996). All participants were under a 6-week ban from tobacco products, and 75% were randomized to a brief smoking cessation intervention, with the other 25% randomized to a control condition. At 1-year follow-up, 18% of smokers were abstinent; women, ethnic minorities, and those intending to stay quit at baseline were more likely to be abstinent. Among smokers not planning to remain abstinent at baseline, those receiving the intervention were 1.73 times more likely to be abstinent. Over time, substantial smoking initiation occurred among nonsmokers (8% of never smokers, 26% of experimental smokers, and 43% of ex-smokers). Forced cessation is associated with good levels of long-term cessation, and brief behavioral interventions enhance cessation in certain subgroups.     

Fluoxetine, smoking, and history of major depression: A randomized controlled trial

The study was a randomized placebo-controlled trial testing whether fluoxetine selectively enhances cessation for smokers with a history of depression. Euthymic smokers with (H+, n = 109) or without (H-, n = 138) a history of major depression received 60 mg fluoxetine or placebo plus group behavioral quit-smoking treatment for 12 weeks. Fluoxetine initially enhanced cessation for H+ smokers (p = .02) but subsequently impaired cessation regardless of depressive history. Six months after quit date, fluoxetine-treated participants were 3.3 times more likely to be smoking (p = .02). Further research is warranted to determine why high-dose fluoxetine produces continuing effects that oppose tobacco abstinence.     

Influences of gender and weight gain on short-term relapse to smoking in a cessation trial

Few researchers have studied whether weight gain has an impact on short-term relapse to smoking. The authors of this study investigated predictors of relapse among 989 participants (60% women) in a randomized, double-blind, 10-week multicenter trial to determine the effect of fluoxetine (30 or 60 mg) versus placebo in combination with behavioral counseling for smoking cessation. Medication compliance and smoking status were biochemically verified. At Visit 2, participants were asked to set a quit date within the subsequent 2 visits. A proportional hazards regression model was used to predict risk of relapse within the first 3 months of quitting. Weight gain predicted relapse, but for men only. Female gender also predicted relapse. The results led the authors to question whether postcessation weight gain interventions should be restricted to women smokers.     

Distress tolerance and early smoking lapse

A significant percentage of smokers attempting cessation lapse to smoking within a matter of days and very few of these individuals recover to achieve abstinence. Current models of relapse devote insufficient attention to this phenomenon of early smoking lapse. Furthermore, studies attempting to relate severity of nicotine withdrawal symptoms to short-term smoking cessation outcomes have yielded equivocal results. The authors argue that how one reacts to the discomfort of nicotine withdrawal is a more promising avenue of investigation than severity of withdrawal and that inability to tolerate the distress of nicotine withdrawal and associated negative affect is a key factor in early smoking lapse and subsequent relapse. Theoretical and clinical implications of distress tolerance in smoking cessation are discussed and the development of a specialized and novel behavioral distress tolerance treatment for early smoking lapsers is proposed.     

Computer-tailored smoking cessation materials: a review and discussion

Tailored smoking cessation materials combine many of the interactive, diagnostic elements of a clinical encounter with the dissemination potential of mass media. In this article, the differences between general, targeted and tailored smoking cessation materials are discussed, and the impact of tailored versus the general or targeted modalities is examined. A review of ten randomized trials of tailored materials found a significant impact of these materials in a majority of the studies. Very few patterns, in terms of the characteristics associated with the tailored materials, subject recruitment, subject characteristics, or follow-up procedures were found when comparing positive versus negative trials. The two trials that combined tailored materials with nicotine replacement therapy found a strong impact on smoking cessation; studies that examine the combined effects of tailored behavioral and pharmacological interventions are suggested. Another notable finding was the effect tailored materials had among precontemplators. Most studies that included precontemplators found a significant positive impact of materials tailored to this group. Taken together, these findings suggest important new avenues for reaching smokers.     

Internet-based smoking cessation programs

OBJECTIVE: To present a smoking cessation website and a reflection on the use of the Internet as a smoking cessation tool. METHODS: A literature review and an Internet survey in 1506 current and former smokers. RESULTS: The Internet may be the only form of smoking cessation support available to many smokers. There is a competition between hundreds of smoking cessation websites, many of which have a similar content. Smoking cessation websites are popular, but little scientific evidence is available on their efficacy. Neither do we know which components of these websites are most effective in motivating and helping smokers quit smoking and avoid relapse. Groups of current and former smokers form spontaneously in discussion forums on the Internet, this is a new feature in the field of addiction treatment. These discussion forums have not yet been the object of much scientific research. CONCLUSION: Research should be conducted to assess the efficacy of smoking cessation website, to identify which of their components are most effective, and to identify subgroups of current and former smokers for whom websites are most effective.     

Smoking, cortisol and nicotine.

Cigarette smoking is associated acutely with elevated cortisol levels. However, the results of comparisons of cortisol levels in smokers and non-smokers have been inconsistent, and the significance of cortisol responses in smoking cessation is unclear. Here we describe one study comparing the cortisol profiles of smokers and nonsmokers over the day, and a second investigation in which cortisol was monitored during smoking cessation. In the first study, we collected saliva samples from 196 middle-aged men and women on working and weekend days repeatedly through the day. On both working and weekend days, cortisol levels were significantly higher in smokers after adjustment for age, gender and grade of employment. Cortisol responses to waking (the increase between waking and 30 min) were also greater in smokers. The elevation in cortisol among smokers is generally attributed to nicotine exposure. Nicotine replacement therapy substantially improves abstinence rates, and has become a standard component of smoking cessation treatments, but the effects of nicotine replacement on cortisol are not known. In the second study, cortisol was monitored over 6 weeks of abstinence in 112 smokers treated with behavioural support and 15 mg nicotine patches. Smoking cessation was accompanied by an abrupt decrease in salivary cortisol, and this was sustained over the abstinence period. There was a marginal association between the decrease in cortisol and smoking relapse rates. These results suggest that the nicotine supplied through patches was not sufficient to block the cortisol reduction following smoking cessation. The contribution of these findings to understanding the role of neuroendocrine function in smoking is described.     

The influence of situation and coping on relapse crisis outcomes after smoking cessation

Examines the influence of situational characteristics and coping on the outcome of a relapse crisis for 232 Ss followed for 1 month after a self-initiated smoking cessation attempt. Survival of a relapse crisis was most strongly related to the number of coping strategies used. All coping strategies were equally effective; furthermore, combining cognitive and behavioral coping strategies was not more effective than using multiple cognitive or multiple behavioral strategies. During the second half of the follow-up period (Weeks 3 and 4 postcessation), the presence of smokers resulted in a decreased likelihood of coping and an increased likelihood of smoking. In addition, active coping was marginally related to higher baseline levels of motivation to quit. When motivation and the presence of smokers were controlled, however, coping still significantly predicted outcome. Results are discussed with reference to previous relapse studies.     

Self-administered treatment for smoking cessation

Self-administered treatment for smoking cessation has the potential to reach a broad spectrum of the population of smokers. This article focuses on self-administration of behavioral and pharmacological treatments for smoking cessation. Evidence for the effectiveness of written manuals to self-administer behavioral treatment is mixed. There is no evidence that self-help manuals alone are effective. However, they do increase quit rates when combined with personalized adjuncts such as written feedback and outreach telephone counseling. Efficacy trials of first-line pharmacotherapies (nicotine gum, nicotine patch, and bupropion) result in doubling of cessation rates compared to placebo. It is difficult to evaluate the effectiveness of pharmacotherapies when self-administered under real-world conditions. The general consensus is that they improve quit rates, although poor compliance and early discontinuation reduce their effectiveness. Areas for further research include randomized trials of the use of new technologies (e.g., hand-held computers and the Internet) to disseminate self-administered treatments as well as improved surveillance of the use of self-administered treatment in population-based health surveys.     

Prevalence and Frequency of mHealth and eHealth Use Among US and UK Smokers and Differences by Motivation to Quit

BackgroundBoth mHealth and eHealth interventions for smoking cessation are rapidly being developed and tested. There are no data on use of mHealth and eHealth technologies by smokers in general or by smokers who are not motivated to quit smoking.ObjectiveThe aims of our study were to (1) assess technology use (eg, texting, social media, Internet) among smokers in the United States and United Kingdom, (2) examine whether technology use differs between smokers who are motivated to quit and smokers who are not motivated to quit, (3) examine previous use of technology to assist with smoking cessation, and (4) examine future intentions to use technology to assist with smoking cessation.MethodsParticipants were 1000 adult smokers (54.90%, 549/1000 female; mean age 43.9, SD 15.5 years; US: n=500, UK: n=500) who were recruited via online representative sampling strategies. Data were collected online and included demographics, smoking history, and frequency and patterns of technology use.ResultsAmong smokers in general, there was a high prevalence of mobile and smartphone ownership, sending and receiving texts, downloading and using apps, using Facebook, and visiting health-related websites. Smokers who were unmotivated to quit were significantly less likely to own a smartphone or handheld device that connects to the Internet than smokers motivated to quit. There was a significantly lower prevalence of sending text messages among US smokers unmotivated to quit (78.2%, 179/229) versus smokers motivated to quit (95.0%, 229/241), but no significant differences between the UK groups (motivated: 96.4%, 239/248; unmotivated: 94.9%, 223/235). Smokers unmotivated to quit in both countries were significantly less likely to use a handheld device to read email, play games, browse the Web, or visit health-related websites versus smokers motivated to quit. US smokers had a high prevalence of app downloads regardless of motivation to quit, but UK smokers who were motivated to quit had greater prevalence of app downloads than smokers unmotivated to quit. US smokers were significantly more likely to have a Facebook account (87.0%, 435/500) than UK smokers (76.4%, 382/500), but smokers unmotivated to quit in both countries used Facebook less frequently than smokers motivated to quit. Smokers who were unmotivated to quit were less likely to have used eHealth or mHealth platforms to help them quit smoking in the past and less likely to say that they would use them for smoking cessation in the future.ConclusionsAlthough smokers unmotivated to quit make less use of technology than smokers motivated to quit, there is sufficient prevalence to make it worthwhile to develop eHealth and mHealth interventions to encourage cessation. Short and low-effort communications, such as text messaging, might be better for smokers who are less motivated to quit. Multiple channels may be required to reach unmotivated smokers.     

Prevalence and correlates of tobacco use among Russian cancer patients: Implications for the development of smoking cessation interventions at a cancer center in Russia

This study examined the rate of smoking among 399 cancer patients in Russia and assessed correlates of tobacco use and readiness to quit smoking. The results indicated that (a) 41.6% of patients were smokers; and (b) smokers were likely to be male, have lung or colorectal cancer, exhibit low levels of knowledge concerning the negative effects of smoking, report a low level of advantages to quitting smoking and a high level of disadvantages to quitting smoking, show low perceived risk for the adverse effects of smoking, and exhibit high fatalistic beliefs. Though certain findings converge well with data collected from U.S. samples of cancer patients, these results can guide the development of smoking interventions that address the specific needs of Russian cancer patients. In sum, this study fills a critical gap in knowledge concerning the epidemic of tobacco use in Russia and broadens research regarding tobacco use by cancer patients from the United States to the Russian Federation. Support for this study was provided by National Institutes of Health grant CA95678 (R. Schnoll) and by a U.S. federal appropriation to the American-Russian Cancer Alliance.     

Addressing tobacco use disorder in smokers in early remission from alcohol dependence: The case for integrating smoking cessation services in substance use disorder treatment programs

Despite the declining overall rate of cigarette smoking in the general population in the United States, the prevalence of smoking is estimated to be as high as 80% among treatment-seeking alcoholics. The serious adverse health effects of tobacco and heavy alcohol use are synergistic and recent evidence suggests that smoking slows the process of cognitive recovery following alcohol abstinence. In addition, substantial evidence shows that treatment for tobacco dependence does not jeopardize alcohol abstinence. In this paper, we focus on the impact and treatment implications of tobacco dependence among treatment-seeking alcoholics through a review of five areas of research. We begin with brief reviews of two areas of research: studies investigating the genetic and neurobiological vulnerability of comorbid tobacco and alcohol dependence and studies investigating the consequences of comorbid dependence on neurobiological and cognitive functioning. We then review literature on the effects of smoking cessation on drinking urges and alcohol use and the effectiveness of smoking cessation interventions with alcoholic smokers. Finally, we offer recommendations for research with an emphasis on clinical research for enhancing smoking cessation outcomes in this population.