A review of computer and Internet-based interventions for smoking behavior

This article reviews studies of computer and Internet-based interventions for smoking behavior, published between 1995 and August 2004. Following electronic and manual searches of the literature, 19 studies were identified that used automated systems for smoking prevention or cessation, and measured outcomes related to smoking behavior. Studies varied widely in methodology, intervention delivery, participant characteristics, follow-up period, and measurement of cessation. Of eligible studies, nine (47%) reported statistically significant or improved outcomes at the longest follow-up, relative to a comparison group. Few patterns emerged in terms of subject, design or intervention characteristics that led to positive outcomes. The "first generation" format, where participants were mailed computer-generated feedback reports, was the modal intervention format and the one most consistently associated with improved outcomes. Future studies will need to identify whether certain patients are more likely to benefit from such interventions, and which pharmacological and behavioral adjuncts can best promote cessation.     

An updated algorithm for choosing among smoking cessation treatments

Although meta-analyses have documented the efficacy of treatments for smoking cessation, and guidelines have outlined treatment elements, few algorithms for choosing among treatments have been described. The current algorithm updates the author's prior algorithm. The major decisions in the algorithm are (a) use a motivational treatment if the smoker is not currently interested in quitting, (b) assess factors that influence choice of treatment, (c) consider both gradual and abrupt cessation, (d) use combined patch + gum/inhaler/lozenge or varenicline as first line medications, (e) use individual, group, Internet, and phone counseling as first line psychosocial treatments, and (f) continue treatment after a lapse or relapse. Further research is needed to determine whether algorithms improve treatment outcomes.     

Randomized controlled trial of the ACTION smoking cessation curriculum in tobacco-growing communities

We conducted a group randomized trial of an interactive, games-based, tobacco cessation program (ACTION) designed to help adolescents who live in tobacco-growing communities to stop using tobacco. More than 260 high school students participated in this study, in 14 schools across three states. We collected self-reported measures of cigarette and smokeless tobacco use and conducted biochemical validation of self-reported use at three time points (pre-test, immediate post-test, and 90-day follow-up). We used multi-level modeling to account for intraclass clustering at the school and classroom levels, and we analyzed our results using an intent-to-treat approach and a per protocol approach. Using the per protocol analytic approach, ACTION participants were more likely than comparison participants to achieve abstinence at 90-day follow-up. We found no program effects on our secondary outcomes or mediating factors. This study suggests that ACTION has promise as a relatively effective adolescent cessation program, although the overall limited effectiveness of cessation programs for adolescents must be acknowledged.     

A systematic review of the role of pharmacists in vaccination services in low-and middle-income countries

BackgroundPharmacists' role in vaccination has expanded in some countries with pharmacists having greater authority to perform various immunization activities, from vaccine storage, vaccine adverse event reporting, vaccination education and advocacy, to vaccine administration. However, pharmacists’ present involvement in vaccination services is poorly understood across low- and middle-income countries (LMICs).ObjectiveTo identify and synthesize evidence on pharmacists’ roles in offering vaccination services in LMICs.MethodsWe searched three databases (PubMed, Embase, Scopus) and the gray literature to identify articles which described pharmacist involvement in vaccination services in LMICs. We abstracted data on reported roles of pharmacists in vaccination, as well as relevant country, vaccines, and populations served.ResultsFrom the initial 612 records we identified, twenty-five (n = 25) studies representing 25 LMICs met our inclusion criteria. The most commonly reported role of pharmacists in vaccination across identified LMICs was vaccine advocacy and education (n = 15 countries). Pharmacist administered vaccination and storage of vaccines at pharmacies was reported in 8 countries. An additional 6 countries reported allowing vaccination at community pharmacies by other healthcare professionals. Immunization related training for pharmacists was reported or required in 8 countries. Fewer studies reported that pharmacists have access to patient immunization records in their respective LMICs (n = 6 countries) or had reported pharmacist involvement in vaccine adverse event reporting (n = 4 countries).ConclusionsPharmacists have the potential to play an important role in increasing access to vaccines and improving coverage, yet evidence of their role in vaccinations remains limited across LMICs. Greater documentation of pharmacists’ involvement in vaccination services in LMICs is needed to demonstrate the value of successful integration of pharmacists in immunization programs.     

Review of bupropion for smoking cessation

The advent of bupropion hydrochloride sustained release (Zyban) has heralded a major change in the options available for smoking cessation pharmacotherapy. Bupropion is a selective re-uptake inhibitor of dopamine and noradrenalin which prevents or reduces cravings and other features of nicotine withdrawal. Bupropion is a useful oral and non-nicotine form of pharmacotherapy for smoking cessation. For this review a total of 221 papers were reviewed plus poster presentations. This review examines in detail original clinical trials on efficacy, categorised according to whether they were acute treatment trials in healthy smokers; studies in specific populations such as people with depression, chronic obstructive pulmonary disease (COPD) or cardiovascular disease; or relapse prevention studies. Overall, these studies in varying populations comprising over four thousand subjects, showed bupropion consistently produces a positive effect on smoking cessation outcomes. The evidence highlights the major public health role that bupropion has in smoking cessation. The methodological issues of published clinical trials reporting one year outcomes were examined in detail including: completeness of follow-up; loss to follow-up; intention to treat analysis; blindness of assessment; and validation of smoking status. The review discusses contraindications, adverse effects, dose and overdose, addictive potential, and the role of bupropion in reducing cessation-related weight gain. Bupropion combined with or compared to other pharmacotherapies (nicotine patch; nortriptyline) is considered. Impressive evidence exists for the use of bupropion in smoking cessation among difficult patients who are hard-core smokers such as those with cardiovascular disease, chronic obstructive pulmonary disease (COPD) and depression. Bupropion reduces withdrawal symptoms as well as weight gain and is effective for smoking cessation for people with and without a history of depression or alcoholism. Serious side effects of bupropion use are rare. The major safety issue with bupropion is risk of seizures (estimated at approximately 0.1%) and it should not be prescribed to patients with a current seizure disorder or any history of seizures. In clinical trials of bupropion for smoking cessation no seizures were reported. Allergic reactions occur at a rate of approximately 3% and minor adverse effects are common including dry mouth and insomnia. [Richmond R, Zwar N. Review of bupropion for smoking cessation. Drug Alcohol Rev 2003;22:203 - 220]     

Adding addiction to the transtheoretical model for smoking cessation

Addiction is important to account for when designing smoking cessation interventions as withdrawal symptoms impede quitting. Ameliorating symptoms may increase those successfully quitting. A two-group, two-time, five-week, multi-site experimental design using the Transtheoretical Model examined whether addiction predicted post-intervention smoking behavior (point prevalence and stage of change), controlling for NRT (nicotine replacement therapy use) in adult FreshStart participants (N=109). The intervention group self-designated an Indigenous Helper (IH) Inde from their social network; the control group did not. The Fagerstrom Test for Nicotine Dependence (FTND) and the Stage of Change questionnaire were completed at baseline and 4 weeks. NRT use, but not the FTND, predicted smoking behavior. There is a need for an accurate nicotine addiction measure. Future smoking cessation studies should include NRT as a covariate.     

Understanding the role of cessation fatigue in the smoking cessation process

Background

To understand the dynamic process of cessation fatigue (i.e., the tiredness of trying to quit smoking) with respect to its average trend, effect on relapse, time-varying relations with craving and negative affect, and differences among genders and treatment groups.

Method

Randomized placebo-controlled clinical trial. Participants received either placebo, monotherapy (bupropion SR, nicotine patch, nicotine lozenge), or combined pharmacotherapy (bupropion SR + nicotine lozenge, nicotine patch + nicotine lozenge). Data were collected from 1504 daily smokers who were motivated to quit smoking. The participants completed baseline assessments and ecological momentary assessments for 2 weeks post-quit.

Results

Cessation fatigue reduced the likelihood of 6-month post-quit abstinence (OR = 0.97, 95% CI (0.95, 0.99)), and was positively associated with craving and negative affect. After controlling for these two factors, average cessation fatigue increased over time. Compared to men, women experienced greater fatigue (t = −10.69, p < 0.0001) and a stronger relation between fatigue and craving (t = −8.80, p < 0.0001). The relationship between fatigue and negative affect was significantly stronger in men (t = 5.73, p < 0.0001). Cessation fatigue was significantly reduced by combined pharmacotherapy (t = −13.4, p < 0.0001), as well as monotherapy (t = −6.2, p < 0.0001).

Conclusions

Cessation fatigue was closely related to craving, negative affect, and cessation outcomes. Women reported greater cessation fatigue than men. Current treatments appeared to reduce fatigue and weaken its relations with craving and negative affect.     

Correlates of smoking cessation self-efficacy in a community sample of smokers

While numerous studies show that higher levels of smoking cessation self-efficacy predicts motivation to quit smoking and successful smoking cessation, few studies have evaluated factors related to smoking cessation self-efficacy that could be targets of behavioral interventions to promote greater confidence to quit smoking. This study, using a large community sample of smokers enrolled in a smoking cessation treatment program, evaluated potential associations between self-efficacy to quit smoking and demographic (e.g., age, race), smoking-related (e.g., rate, cessation history, past use of treatments), and psychosocial (e.g., stress, cue reactivity, self-medication smoking) variables. The results indicated that Hispanic-American smokers, relative to smokers of other racial/ethnic groups, report significantly lower self-efficacy to quit smoking when facing internal stimuli (e.g., feeling depressed), as do smokers who report that they have little confidence to control abstinence-induced symptoms (F(9,576) = 6.9, p < .001). The results also indicated that smokers who reported that they have little confidence to control abstinence-induced symptoms and report high smoking urge reactivity to situations that illicit positive affect (e.g., at a bar, with coffee, at a party) report lower self-efficacy to quit smoking when facing external stimuli (e.g., during a celebration; F[7,600] = 9.05, p < .05). These findings can be used to refine behavioral smoking cessation interventions to increase self-efficacy to quit smoking.     

Reassessing the evidence relating smoking bans to heart disease

Recent studies have compared rates of acute myocardial infarction before and after introducing smoking bans. Some meta-analyses report post-ban reductions up to 19%, implausibly large considering likely changes in smoking habits and passive smoke exposure. Our literature reassessment demonstrates major weaknesses in many studies and meta-analyses, including failure to consider data from control areas or existing trends in acute myocardial infarction rates, incorrect estimation of variability, and use in some meta-analyses of results for population subsets or estimates apparently unrelated to the data reported. We report meta-analyses using a consistent approach to derive estimates of the ban effect, taking account of time trends and control data, which indicate a much smaller reduction. Preferring national to regional estimates where available, we estimate a 5% reduction (95% CI 3–8%). Omitting estimates where trend adjustment was impossible, this becomes 2.7% (2.1–3.4%), consistent with reported declines of 2–3% in large national populations (England, France, Italy, USA). We discuss some limitations of these estimates. Further evidence is needed, possibly by analyzing national mortality data. Our findings highlight the need for a valid approach when estimating the effect of bans, and demonstrate major weaknesses in many previous publications.     

Smoking in pregnancy and lactation: a review of risks and cessation strategies

Background  Despite documented evidence of harm to fetus and infant, a substantial number of women continue to smoke during pregnancy and lactation. Objective  To examine the literature regarding smoking during pregnancy and breastfeeding to ascertain adverse effects as well as the efficacy of interventions to enable women to stop smoking in the perinatal period. Study design  A comprehensive literature search was undertaken to identify all published studies reporting on smoking in pregnancy and lactation. MEDLINE, EMBASE, PUBMED, and Web of Science databases were searched for studies published in English from 1966 to 2008 that reported on smoking in pregnancy and breastfeeding, with information on adverse effects and on all forms of smoking cessation, including behavioral interventions, nicotine replacement therapy, and pharmacotherapy such as antidepressants. Results  There is evidence that smoking in pregnancy and lactation may cause many adverse affects in the perinatal period, childhood, and up to adulthood. These adverse effects include infertility, ectopic pregnancy, spontaneous abortion, placenta insufficiency, low birth weight, fetal growth restriction, preterm delivery, orofacial clefts, SIDS, craniosynostosis, clubfoot, childhood respiratory disease, attention deficit disorder, and some childhood cancers. A number of strategies have been developed to assist pregnant women in quitting smoking, including both behavioral interventions and pharmacological therapies, such as nicotine replacement and antidepressant therapy. Conclusions  Behavioral interventions report only modest success rates. Nicotine replacement therapy and antidepressants appear to be safe to use in pregnancy, but do not achieve a substantially higher success rate for quitting.     

Utility of biochemical verification of tobacco cessation in the Department of Veterans Affairs

Research on the validity of self-report tobacco use has varied by the population studied and has yet to be examined among smokers serviced by the Department of Veterans Affairs (VA). The purpose of this study was to determine the predictors of returning a biochemical urine test and the specificity and sensitivity of self-reported tobacco use status compared to biochemical verification. This was a sub-analysis of the larger Tobacco Tactics research study, a pre-/post-non-randomized control design study to implement and evaluate a smoking cessation intervention in three large VA hospitals. Inpatient smokers completed baseline demographic, health history and tobacco use measures. Patients were sent a follow-up survey at six-months to assess tobacco use and urine cotinine levels. A total of 645 patients returned six-month surveys of which 578 also returned a urinary cotinine strip at six-months. Multivariate analysis of the predictors of return rate revealed those more likely to return biochemical verification of their smoking status were younger, more likely to be thinking about quitting smoking, have arthritis, and less likely to have heart disease. The sensitivity and specificity of self-report tobacco use were 97% (95% confidence interval = 0.95–0.98) and 93% (95% confidence interval = 0.84–0.98) respectively. The misclassification rate among self-reported quitters was 21%. The misclassification rate among self-reported tobacco users was 1%. The sensitivity and specificity of self-report tobacco use were high among veteran smokers, yet among self-report quitters that misclassification rate was high at 21% suggesting that validating self-report tobacco measures is warranted in future studies especially in populations that are prone to misclassification.     

Smoking cessation interventions among individuals in methadone maintenance: A brief review

Background

Individuals in methadone maintenance treatment are motivated to quit smoking and are interested in smoking cessation treatment. However, few studies have assessed the efficacy of smoking cessation treatment for individuals undergoing methadone maintenance. The purpose of this article is to review interventions for tobacco use cessation among individuals in methadone maintenance with a particular emphasis on the components of such interventions and their effect on smoking cessation/reduction and drug use.

Methods

A comprehensive search of six databases in June 2008 retrieved 584 research studies, which addressed smoking cessation interventions among individuals in substance use treatment. Of the retrieved articles, eight studies addressed smoking cessation among individuals undergoing methadone maintenance treatment. These studies were examined for effect of intervention on smoking cessation/reduction, gender differences in treatment outcomes, and the effect of the smoking cessation intervention on substance use behaviors.

Results

Few studies demonstrated successful smoking abstinence among individuals in methadone maintenance treatment. Most interventions were associated with significant smoking reduction from baseline. Few studies assessed differences between men and women in smoking cessation treatment outcome. Smoking cessation treatment was not associated with increased substance use.

Conclusions

To date, interventions among individuals in methadone treatment have been largely unsuccessful in achieving sustained smoking abstinence. However, smoking cessation treatment does not worsen substance use. Future studies are necessary to determine intervention designs and components that can enhance smoking cessation among individuals in methadone maintenance.     

Mental health training programs for community pharmacists,pharmacy staff and students: A systematic review

BackgroundPrimary care is often the first point of contact for people living with mental disorders. Community pharmacists, pharmacy staff and students are increasingly being trained to deliver mental health care. However, there is still a gap in the literature exploring the characteristics of all available mental health training programs and their components and their influence on pharmacists, pharmacy staff and students’ outcomes.ObjectivesTo summarize the evidence evaluating mental health training programs completed by community pharmacists, pharmacy staff and students. More specifically, to explore the components of mental health training programs and identify those that facilitate significant improvements in outcomes.MethodsA systematic review was conducted following the Cochrane handbook and reported according to PRISMA guidelines. A search for published literature was conducted in three databases (PubMed, Scopus, and Web of Science) in July 2021. Eligible studies were included if they described and evaluated the impact of mental health training programs delivered to community pharmacists, pharmacy staff and pharmacy students regardless of design or comparator. The methodological quality of included studies was appraised using both the NIH quality assessment, to evaluate studies with an uncontrolled pre-post design, and the Cochrane EPOC risk of bias assessment, to evaluate studies with a controlled (randomized and non-randomized) study design.ResultsThirty-three studies were included. Most of the identified mental health training programs contained knowledge-based components and active learning activities. Changes in participants' attitudes, stigma, knowledge, confidence and skills were frequently assessed. An extensive range of self-assessment and observational instruments used to evaluate the impact of the training programs were identified. Positive improvements in participants’ attitudes, knowledge and stigma were frequently identified following participation in training programs.ConclusionsThis systematic review highlights the importance of mental health training programs in increasing pharmacists', pharmacy staff and pharmacy students’ skills and confidence to deliver mental health care in community pharmacy. Future research should build upon this basis and further focus on finding the most efficient measures to evaluate these training programs and assess their long-term effectiveness, allowing comparison between programs.     

Testing the Cigarette Dependence Scale in 4 samples of daily smokers: Psychiatric clinics,smoking cessation clinics,a smoking cessation website and in the general population

Aim

To assess the properties of the Cigarette Dependence Scale (CDS-12) in various samples of daily smokers and to provide reference scores in a general population sample.

Methods

Surveys in 4 samples of daily cigarette smokers: psychiatric out-patients in Geneva, Switzerland (n = 226), clients of smoking cessation clinics in France (n = 370), visitors of a French-language smoking cessation website (n = 13,697) and a representative sample of the general population of Geneva (n = 292).

Results

In all 4 samples, Cronbach's alpha coefficients were > 0.87 and factor analyses indicated that CDS-12 was unidimensional. CDS-12 was slightly skewed towards higher values, and it was associated with expired carbon monoxide, but this association was not strong (9% of variance explained, p < 0.001). CDS-12 scores were highest in clients of smoking cessation clinics (mean = 47.7, SD = 10.2), followed by psychiatric patients (mean = 44.4, SD = 8.4), visitors of smoking cessation websites (mean = 43.3, SD = 11.6) and the general population sample (mean = 36.9, SD = 12.3). Except for tolerance, each element in the DSM-IV and ICD-10 definitions of dependence is reflected by at least one item in CDS-12, even though the match with these definitions is sometimes indirect.

Conclusions

This paper presents reference scores and validity and reliability tests for CDS-12 in a diversity of samples of daily smokers. This information should be useful to clinicians and researchers.     

Overcoming recruitment challenges of web-based interventions for tobacco use: The case of web-based acceptance and commitment therapy for smoking cessation

Web-based behavioral interventions for substance use are being developed at a rapid pace, yet there is a dearth of information regarding the most effective methods for recruiting participants into web-based intervention trials. In this paper, we describe our successful recruitment of participants into a pilot trial of web-based Acceptance and Commitment Therapy (ACT) for smoking cessation and compare traditional and web-based methods of recruitment in terms of their effects on baseline participant characteristics, association with study retention and treatment outcome, yield, and cost-effectiveness. Over a 10-week period starting June 15, 2010, we recruited 222 smokers for a web-based smoking cessation study using a variety of recruitment methods. The largest portion of randomized participants were recruited through Google AdWords (36%), followed by medical Internet media (23%), standard media (14%), word of mouth (12%), broadcast emails (11%), and social media (6%). Recruitment source was not related to baseline participant characteristics, 3-month data retention, or 30-day point prevalence smoking abstinence at the 3-month outcome assessment. Cost per randomized participant ranged from $5.27/participant for word of mouth to $172.76/participant for social media, with a mean cost of $42.48/participant. Our diversified approach to recruitment, including both traditional and web-based methods, enabled timely enrollment of participants into the study. Because there was no evidence of a substantive difference in baseline characteristics, retention, or outcomes based on recruitment channel, the yield and cost-effectiveness of recruitment methods may be the more critical considerations in developing a feasible recruitment plan for a web-based smoking cessation intervention study.     

The role of community pharmacists in delivering interventions for osteoporosis: A systematic review

BackgroundOsteoporosis is a major public health concern, given that disease prevalence is expected to substantially increase due to the aging population. Community pharmacists can play a key role in the identification and management of chronic diseases.ObjectivesThe purpose of this systematic review was to present an overview of the literature on the role of community pharmacists in providing osteoporosis interventions to patients. The secondary objective was to assess the impact of these interventions on patient outcomes.MethodsA literature search was conducted in Embase, CINAHL, Scopus, MEDLINE, and Web of Science from database inception to March 2021. The search was limited to human studies in the English language. Primary studies were included if they described or assessed a patient-directed osteoporosis intervention conducted by community pharmacists. The following data were extracted and tabulated: citation, study location, study design, subject, number of participants, nature of intervention, classification of intervention, outcome measures, measurement methods, findings, and effect. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized trials (RoB 2) and Risk of Bias in Non-randomized Studies (ROBINS-I).ResultsTwenty-one studies were included in this review. The main interventions were education, screening, and medication management. Nineteen of these studies reported patient outcomes, all yielding positive outcomes. Outcomes included increased physician follow-up, risk factor reduction, increased osteoporosis knowledge, increased medication adherence, identification of medication-related problems, and positive patient-reported experience measures (PREMs). Three studies were considered to have a moderate risk of bias, whereas the remaining 18 studies had a high risk of bias.ConclusionThere is some evidence that pharmacist-led osteoporosis interventions have a positive impact on patient outcomes. More high-quality studies using objective outcome measures are needed to determine whether this translates into clinical outcomes such as decreased hospitalization and fractures.     

The role of pharmacists in opioid stewardship: A scoping review

BackgroundThe opioid epidemic is an international public health concern. Pharmacists are in a strategic position to promote and implement effective opioid stewardship due to both their central role on health care teams and frequent interaction with patients. Despite this integral role, pharmacists do not have harmonized scopes of practice in opioid stewardship.ObjectivesThis scoping review was conducted to identify and critically review the role of pharmacists in opioid stewardship and identify future areas of study.MethodsThe scoping review was conducted according to the methodological framework proposed by Arksey and O'Malley, which was further modified by the Joanna Briggs Institute. Six databases were searched for original, peer-reviewed research; PubMed (MEDLINE), Ovid Embase, Ovid International Pharmaceutical Abstracts, Scopus, Cochrane Library, and APA PsycInfo.ResultsIn 92% of the included studies (n = 77), opioid stewardship interventions led by either a pharmacist or in an interdisciplinary team resulted in improvements in at least one outcome measure, with education and medication therapy adjustments being the most predominant activities. Other areas supported by evidence include community stakeholder education, policy and guideline setting, and risk assessment.ConclusionThis scoping review provides valuable insight into the various roles pharmacists can have in opioid stewardship. The findings from this review identified opioid stewardship activities that can make significant contributions towards reducing the impact of the opioid crisis. This review informs future research and has the potential to influence pharmacy practice on a national and international scale.     

Nicotine metabolic rate predicts successful smoking cessation with transdermal nicotine: A validation study

Transdermal nicotine is widely used for smoking cessation, but only ~ 20% of smokers quit successfully with this medication. Interindividual variability in nicotine metabolism rate may influence treatment response. This study sought to validate, and extend in a larger sample, our previous finding that the ratio of plasma nicotine metabolites 3′-hydroxycotinine (3-HC)/cotinine, a measure of nicotine metabolism rate, predicts response to nicotine patch. A sample of 568 smokers was enrolled in a study that provided counseling and 8-weeks of 21 mg nicotine patch. Pretreatment 3-HC/cotinine ratio was examined as a predictor of 7-day point prevalence abstinence, verified with breath carbon monoxide (CO), 8 weeks after the quit date. Controlling for sex, race, age, and nicotine dependence, smokers in the upper 3 quartiles of 3-HC/cotinine ratio (faster metabolizers) were ~ 50% less likely to be abstinent vs. smokers in the first quartile (slow metabolizers; 28% vs. 42%; OR = .54 [95% CI:.36-.82], p = .003). Among abstainers, plasma nicotine levels (assessed 1 week after treatment began) decreased linearly across the 3-HC/cotinine ratio (β = − 3.38, t[355] = − 3.09, p < .05). These data support the value of the 3-HC/cotinine ratio as a biomarker to predict success with transdermal nicotine for smoking cessation.