Outcome of a smoking cessation programme run in a routine hospital setting

Abstract
Background : Although tobacco smoking remains the largest preventable cause of mortality in Australia, resources to assist with cessation remain scarce. Research studies have demonstrated improved cessation rates with interventions such as counselling and pharmacotherapy, but there is little information on success in routine clinical practice.
Aims : To determine the outcome of a smoking cessation programme run in a routine hospital outpatient setting.
Methods : A prospective audit of patients referred to an outpatient smoking cessation programme by hospital specialists or general practitioners. The programme consisted of fortnightly counselling sessions, with nicotine replacement therapy when clinically indicated. Self-reported abstinence rates were determined by contacting patients by letter or telephone at 3 and 12 months. Abstinence was confirmed, whenever possible, by measuring the expired carbon monoxide (CO) concentration.
Results : Over 12 months, 226 new patients were seen through the programme. There was a correlation between the number of cigarettes smoked and the baseline Fagerstrom score ( r = 0.49, P < 0.001). Approximately 40% of subjects could not be contacted for follow up. At 3 months the self-reported abstinence rate was 31%, falling to 19% by 12 months. Measurement of expired CO concentrations proved that self-reported abstinence was reliable.
Conclusions : The abstinence rates achieved by our programme compared well with those previously reported in the literature, demonstrating the effectiveness of a smoking cessation programme run in routine clinical practice. There was an increasing relapse rate during the period of follow up. (Intern Med J 2002; 32: 24–28)     

The role of genes in tobacco smoking during adolescence and young adulthood: a multivariate behaviour genetic investigation

Aims To incorporate a psychosocial model of tobacco smoking into a behaviour genetic design to examine genetic and environmental influences on variation in smoking involvement. Design Longitudinal twin study. Setting and participants Twins initially aged between 13 and 18 years and registered with the Australian Twin Registry were surveyed three times between 1988 and 1996. A total of 414 pairs of identical and same‐sex fraternal twin pairs participated in all three surveys, aged between 20 and 25 at wave 3. Biometric modelling estimated the influence of genetic and environmental factors in determining variation in smoking at each wave, both before and after adjusting for perceived smoking behaviours of peers and parents. Measurements Twins answered a questionnaire on their own smoking status and reported on the use of tobacco by parents and friends as they perceived it, at each survey wave. Findings At all three surveys, current smokers were more likely to have parents who smoked and to have smokers among their peers. Genes and environmental factors, both common and unique, contributed to variation in smoking behaviours. However, after controlling for the smoking behaviours of peers and parents, the role of genes in determining variation in smoking involvement was reduced by 100% at wave 1 and by 30% at wave 2. Friends’ smoking reduced the magnitude of the common environment variance by 11%, 30% and 40% at waves 1, 2 and 3, respectively. Parents’ smoking behaviours explained part of the common environment. Biometric modelling of the covariation between smoking involvement and peer smoking suggested that genes might influence smoking involvement at wave 1 by influencing choice of peers. Conclusion Environmental factors play the greatest role in determining variation in tobacco smoking among adolescents and young adults. Among adolescents, genes may influence variation in smoking behaviours indirectly by influencing choice of peers. However, genes seem to have a direct influence on variations in the smoking behaviours of young adults.     

Short-term Changes in Self-rating Depression Scale Scores after Smoking Cessation in Neurotic Patients

Objective The psychological status is a key factor in smoking continuance. However, details on short-term changes in mild depressive states after smoking cessation (SC) are still unknown. The purpose of the present study was to investigate these short-term changes. Methods A total of 989 patients who visited our SC Clinic were assessed using the Zung Self-Rating-Depression-Scale (SDS), an official instrument to measure depressive tendencies. The participants were classified into normal and neurotic groups based on their SDS scores during their initial visit; they were assessed again 2, 4, 8, and 12 weeks thereafter. Results The majority of patients in the neurotic group were women. These patients were also younger, with a higher nicotine dependence, and presented with a lower successful SC rate than the patients in the normal group. A decrease in SDS scores after starting the SC treatment was observed only in the neurotic group, especially during the first two weeks. In patients who continued to smoke, no improvement in depressive tendencies was noted in this period. Conclusion Depressive tendencies of patients with neurosis improve in the initial stages of the SC treatment (i.e., within two weeks after starting the treatment). This finding fills the mentioned knowledge gap regarding the effects of SC on mild depressive states in the short term.     

Very low rate and light smokers: smoking patterns and cessation-related behaviour in England, 2006-11

Aims There is a growing interest in very low rate [fewer than one cigarette per day (CPD)] and light (one to nine CPD) smokers and in some parts of the world their numbers appear to be increasing. This paper examined changes in prevalence over the past 5 years, cessation patterns, and smoking and demographic characteristics of very low rate, light and moderate‐to‐heavy (10+ CPD) smokers in England. Design Cross‐sectional and longitudinal data from aggregated monthly waves of a household survey: the Smoking Toolkit Study. Setting England. Participants A total of 23 245 smokers interviewed between November 2006 and May 2011 and 4147 who provided data at 6‐month follow‐up. Measurements We compared the demographic and smoking characteristics between the three groups of smokers at baseline, and the rate of attempts to quit, use of aids to cessation and success of quit attempts at follow‐up. Findings Very low rate smoking remained extremely rare (1.9% of smokers in 2006 to 2.8% in 2011), but light smoking became increasingly common (23.9–32.8%). Compared with moderate‐to‐heavy smokers, very low rate and light smokers were younger, more often female and from a higher socio‐economic background. They were more motivated to quit and enjoyed smoking less. During the 6‐month follow‐up period, light smokers, but not very low rate smokers, were more likely to attempt to quit than moderate‐to‐heavy smokers. When they tried to quit, very low rate and light smokers used aids to cessation less than moderate‐to‐heavy smokers but still used them to a substantial degree: 18%, 31% and 44% used over‐the‐counter nicotine replacement therapy in their most recent quit attempt for the three types of smoker, respectively. Even very low rate smokers had a substantial failure rate: 65% failed in their most recent quit attempt within 6 months. Conclusions Very low rate (fewer than one cigarette per day) and light (one to nine cigarettes per day) smokers in England are at least as motivated to quit as heavier smokers. Although they use cessation medication less than heavier smokers and are more likely to succeed, they still use such medication and fail in quit attempts to a substantial degree.     

Parental Smoking and Smoking Behavior in Asthmatic and Nonasthmatic Adolescents

Background. Smoking may have serious consequences for asthmatics. Nevertheless, studies have shown that smoking behavior among asthmatics is similar to or even higher than that of nonasthmatics. Since the relationship between parental smoking and child smoking is well established, this study examined whether the association between parental and child smoking behavior is similar for asthmatic and nonasthmatic adolescents. The impact of parental smoking history was also explored. Methodology. A cross-sectional sample of 10,087 Dutch adolescents was used to assess the prevalence of asthma and smoking behavior. Moreover, respondents had to report whether one of their parents currently smoked, had stopped, or had never smoked. In case a parent was a former smoker, the respondent had to report his or her own age at the moment that the parent stopped smoking. Results. Logistic regression analyses showed that, compared with nonasthmatic adolescents, asthmatic adolescents were more likely to have smoking parents. Furthermore, similar associations were found between parental smoking and adolescent smoking among asthmatic and nonasthmatic adolescents. The time at which maternal smoking ceased was associated with a decreased likelihood for ever smoking for both asthmatic and nonasthmatic adolescents. Conclusions. Asthmatic adolescents need to become more aware of the health risks of smoking. Therefore, tailor-made antismoking campaigns are needed at schools to reduce misconceptions among asthmatic adolescents about the risks of smoking. In addition, a personal intervention approach aimed particularly at smoking parents of an asthmatic child, may make them aware of the consequences for their offspring and help them to stop smoking.     

Parental Smoking and Smoking Behavior in Asthmatic and Nonasthmatic Adolescents

Background. Smoking may have serious consequences for asthmatics. Nevertheless, studies have shown that smoking behavior among asthmatics is similar to or even higher than that of nonasthmatics. Since the relationship between parental smoking and child smoking is well established, this study examined whether the association between parental and child smoking behavior is similar for asthmatic and nonasthmatic adolescents. The impact of parental smoking history was also explored. Methodology. A cross-sectional sample of 10,087 Dutch adolescents was used to assess the prevalence of asthma and smoking behavior. Moreover, respondents had to report whether one of their parents currently smoked, had stopped, or had never smoked. In case a parent was a former smoker, the respondent had to report his or her own age at the moment that the parent stopped smoking. Results. Logistic regression analyses showed that, compared with nonasthmatic adolescents, asthmatic adolescents were more likely to have smoking parents. Furthermore, similar associations were found between parental smoking and adolescent smoking among asthmatic and nonasthmatic adolescents. The time at which maternal smoking ceased was associated with a decreased likelihood for ever smoking for both asthmatic and nonasthmatic adolescents. Conclusions. Asthmatic adolescents need to become more aware of the health risks of smoking. Therefore, tailor-made antismoking campaigns are needed at schools to reduce misconceptions among asthmatic adolescents about the risks of smoking. In addition, a personal intervention approach aimed particularly at smoking parents of an asthmatic child, may make them aware of the consequences for their offspring and help them to stop smoking.     

Smoking reduction and biomarkers in two longitudinal studies

AIMS: To measure reduction in exposure to smoke in two population-based studies of self-reported smoking reduction not using nicotine replacement. DESIGN: Cross-sectional analyses of biomarkers and smoking. SETTING: Data from two time-points in the Copenhagen City Heart Study (CCHS), 1981/83 and 1991/94, and the Copenhagen Male Study (CMS) in 1976 and 1985/86, respectively. PARTICIPANTS: There were 3026 adults who were smokers at both time-points in the CCHS and 1319 men smoking at both time-points in the CMS. MEASUREMENTS: Smoking status and tobacco consumption were assessed by self-completion questionnaire. Measurements of biomarkers of smoke intake were taken at the second time-point in the two studies: expired-air carbon monoxide (CO) in the CCHS and serum cotinine in the CMS. Biomarker levels in medium (15-29 g tobacco/day) and heavy (> 30 g/day) smokers at the first time-point who later reported a reduction in cigarettes per day of 50% or more without quitting were compared with continuing medium, heavy and light smokers (1-14 g/day) using linear regression. Sex (CCHS only), age, self-reported inhalation of smoke, duration of smoking, type of tobacco and amount smoked were included as covariates in multivariate models. FINDINGS: Heavy smokers who reduced did not show lower levels of biomarkers at follow-up. Medium smokers who reduced showed a reduction in cotinine but not CO. The reduction in cotinine was not commensurate with the reported reduction in consumption. CONCLUSIONS: Long-term reductions in self-reported tobacco smoking are probably associated with, at best, modest reductions in smoke exposure.     

An examination of early smoking experiences and smoking status in a national cross-sectional sample

AIMS: To extend previous work showing lightheadedness from and liking for smoking to be associated with continued smoking while controlling for demographics and social influences that can also contribute to progression to established smoking. DESIGN AND SETTING: Random digit dialing telephone survey conduced on 3383 never smokers, non-smokers, former smokers and current smokers in the continental United States. MEASUREMENTS: Demographic information (sex, race, age, education level), smoking history, reactions to early experiences with smoking (lightheadedness, liking), whether parents, siblings or friends smoked when respondent was a teenager. FINDINGS: Lightheadedness and liking interacted-those who liked smoking (regardless of lightheadedness) were very likely to progress to established smoking, while non-likers who experienced lightheadedness were more likely than non-likers who did not experience lightheadedness to progress. These results held even after adjusting for demographic (sex, age, race, education) and social influences (parents, siblings and friends smoking). CONCLUSIONS: Lightheadedness from early smoking appears to be associated with having smoked 100 cigarettes only among those who report not liking early smoking. Overall, this study supports the literature suggesting that early experiences, particularly liking smoking, are associated with becoming a regular smoker.     

Motives underlying smoking in college students with ADHD

Background. The positive association between attention deficit hyperactivity disorder (ADHD) symptoms and smoking in youth has been well documented. Less research has examined why individuals with ADHD, particularly college students, are at increased risk for smoking. Objectives. This longitudinal study examined whether smoking motives [cognitive enhancement, tolerance, negative reinforcement (smoking to reduce negative affect or stress), craving, social influences, and weight control] helped to explain the relation between ADHD symptoms (inattention and hyperactivity/impulsivity) and cigarette smoking among college students. Methods. Participants were 889 undergraduates (21% men) and their parents who completed online surveys at the beginning and end of the Fall semester regarding their smoking behaviors, ADHD symptoms, and smoking motives. Structural equation modeling was used to analyze data and answer research questions. Results. Nineteen percent of students reported smoking, while 20% reported one or more inattentive symptoms, 35% reported one or more hyperactive/impulsive symptoms, and 3.3% met criteria for ADHD. All smoking motives significantly moderated the relation between inattentive symptoms and smoking, while most smoking motives (negative reinforcement, tolerance, craving, cognitive enhancement, and weight control) moderated the link between hyperactive/impulsive symptoms and smoking. Results remained significant after controlling for stimulant medication use and conduct disorder symptoms. Conclusions/Importance. Addressing negative reinforcement, craving, social influences, and tolerance in prevention and intervention efforts on college campuses may reduce smoking. Results also highlight the importance of assessing a range of ADHD symptoms in college students as ADHD symptoms, even at subthreshold levels, were associated with increased smoking rates among college students.     

Smoking and smoking cessation in Latin America: a review of the current situation and available treatments

Tobacco smoking is a growing problem throughout Latin American countries, especially in underdeveloped countries where poverty and lack of education about the dangers of smoking may make people more susceptible to becoming smokers. Moreover, the economies of many Latin American countries have become dependent on the production of tobacco. Furthermore, because of the associated promotion of tobacco, smoking has integrated into many Latin American cultures. Nevertheless, the harmful health effects of tobacco use are well documented, including greatly increased risks of developing chronic obstructive pulmonary disease, cardiovascular disease, and many forms of cancer. The medical costs associated with treating these diseases far outweigh the economic benefits of producing and selling this deadly crop. To control the tobacco pandemic in Latin American countries, nicotine addiction must be recognized and treated as a disease. Governments, both national and local, need to be more involved in enacting anti-smoking policies such as higher tobacco taxation, control of illegal tobacco smuggling, and reimbursement of medical smoking cessation interventions. The training of health professions in the area of nicotine addiction must also be improved, so that they may better assist smokers in their quit attempts and advise patients on, and prescribe, effective smoking cessation pharmacotherapies.     

Associations of CYP2A6 genotype with smoking behaviors in southern China

Aims To investigate the association of CYP2A6 genetic polymorphisms with smoking‐related phenotypes in Chinese smokers. Design Case‐only genetic association study. Setting Southern China. Participants A total of 1328 Han Chinese smokers who participated in a community‐based chronic disease screening project in Guangzhou and Zhuhai from 2006 to 2007. Measurements All participants answered a structured questionnaire about socio‐demographic status and smoking behaviors and informative alleles were genotyped for the cytochrome P450 2A6 (CYP2A6) gene (CYP2A6*4,*5,*7,*9 and *10). Findings The frequencies of CYP2A6*4, *5, *7, *9 and *10 alleles were 8.5, 1.2, 6.3, 13.5 and 2.4%, which corresponded to 48.9, 15.4, 24.2 and 11.5% of participants being classified as normal, intermediate, slow and poor metabolizers, respectively. Multivariate analyses in male smokers demonstrated that compared with normal metabolizers, poor metabolizers reported smoking fewer cigarettes per day [adjusted odds ratio (OR) = 0.49; 95% confidence interval (CI): 0.32–0.76], started smoking regularly later in life (adjusted OR = 1.55; 95% CI: 1.06–2.26) and, among former smokers, reported smoking for a shorter duration prior to quitting (adjusted OR = 0.33; 95% CI: 0.12–0.94). However, poor metabolizers were less likely to quit smoking and remain abstinent than normal metabolizers (adjusted OR = 0.54; 95% CI: 0.34–0.86). Conclusions Reduced metabolism function of cytochrome P450 2A6 in smokers appears to be associated with fewer cigarettes smoked, later initiation of smoking regularly, shorter smoking duration and lower likelihood of smoking cessation.     

Smoking cessation in severe mental illness: what works?

Aims The physical health of people with severe mental illness (SMI) is poor. Smoking‐related illnesses are a major contributor to excess mortality and morbidity. An up‐to‐date review of the evidence for smoking cessation interventions in SMI is needed to inform clinical guidelines. Methods We searched bibliographic databases for relevant studies and independently extracted data. Included studies were randomized controlled trials (RCTs) of smoking cessation or reduction conducted in adult smokers with SMI. Interventions were compared to usual care or placebo. The primary outcome was smoking cessation and secondary outcomes were smoking reduction, change in weight, change in psychiatric symptoms and adverse events. Results We included eight RCTs of pharmacological and/or psychological interventions. Most cessation interventions showed moderate positive results, some reaching statistical significance. One study compared behavioural support and nicotine replacement therapy (NRT) to usual care and showed a risk ratio (RR) of 2.74 (95% CI 1.10–6.81) for short‐term smoking cessation, which was not significant at longer follow‐up. We pooled five trials that effectively compared bupropion to placebo giving an RR of 2.77 (95% CI 1.48–5.16), which was comparable to Hughes et al.'s 2009 figures for general population data; RR = 1.69 (95% CI 1.53–1.85). Smoking reduction data were too heterogeneous for meta‐analysis, but results were generally positive. Trials suggest few adverse events. All trials recorded psychiatric symptoms and the most significant changes favoured the intervention groups over the control groups. Conclusions Treating tobacco dependence is effective in patients with SMI. Treatments that work in the general population work for those with severe mental illness and appear approximately equally effective. Treating tobacco dependence in patients with stable psychiatric conditions does not worsen mental state.     

Evolving patterns of tobacco use in northern Sweden

BACKGROUND AND OBJECTIVES: Cross-sectional data from northern Sweden suggest that the increased use of Swedish moist snuff (snus) may have contributed to a decline in the prevalence of smoking, especially amongst men. This study describes the evolving patterns of tobacco use in this population over the period 1986-1999. DESIGN: This is a prospective follow-up study of 1651 men and 1756 women, aged 25-64 years, who were enrolled in the northern Sweden MONICA project (entry in 1986, 1990, 1994) and who were followed-up in 1999. Information on tobacco use at entry and at follow-up was used to describe the stability of tobacco use over a period of 5-13 years ending in 1999. RESULTS: Snus was the most stable form of tobacco use amongst men (75%); only 2% of users switched to cigarettes and 20% quit tobacco altogether. Smoking was less stable (54%); 27% of smokers were tobacco-free and 12% used snus at follow-up. Combined use (smoking and snus) was the least stable (39%), as 43% switched to snus and 6% switched to cigarettes. Former users of both products were much less stable than former users of either cigarettes or snus. The stability of smoking amongst women was 69%, which was higher than that amongst men (P < 0.05). CONCLUSIONS: The use of snus played a major role in the decline of smoking rates amongst men in northern Sweden. The evolution from smoking to snus use occurred in the absence of a specific public health policy encouraging such a transition and probably resulted from historical and societal influences.     

上海邮政电信移动通信系统在职职工吸烟现状调查

目的 通过分析上海邮政电信移动通信系统(上海邮电系统)职工的吸烟行为和特点,为本领域制定针对性的控烟措施提供临床资料和依据.方法 对8389名上海邮政电信移动通信系统在职职工进行吸烟行为问卷调查,对吸烟率、现在吸烟率、重度吸烟率、戒烟率、复吸率、意愿戒烟率、被动吸烟率、工作场所被动吸烟率及家庭被动吸烟率等指标进行描述性分析.结果 上海邮电系统职工的吸烟率为35.81％,男性高于女性(57.09％ vs 0.48％,P＜0.01),现在吸烟率为34.47％,重度吸烟率为17.02％,吸烟率、现在吸烟率和重度吸烟率随年龄增长而逐渐升高,且邮政部门比电信及移动通信部门高.戒烟率为7.32％,复吸率为3.63％,被动吸烟率为61.82％,工作场所被动吸烟率为44.42％,家庭被动吸烟率为29.96％.结论 上海邮电系统在职职工的吸烟率仍高,男性高于女性,并随年龄的增长逐渐增高,特别是邮政系统.但戒烟率不高,并有较高的复吸率.因此需要加快企业内部控烟制度的执行及完善,加强控烟力度,扩大控烟范围,营造良好的无烟环境,使更多的人远离烟草的危害.     

Evaluation of patients followed up in a cigarette cessation clinic

Objectives: The aim of this study was to evaluate the demographic characteristics and factors determining success in a smoking cessation clinic in smokers who completed a 1‐year follow up. Method: A total of 349 patients were assessed retrospectively. Results: There were 238 men (mean age: 41 ± 13.5 years) and 111 women (mean age: 37 ± 11.9 years) (t‐test P = 0.004). The average age at which they began to smoke, number of years of smoking and the number of cigarettes/day were 17.5 ± 5.2 years (median 17), 22.1 ± 13.3 years, 23.5 ± 12.0, respectively. Cigarette smoking was mostly observed in university graduates (56.8%) and a moderate negative correlation existed between education status and smoking duration (r = ?0.27, P = 0.000). Patients with a Fagerström Tolerance Questionnaire score of ≥6 and those exposed to cigarette smoke in childhood tended to commence and become commited smokers later in life (χ² = 4.915, P = 0.027). In all, 151 patients (43.26%) were successful in quitting (χ² = 36.4, P = 0.000). Of these, 87 (24.93%) used medication such as nicotine patches (13.5%), bupropion (7.2%), nicotine patches + bupropion (4.3%) and 64 (18.33%) refused medication, but came for professional support. Conclusion: Increased education level, behavioural therapy and intensive motivational support, follow‐up visits and phone calls all appear to play important roles in smoking cessation. Families also play a major role.     

Cigarettes and social differentiation in France: is tobacco use increasingly concentrated among the poor?

Aims   This paper aimed to assess whether the increase of social differentiation of smoking is observed in France.
Design and setting   Five cross-sectional telephone surveys conducted in France between 2000 and 2007.
Participants   The surveys were conducted among national representative samples of French subjects aged 18–75 years ( n  = 12 256, n  = 2906, n  = 27 499, n  = 2887, n  = 6007 in 2000, 2003, 2005, 2006 and 2007, respectively). We focused on three groups: executives, manual workers and the unemployed.
Measurements   Time trends of smoking prevalence were assessed, and socio-economic factors (especially occupation and job status) associated with smoking were identified and compared in 2000 and 2005. We also computed respondents' equivalized household consumption (EHI) and their cigarette budget to assess the financial burden of smoking.
Findings   Between 2000 and 2007, smoking prevalence decreased by 22% among executive managers and professionals and by 11% among manual workers, and did not decrease among the unemployed. Indicators of an underprivileged social situation were associated more markedly with smoking in 2005 than in 2000. In addition, the falling-off of smoking initiation occurred later and was less marked among manual workers than it was among executive managers and professionals. Finally, in 2005 15% of French smokers devoted at least 20% of their EHI to the purchase of cigarettes, versus only 5% in 2000, and smoking weighted increasingly heavily on the poorest smokers' budgets.
Conclusions   While these results point out an increased social differentiation in tobacco use, they underline the need to design and implement other forms of action to encourage people to quit, in particular targeting individuals belonging to underprivileged groups.