Maximizing help for dissonant smokers

'Consonant' smokers know and accept the risks associated with tobacco consumption, and do not wish to change their smoking, whereas 'dissonant' smokers are tobacco consumers whose attitudes differ from their behaviour. Dissonant smokers have several options: to quit smoking (the optimal solution), reduce their smoking, switch products or brands, or do nothing. To date, nicotine replacement therapy (NRT) is the best-established medical aid to smoking cessation, but several important factors impact on NRT use. As smokers constitute a diverse group there is a need for various different formulations, some of which will suit certain smokers better than others. Smokers should be allowed to select their preferred products in order to increase compliance, and should also be permitted to combine various products if desired. Adequate dosage regimens should be stressed in order to avoid under-dosing, which is common with NRT. It is also essential that the medical system focuses increasingly on the diagnosis and treatment of those smokers who are unable or unwilling to quit smoking. High nicotine dependence correlates with a high risk of pulmonary and cardiovascular disease; because these smokers cannot quit, cessation efforts have little impact on the incidence of tobacco-related diseases in this population. Additional smoking control interventions, such as smoking reduction therapy, are therefore required to treat this group. Our experience in Vienna shows that these smokers can be targeted through approaches that utilize new messages offering alternatives to cessation.     

Tobacco Industry Research on Smoking Cessation

BACKGROUND:  Smoking rates are declining in the United States, except for young adults (age 18 to 24). Few organized programs target smoking cessation specifically for young adults, except programs for pregnant women. In contrast, the tobacco industry has invested much time and money studying young adult smoking patterns. Some of these data are now available in documents released through litigation.
OBJECTIVE:  Review tobacco industry marketing research on smoking cessation to guide new interventions and improve clinical practice, particularly to address young adult smokers' needs.
METHODS:  Analysis of previously secret tobacco industry documents.
RESULTS:  Compared to their share of the smoking population, young adult smokers have the highest spontaneous quitting rates. About 10% to 30% of smokers want to quit; light smokers and brand switchers are more likely to try. Tobacco companies attempted to deter quitting by developing products that appeared to be less addictive or more socially acceptable. Contrary to consumer expectations, "ultra low tar" cigarette smokers were actually less likely to quit.
CONCLUSIONS:  Tobacco industry views of young adult quitting behavior contrast with clinical practice. Tobacco marketers concentrate on recapturing young quitters, while organized smoking cessation programs are primarily used by older smokers. As young people have both the greatest propensity to quit and the greatest potential benefits from smoking cessation, targeted programs for young adults are needed. Tobacco marketing data suggest that aspirational messages that decrease the social acceptability of smoking and support smoke-free environments resonate best with young adult smokers' motivations.     

The importance of treating tobacco dependence

Smoking is a well-established risk factor for cardiovascular disease (CVD). Stopping smoking confers significant health benefits and is especially important for those with pre-exisiting CVD. Healthcare facilities should have systems in place to enable the identification of people who smoke, and ensure that smokers receive evidence based treatments to provide the best possible chances of stopping for good. Physicians have a crucial role to play to prompt quit attempts by giving brief advice to stop, and offering cessation support. Behavioural support strategies such as telephone, individual and group-based counselling improve the chances of long-term abstinence. Nicotine replacement therapy, bupropion and varenicline are medicines that have proven efficacy in aiding smoking cessation and increase the odds of quitting about 2-3 fold compared to placebo. Even patients with established cardiovascular disease can safely use nicotine replacement therapy to help them quit. For the greatest chance of success, physicians should recommend a combination of behavioural support and pharmacotherapy.     

Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy

Aims To assess the profile, utilization patterns, satisfaction and perceived effects among users of electronic cigarettes (‘e‐cigarettes’). Design and Setting Internet survey in English and French in 2010. Measurements Online questionnaire. Participants Visitors of websites and online discussion forums dedicated to e‐cigarettes and to smoking cessation. Findings There were 3587 participants (70% former tobacco smokers, 61% men, mean age 41 years). The median duration of electronic cigarette use was 3 months, users drew 120 puffs/day and used five refills/day. Almost all (97%) used e‐cigarettes containing nicotine. Daily users spent $33 per month on these products. Most (96%) said the e‐cigarette helped them to quit smoking or reduce their smoking (92%). Reasons for using the e‐cigarette included the perception that it was less toxic than tobacco (84%), to deal with craving for tobacco (79%) and withdrawal symptoms (67%), to quit smoking or avoid relapsing (77%), because it was cheaper than smoking (57%) and to deal with situations where smoking was prohibited (39%). Most ex‐smokers (79%) feared they might relapse to smoking if they stopped using the e‐cigarette. Users of nicotine‐containing e‐cigarettes reported better relief of withdrawal and a greater effect on smoking cessation than those using non‐nicotine e‐cigarettes. Conclusions E‐cigarettes were used much as people would use nicotine replacement medications: by former smokers to avoid relapse or as an aid to cut down or quit smoking. Further research should evaluate the safety and efficacy of e‐cigarettes for administration of nicotine and other substances, and for quitting and relapse prevention.     

Does improved access and greater choice of nicotine replacement therapy affect smoking cessation success? Findings from a randomized controlled trial

Aims To determine the effect of offering smokers who want to quit easy access to nicotine replacement therapy (NRT), a period of familiarization and choice of product on smoking abstinence at 6 months. Design Single‐blind, randomized controlled trial. Setting New Zealand. Participants A total of 1410 adult smokers who called the national Quitline for quitting support were randomized to usual Quitline care or a box containing different NRT products (patch, gum, inhaler, sublingual tablet, oral pouch) to try for a week prior to quitting, and then to choose one or two of these products for 8 weeks' use. Measurements The primary outcome was 7‐day point prevalence smoking abstinence 6 months after quit day. Secondary outcomes included continuous abstinence, cigarette consumption, withdrawal, NRT choice and serious adverse events at 1 and 3 weeks and 3 and 6 months. Findings No differences in 6‐month quit rates (7‐day point prevalence or continuous abstinence) were observed between the groups. However, smokers allocated to the intervention group were more likely to have quit smoking at 3 months [self‐reported point prevalence, relative risk (RR) = 1.17, 95% confidence interval (CI): 1.02, 1.35, P = 0.03], had a longer time to relapse (median 70 days versus 28 days, P < 0.01) and used significantly more NRT. The selection box concept was highly acceptable to users, with the patch and inhaler combination the most popular choice (34%). Conclusions In terms of smoking abstinence at 6 months, offering smokers who want to quit free access to a wide range of nicotine replacement therapy, including a 1‐week period of familiarization and choice of up to two products, appears no different to offering reduced cost and choice of nicotine replacement therapy, with no familiarization period.     

Smoking and Smoking Cessation During Pregnancy and Postpartum

Smoking cessation during and after pregnancy can confer many health benefits to women and their children. Smoking behavior can fluctuate from quitting or reducing during the first trimester to relapses later in pregnancy and postpartum. Abstinence during pregnancy is associated with level of addiction, socioeconomic status, level of education, maternal age, age to start smoking, partner's smoking habit, and secondhand smoke exposure. Low-barrier interventions that reach impoverished and disadvantaged women who are most at risk for smoking and also have the hardest time quitting are needed. At a minimum, pregnant smokers should be offered self-help materials and a 10-minute face-to-face psychosocial intervention. Offering incentives to pregnant women to quit smoking is the most effective intervention. Data are inconclusive regarding the efficacy of smoking cessation pharmacotherapy during pregnancy and postpartum. Because there are also safety concerns about fetal exposure, the use of pharmacotherapy for pregnant women remains controversial.     

Altering risk in patients who smoke

Because of the inherent difficulty of quitting smoking and the enormous health and societal burden of smoking, a multitude of interventions have been developed and tested for their efficacy in sustaining abstinence in smokers. Although most smokers' attempts to quit on their own end in failure, with 12-month abstinence rates as low as 5.7%, several psychosocial and pharmacological interventions have been noted for substantially increasing, even doubling or tripling abstinence rates. Given the substantial costs of treating illnesses caused by smoking, even a 1% increase in abstinence rates is notable for its public health benefit. Moreover, research has indicated that it may take the majority of smokers several attempts at quitting before total continuous abstinence is achieved. Thus any quit attempt should be construed as a step forward in the direction of sustained abstinence. The relative ease with which clinician-initiated effective treatments can be implemented. and evidence that many smokers would like to stop smoking and look to health-care practitioners for guidance and motivation, suggest that pulmonary medicine specialists can have a substantial impact on morbidity and mortality associated with smoking.     

Tobacco smoking and new developments in public health and clinical interventions

The public policy environment regarding tobacco use in the United States has experienced a dramatic change during the past year. Along with calls for regulatory review of cigarettes, important new scientific information has become available regarding the health effects of environmental tobacco smoke and the efficacy of nicotine replacement therapy, which is used to support smoking cessation efforts. Specifically, recent studies have suggested that environmental tobacco smoke exposure increases risk for coronary heart disease in nonsmoking adults in addition to causing lung cancer and other respiratory diseases. Children are exposed to environmental tobacco smoke at home and in public, resulting in increased risk of bronchitis, pneumonia, bronchial hyperresponsivity, and sudden infant death syndrome. In a climate of increasing concern about the direct and indirect effects of tobacco smoke, three independent meta-analyses concluded that nicotine replacement therapy increased smoking cessation efficacy two- to threefold. In addition, research is beginning to identify factors associated with successful and unsuccessful cessation attempts using nicotine replacement therapy, resulting in the possibility of individualized treatments and clinical interventions designed for maximum efficacy.     

Smoking Cessation Interventions and Older Adults

Older adults suffer a large proportion of the health consequences from smoking and can greatly benefit their health by quitting smoking. This article examines the current state of research and practice for older adults and smoking cessation interventions. For over 17 years, the health care literature has mandated that people of all ages be provided with smoking cessation interventions. However, smoking cessation interventions are offered to older adults at suboptimal rates. Nurses, especially those caring for clients in the inpatient setting, have an opportunity to provide smoking cessation interventions to older smokers. Recent research has shown that older smokers, particularly those hospitalized with cardiovascular disease, can quit at high rates when provided an intervention. Furthermore, use of nicotine replacement therapy has been shown to be safe and efficacious among older smokers with cardiovascular disease.     

Smoking cessation: which aids are worthwhile?

Smoking is a major preventable health risk in western society. In the Netherlands, it is held responsible for 86 and 36% of annual mortality from lung cancer and cardiovascular disease, respectively. Nevertheless about 33% of Dutch people smoke. Only 2% of smokers quit successfully after being advised to stop once by a physician. Although the medical profession should play a leading role in campaigns to stop smoking, general practitioners advise only 10% of their smokers to quit. An overview was made of the various aids that can be used to support attempts to quit smoking. Three aids: supportive schedules, nicotine replacement and bupropion chloride had proven long-term effectiveness in up to 5-10, 3-13 and 11-15% of the subjects, respectively. In conclusion, supportive counselling combined with nicotine substitutes or bupropion chloride is the most worthwhile intervention to support quitting attempts. Wider application of this strategy is expected to have major implications on morbidity (50% myocardial infarct risk reduction) and mortality in the Netherlands.     

Role of nicotine pharmacokinetics in nicotine addiction and nicotine replacement therapy: a review.

Smoking is a complex behaviour involving both pharmacological and psychological components. Nicotine is the main alkaloid found in tobacco, and is responsible for its addictive potential. Nicotine-positive effects on mood and cognition are strong reinforcements for smokers that contribute to their addiction, and cigarette smoking is particularly addictive because inhaled nicotine is absorbed through the pulmonary venous rather than the systemic venous system, and thus reaches the brain in 10-20 seconds. As the likelihood that a substance will be abused depends on the time between administration and central reinforcement, tobacco smoking can easily become addictive. Nicotine replacement therapy (NRT) is available in different forms (gum, transdermal patch, nasal spray, inhaler, sublingual tablet and lozenge), and has been shown to relieve withdrawal symptoms and to double abstinence rates compared to placebo. Most NRT forms deliver nicotine more slowly than smoking, and the increase in nicotine blood levels is more gradual. Compared to tobacco smoking or even tobacco chewing, few positive (reinforcing) effects are obtained from NRT use. Nasal spray provides faster withdrawal relief than other NRT, but compared to smoking absorption is slower and nicotine blood levels obtained are lower than with smoking. These differences in pharmacokinetic profiles compared with smoking may explain that some smokers still have difficulties quitting smoking even when using NRT (apart from psychological and/or social factors). Combination therapy (e.g., patch+gum, patch+inhaler), higher dosage, temporary abstinence or smoking reduction (using NRT to reduce smoke intake) may be needed to help more smokers to quit.     

Harm reduction--a treatment approach for resistant smokers with tobacco-related symptoms

Smokers with chronic obstructive pulmonary disease (COPD) appear to represent a hard-core group, and this presents a dilemma for chest physicians. A reduction in cigarette smoking benefits health, and nicotine replacement therapy (NRT) can aid smoking reduction. Hence we studied the efficacy of nicotine gum in helping hard-core smokers with severe COPD to quit. Seventeen smokers with severe COPD (FEV(1) 38-47% of predicted normal) who smoked >30 cigarettes/day but were unable to quit were encouraged to reduce their smoking as much as possible by using 4-mg nicotine gum. Five gradually reduced their daily tobacco consumption and, 18 months after starting NRT, were smoking an average of 6 cigarettes/day while still using nicotine gum. Compared to baseline, their respiratory symptoms had improved, and both FEV(1) and FVC had increased. There was no improvement in pulmonary function in the group of smokers who did not reduce their cigarette consumption. No adverse events relating to nicotine occurred among the patients who used NRT to reduce their smoking. We propose that this reduction approach should be considered for patients with respiratory disease who are unable or unwilling to stop smoking.     

Is attributing smoking to genetic causes associated with a reduced probability of quit attempt success? A cohort study

AIMS: Pharmacogenetic smoking cessation interventions would involve smokers being given information about the influence of genes on their behaviour. However, attributing smoking to genetic causes may reduce perceived control over smoking, reducing quit attempt success. This study examines whether attributing smoking to genetic influences is associated with reduced quitting and whether this effect is mediated by perceived control over smoking. DESIGN: Cohort study. PARTICIPANTS: A total of 792 smokers, participating in a trial of nicotine replacement therapy (NRT)-assisted smoking cessation. Participants were informed that the trial investigated relationships between genetic markers and smoking behaviour, but personalized genetic feedback was not provided. SETTING: Primary care in Oxfordshire and Buckinghamshire, UK. MEASUREMENTS: Perceived control over smoking and perceived importance of genetic factors in causing smoking assessed pre-quit; abstinence 4, 12, 26 and 52 weeks after the start of treatment. FINDINGS: A total of 515 smokers (65.0%) viewed genetic factors as playing some role in causing their smoking. They had lower perceived control over smoking than smokers who viewed genetic factors as having no role in causing their smoking. Attributing smoking to genetic causes was not associated significantly with a lower probability of quit attempt success. CONCLUSIONS: Attributing smoking to genetic factors was associated with lower levels of perceived control over smoking but not lower quit rates. This suggests that learning of one's genetic predisposition to smoking during a pharmacogenetically tailored smoking cessation intervention may not deter quitting. Further research should examine whether the lack of impact of genetic attributions on quit attempt success is also found in smokers provided with personalized genetic feedback.     

Do smokers know how to quit? Knowledge and perceived effectiveness of cessation assistance as predictors of cessation behaviour

AIMS: Despite the existence of effective cessation methods, the vast majority of smokers attempt to quit on their own. To date, there is little evidence to explain the low adoption rates for effective forms of cessation assistance, including pharmaceutical aids. This study sought to assess smokers' awareness and perceived effectiveness of cessation methods and to examine the relationship of this knowledge to cessation behaviour. DESIGN: A random-digit-dial telephone survey (response rate = 76%) with 3-month follow-up was conducted with 616 adult daily smokers in South-Western Ontario, Canada. MEASUREMENTS: A baseline survey assessed smoking behaviour, as well as smokers' awareness and perceived effectiveness of cessation assistance. A follow-up survey measured changes in smoking behaviour and adoption of cessation assistance at 3 months. FINDINGS: Participants demonstrated a poor recall of cessation methods: 45% of participants did not recall nicotine gum, 33% did not recall the nicotine patch and 57% did not recall bupropion. Also, many participants did not believe that the following cessation methods would increase their likelihood of quitting: nicotine replacement therapies (36%), bupropion (35%), counselling from a health professional (66%) and group counselling/quit programmes (50%). In addition, 78% of smokers indicated that they were just as likely to quit on their own as they were with assistance. Most important, participants who perceived cessation methods to be effective at baseline, were more likely to intend to quit (OR = 1.80, 95% CI: 1.12-2.90), make a quit attempt at follow-up (OR = 1.80, 95% CI: 1.03-3.16) and to adopt cessation assistance when doing so (OR = 3.62, 95% CI: 1.04-12.58). CONCLUSIONS: This research suggests that many smokers may be unaware of effective cessation methods and most underestimate their benefit. Further, this lack of knowledge may represent a significant barrier to treatment adoption.     

Depressive symptoms and smoking among Hong Kong Chinese adolescents

AIMS: To examine associations among depressive symptoms, smoking, smoking trajectories and quitting smoking in Hong Kong. DESIGN: Prospective longitudinal design, with wave 1 at baseline (T1) and wave 2 (T2) 12 months later. SETTING AND PARTICIPANTS: Form 1 (equivalent to 7th grade in the United States) students, mean age = 12.7 years, n = 1894. MEASUREMENTS: Self-reported smoking status, attempts to quit and depressive symptoms. FINDINGS: At both waves, current as well as ex-smokers had higher depressive symptoms than never smokers. T1 smoking predicted T2 depressive symptoms among those with low baseline depressive symptoms. Depressive symptoms at T1 predicted smoking at T2 among non-smokers at T1. Trajectories were defined by separating participants who were never smokers at both waves ('non-smokers'), those who smoked at both waves ('persistent smokers'), those who smoked at one time but were not smoking at either wave ('past smokers), and those who had never smoked at T1 but reported smoking a year later ('new smokers'). Persistent, past and new smokers had higher depressive symptoms at both waves than non-smokers. Smokers who reported not wanting or trying to quit and those who had been unsuccessful at quitting had higher depressive symptoms at T2 than those who successfully quit. CONCLUSION: Our results suggest that depressive symptoms promote tobacco use in Asian adolescents by making it more likely that an adolescent will begin smoking and less likely that she or he will quit. These findings elucidate risk factors in Hong Kong for two important public health concerns for adolescents: smoking and depression.     

Effect of transdermal nicotine delivery as an adjunct to low-intervention smoking cessation therapy. A randomized, placebo-controlled, double-blind study

To assess the smoking cessation efficacy of transdermal nicotine patches as an adjunct to low-intervention therapy, we conducted a double-blind, placebo-controlled trial in 158 smokers. Participants were randomly assigned to one of the following three study regimens that required daily application of two 15-cm2 patches: (1) 24-hour nicotine delivery, (2) nicotine delivery during wakeful hours only, and (3) placebo. The impact of the three regimens on smoking cessation rates and tobacco withdrawal symptoms was examined. During the last 2 weeks of the trial, 39% of the 24-hour nicotine regimen delivery group, 35% of those on wakeful hour nicotine regimens, and 13.5% of the placebo treatment group achieved abstinence. Self-reported quit rates for the two nicotine patch-wearing regimens, as compared with that for the placebo group, continued to be significantly higher at 6 months. Moreover, compared with placebo, the transdermal nicotine patches significantly reduced tobacco withdrawal symptoms during the first few weeks of quitting. The differences in quit rates and tobacco withdrawal symptoms between the two active groups were not statistically significant. The patches were well tolerated both topically and systemically. We concluded that transdermal nicotine, when used as an adjunct to low-intervention therapy, significantly reduced tobacco withdrawal symptoms and enhanced smoking cessation rates.     

Evaluation of smoking cessation success in adults

BACKGROUND: Smoking is a preventable cause of increased morbidity and mortality. Therefore, interventions have been used to assist smokers in overcoming their addiction. The aim of the study was to describe factors associated with smoking cessation, in patients applied to our smoking cessation (SC) unit in 1999, in a prospective study. METHODS: Patients were followed-up during two years. Detailed medical history, Fagerstrom test, Hospital Anxiety and Depression (HAD) scale questionnaire, Motivation scale and replacement therapy were systematically recorded. RESULTS: Three hundred patients (58% men, 42% women) applied to the SC unit from January to December 1999. The mean age was 42 yrs old. They smoked in average 24 cig/d. Mean duration of smoking was 20 years. Fagerstrom score was 5.86 (min 0; max: 10). Patients seemed to be more anxious (score 9.6) than depressed (5.09), according to the HAD score. 79% of them received both psychosocial intervention, pharmacotherapy and nicotine replacement therapy. 66% of patients were followed-up (n=198). Two years later, the smoking cessation rate was 12% (n=36). Motivation, Fagerstrom and HAD scores were not associated with the quitting rate. Quitting rate was higher (25.9%) in patients who attempted to quit smoking for the first time than in others (19%). By contrast, the quitting rate was significantly associated with age (P=0.03). CONCLUSION: Success to quit smoking was positively associated with age, and negatively with alcohol dependence.     

Diagnosis and treatment of nicotine dependence with emphasis on nicotine replacement therapy. A status report.

Tobacco use is a global health care problem. Repetitive exposure to nicotine produces neuroadaptation resulting in nicotine dependence. Cigarette smoking is particularly addictive due to the repeated delivery of bolus doses of nicotine to the bloodstream. Although compulsive tobacco use is sustained by nicotine addiction, it is the toxic combustion products in tobacco smoke such as carbon monoxide and oxidant gases that adversely affect the cardiovascular system. Smoking cessation produces significant health benefits and is a very cost-effective intervention. Evidence that nicotine is the addictive component of tobacco provides the rationale for using nicotine replacement therapy to aid cessation. Nicotine replacement therapy doubles successful smoking cessation rates and evidence-based guidelines for the treatment of tobacco addiction recommend routine use of nicotine replacement therapy, particularly in heavily dependent smokers. Success rates of up to 40% can be achieved in specialist clinics. Despite early concerns regarding the safety of nicotine replacement therapy in smokers with heart disease, it is now clear that the health risks of using nicotine replacement therapy to assist such patients to stop, or significantly reduce, smoking far outweigh any treatment-related risks.     

Return to smoking following a smoke-free psychiatric hospitalization

This study examined the smoking behaviors and motivations of 100 patients hospitalized in a smoke-free psychiatry unit. The sample averaged nineteen cigarettes per day and had a history of repeated failed quit attempts, yet 65% expressed interest in quitting. During hospitalization, nicotine replacement was provided to 70% of smokers to manage nicotine withdrawal. Provider counseling for smoking cessation, however, was rare, and all patients returned to smoking within five weeks of hospital discharge. The inpatient setting provides a potential site for initiating tobacco dependence treatment; however to maintain abstinence following hospital discharge, greater support is needed.