Tobacco cessation counseling across the ages

OBJECTIVES: To examine recent rates of tobacco cessation counseling and whether patient age or sex was associated with providers' adherence to tobacco cessation guidelines. DESIGN: Survey study. SETTING: The 2002 National Ambulatory Medical Care Survey (NAMCS). PARTICIPANTS: Analysis of 22,605 records representing 687 million ambulatory care appointments with adults from the 2002 NAMCS. MEASUREMENTS: The proportion of visits by sex and age category during which physicians identified a patient's tobacco use status and counseled tobacco users to quit. RESULTS: The rates at which providers inquired about tobacco use were similar across groups, ranging from 65% of visits with men aged 20 to 44 to 73% of visits with women aged 45 to 59, but providers' rates of tobacco cessation counseling differed by age, ranging from 27% of visits with male tobacco users aged 45 to 59 to 6% of visits with male tobacco users aged 75 old and older. CONCLUSION: Although providers frequently ask their patients about tobacco use, they infrequently counsel patients to quit, especially if those patients are older men. Provider time constraints, misconceptions about older patients' ability and willingness to quit, or doubt about the potential health benefits of tobacco cessation in this age group may explain the lower counseling rates provided to older male patients. Because rates of counseling have declined in the last decade, providers should be reeducated about the need for and effectiveness of tobacco cessation counseling for men and women of all ages.     

It's time to change the default for tobacco treatment

The World Health Organization estimates that 1 billion people will die from tobacco‐related illnesses this century. Most health‐care providers, however, fail to treat tobacco dependence. This may be due in part to the treatment ‘default’. Guidelines in many countries recommend that health‐care providers: (i) ask patients if they are ‘ready’ to quit using tobacco; and (ii) provide treatment only to those who state they are ready to quit. For other health conditions—diabetes, hypertension, asthma and even substance abuse—treatment guidelines direct health‐care providers to identify the health condition and initiate evidence‐based treatment. As with any medical care, patients are free to decline—they can ‘opt out’ from care. If patients do nothing, they will receive care. For tobacco users, however, the treatment default is often that they have to ‘opt in’ to treatment. This drastically limits the reach of tobacco treatment because, at any given encounter, a minority of tobacco users will say they are ready to quit. As a result, few are offered treatment. It is time to change the treatment default for tobacco dependence. All tobacco users should be offered evidence‐based care, without being screened for readiness as a precondition for receiving treatment. Opt‐out care for tobacco dependence is warranted because changing defaults has been shown to change choices and outcomes for numerous health behaviors, and most tobacco users want to quit; there is little to no evidence supporting the utility of assessing readiness to quit, and an opt‐out default is more ethical.     

Pharmacists' attitudes, role perceptions and interventions regarding smoking cessation: findings from four Canadian provinces

Pharmacists in Ontario, Quebec, Saskatchewan and Prince Edward Island were surveyed in 2002 regarding their professional involvement in smoking cessation. In all provinces, at least 70 percent had positive attitudes toward smoking cessation. At least 50 percent thought that pharmacists have important roles in motivating patients to quit and in most aspects of motivating, assisting and referring patients. However, in all provinces, less than 40 percent had intervened in various ways in the past year with more than one half of their patients who smoked. Advising cutting down or quitting, attempting to increase motivation to quit and suggesting the use of nicotine replacement therapy were the most often performed interventions. Consistent inter-provincial patterns of differences in attitudes, role perceptions and interventions were not found. Some differences in attitudes and role perceptions were found between pharmacists practicing in provinces either banning or not banning tobacco sales in pharmacies, but there was no difference in overall interventions. The findings provide a baseline for provincial monitoring of pharmacists' professional smoking cessation attitudes, role perceptions and interventions. They also may inform tobacco control initiatives. Key words: pharmacists, smoking cessation, attitudes, professional roles, interventions, Canada.     

Opportunities for Adolescent Tobacco Cessation: Developmental and Ecological Perspectives

Several distinctive factors support the argument for developmentally appropriate youth tobacco cessation programs, including the science of adolescents’ evolving brains, as well as the incidence and risks of adolescent tobacco use, and its endemic nature in adolescent milieus and culture. This paper utilizes these factors and insights from the Youth Tobacco Awareness Program (YTAP), a cognitive-behavioral adolescent tobacco cessation program, to support 5 opportunities for developmentally and ecological-based tobacco cessation programs for youth. These opportunities include the continuing need for tobacco cessation, adolescents’ desire to quit tobacco, the need for effective youth tobacco cessation strategies amid broader-based community efforts, and the support of scientific research for program effectiveness. In our experience, the conundrum of youth tobacco use has presented these opportunities for debate, research, and development of enhanced, appropriate, and more effective models of cessation delivery.     

Smoking behavior, cessation techniques, and the health decision model

The magnitude of the problem of smoking challenges health providers to persuade patients of the importance of trying to quit. Smoking behavior and cessation techniques are discussed in terms of the health decision model, a third-generation model combining health beliefs, decision analysis, and behavioral decision theory. This review suggests the need for physicians to emphasize factors such as health beliefs, self-efficacy, social support, and reduction of stress in smoking cessation efforts. Patients experiencing symptoms, particularly relating to the lungs or heart, may have stronger health beliefs and are clearly more likely to quit smoking. In the absence of a clear-cut advantage for any particular smoking cessation technique, physicians should provide advice about smoking as a regular part of every patient visit.     

Smoking Among HIV Positive New Yorkers: Prevalence,Frequency, and Opportunities for Cessation

Tobacco use presents unique health risks for persons living with HIV/AIDS (PLWHA). There is an urgent need to characterize tobacco use among PLWHA, and to assess the capacity of HIV/AIDS service providers to deliver smoking cessation interventions. Questionnaires were administered to PLWHA in care in New York State (n = 1,094) and to State-funded HIV/AIDS service providers (n = 173) from 2005 to 2007. Current PLWHA smoking prevalence was 59%, three times the general population rate. Over 50% of current smokers were moderately or highly dependent on nicotine. Three-quarters of smokers indicated an interest in quitting, and 64% reported a least one quit attempt during the past year. Less than half of HIV/AIDS service providers reported always assessing tobacco use status, history, dependence, or interest in quitting at intake. Medical care providers were more likely to conduct assessments and provide services. Although 94% of providers indicated a willingness to incorporate tobacco cessation services, 65% perceived client resistance as a barrier to services. HIV/AIDS service providers are inadequately addressing the high smoking rate among PLWHA, despite being uniquely suited to do so. Efforts are needed to educate providers about the need for, and interest in, tobacco cessation.     

Intention to quit smoking according to smoking preferences and perceptions of electronic cigarettes among university students in South Korea

This study aimed to alleviate unhealthy smoking habits among university students and provide the basic data necessary for public health-oriented approaches such as developing regulations and policies on electronic cigarettes by analyzing the relationship between university students’ smoking preferences, perceptions of electronic cigarettes, and intention to quit smoking.This study involved 567 college students and conducted frequency and chi-squared analyses of the general characteristics, smoking preferences, and perceptions of electronic cigarettes. This study also performed logistic regression analysis to analyze the relationship between intention to quit smoking stratified by smoking preferences and the perceptions about electronic cigarettes. SPSS version 25.0 was used for data analysis.This study showed that electronic cigarette smokers were approximately 6.4 to 10.8 times more likely to think that electronic cigarettes positively affect smoking cessation attitude than nonsmokers. This study showed that regular cigarette smokers were approximately 1.7 to 2.2 times and other smoker 3.3 to 3.9 times more likely to think that electronic cigarettes positively affect smoking cessation attitude than nonsmokers. Those who perceived harmless to the human body, capable of reducing the frequency of smoking, and less harmful than tobacco were approximately 2.6 to 2.9, 11.6 to 12.8, and 3.3 to 3.7 times more likely have intention to quit smoking, respectively.Regular health education, advertising awareness of health hazards, and public health science-oriented approaches and policies for smoking cessation support services are needed to create awareness on electronic cigarettes among university students.     

How can we increase the involvement of primary health care in the treatment of tobacco dependence? A meta‐analysis

Aims A systematic review of studies testing the effectiveness of educational and practice base strategies to increase the involvement of primary health‐care practitioners in the treatment of tobacco dependence. Data sources MEDLINE, EMBASE, CINAHL and the Cochrane Library (1966–2001). Selection criteria included studies that used randomized or controlled clinical designs, controlled before and after trials and interrupted time‐series designs and that presented objective and interpretable measures of practitioners’ behaviour and biochemically verified patient quit rates. Review methods A meta‐analysis, using a random effects model, of 24 programmes identified in 19 trials. Effect sizes were adjusted by inverse variance weights to control for studies’ sample sizes. Findings Analyses to explain the heterogeneity of effect sizes found that interventions were equally effective in changing practitioners’ screening and advice‐giving rates and their patients’ quit rates. Absolute increases for the intervention above the comparison groups were 15% (95% CI = 7–22) for screening rates, 13% (95% CI = 9–18) for advice‐giving rates and 4.7% (95% CI = 2.5–6.9) for biochemically verified patient quit rates. Practitioners in training programmes were effective in changing their patients’ quit rates but not their own screening rates; educational interventions were more effective than practice‐based interventions. For established practitioners, programmes were effective in changing their screening and advice‐giving rates, but not their patients’ quit rates; a combination of practice‐based and educational interventions were more effective. Conclusions Primary health‐care practitioners can be engaged in the treatment of tobacco dependence to increase equally their screening and advice‐giving rates and their patients’ quit rates with outcomes of considerable public health and clinical significance. The provision of educational interventions for practitioners in training in combination with systematic outreach practice‐based support for established practitioners is likely to be an effective strategy to increase smoking quit rates throughout primary health care.     

Smoking cessation: evidence-based recommendations]

Smoking is an important cause of morbidity and mortality, and is considered the most important preventable cause of disease and death in the developed world. It is a cause of cancer, heart disease, stroke, chronic obstructive pulmonary disease and pregnancy complications. Even though smoking is known as an important health hazard, tobacco use remains surprisingly high. In Portugal, 18% of the adult population smokes, and the prevalence of adolescent smoking has risen dramatically during the 90s. A significant percentage of actual smokers are willing to quit, creating a major responsibility for health care providers. Cardiologists bear a special responsibility, because there is good observational evidence that patients with coronary disease that quit smoking significantly lower their risk of recurrent ischemic events or death, and patients with peripheral vascular disease or stroke also get benefits, with better exercise tolerance, diminished rates of limb amputation, increased survival and less stroke recurrence. We wrote this paper to summarize the main recommendations on techniques of smoking cessation, based on evidence-based recommendations.     

Effectiveness of Non-Primary Care-Based Smoking Cessation Interventions for Adults with Diabetes: A Systematic Literature Review

Diabetes is a chronic disease that affects over 25 million adults, many of whom are smokers. The negative health impact of diabetes and comorbid smoking is significant and requires comprehensive interdisciplinary management. The National Diabetes Education Program has identified specific providers, known as PPOD, who include pharmacists, podiatrists, optometrists, and dentists, as key individuals to improve diabetes-related clinical outcomes. These providers are encouraged to work together through interdisciplinary collaboration and to implement evidence-based strategies as outlined in the PPOD toolkit. The toolkit encourages healthcare providers to ask, advise, and assist patients in their efforts to engage in risk reduction and healthy behaviors, including smoking cessation as an important risk factor. While individual PPOD providers have demonstrated effective smoking cessation interventions in adults with other acute and chronic systemic diseases, they lack specific application and focus on adults with diabetes. This literature review examines the current role of PPOD providers in smoking cessation interventions delivered to adults with diabetes.     

Promoting smoking cessation during hospitalization for coronary artery disease

BACKGROUND: Quitting smoking is the most effective intervention to reduce mortality in patients with coronary artery disease who smoke. Guidelines for the treatment of tobacco dependency recommend that health care institutions develop plans to support the consistent and effective identification and treatment of tobacco users. The University of Ottawa Heart Institute (Ottawa, Ontario) has implemented an institutional program to identify and treat all smokers admitted to the Institute. OBJECTIVES: The objectives of the present paper are to describe core elements of this program and present data concerning its reach and effectiveness. PROGRAM DESCRIPTION: The goal of the program is to increase the number of smokers who are abstinent from smoking six months after a coronary artery disease-related hospitalization. Core elements of the program include: documentation of smoking status at hospital admission; inclusion of cessation intervention on patient care maps; individualized, bedside counselling by a nurse counsellor; the appropriate and timely use of nicotine replacement therapy; automated telephone follow-up; referral to outpatient cessation resources; and training of medical residents and nursing staff. Program reach and effectiveness were measured over a one-year period. RESULTS: Between April 2003 and March 2004, almost 1300 smokers were identified at admission, and 91% received intervention to help them quit smoking. At six-month follow-up, 44% were smoke-free. CONCLUSIONS: Hospitalization for coronary artery disease provides an important opportunity to intervene with smokers when their motivation to quit is high. An institutional approach reinforces the importance of smoking cessation in this patient population and increases the rate of smoking cessation. Posthospitalization quit rates should be a benchmark of cardiac program performance.     

Direct telemarketing of smoking cessation interventions: will smokers take the call?

AIMS: Few smokers currently make use of available and effective cessation strategies, despite their expressed desire to quit and reported interest in cessation support. This study aimed to explore the feasibility of a telephone-based direct-marketing approach to delivering cessation strategies. DESIGN, SETTING, MEASUREMENTS AND PARTICIPANTS: A community survey was conducted to explore the views of current adult smokers regarding the acceptability, likely uptake and barriers to uptake of smoking cessation services offered by direct telephone marketing. FINDINGS: Three quarters (73.8%) of smokers contacted agreed to be surveyed. Of the 194 study participants, 75.3% reported that they would utilize vouchers for discount nicotine replacement therapy (NRT), 66.5% would use a mailed self-help booklet, 57.2% would take up the offer of regular mailings of personalized letters and self-help materials and 46.4% would utilize a 'we-call-you' telephone counselling service. The characteristics of those indicating likely uptake of these services were also explored. The two major barriers to uptake of services were preferring to quit without help and a belief that a particular service would not help the participant. CONCLUSIONS: The data suggest strong support for the direct marketing of smoking cessation strategies; they also highlight the need for further study of the cost-effectiveness of telephone-based direct marketing of smoking cessation strategies as a population-based strategy for reducing the prevalence of smoking in the community.     

Methods for smoking cessation.

Smoking cessation treatment consists of three phases: preparation, intervention, and maintenance (support and coping strategies). Although most people who quit smoking do so without going through a formal program, many people act on the advice of a health professional. Self-help techniques appear to be cost effective in terms of their minimal use of professionals. The popularity of hypnosis and acupuncture as quitting methods are not warranted by their quit rates. Quit rates can be improved if physicians provide more help to their patients than just simple advice and warnings.     

A Clinical Imperative: Assisting Patients Who Smoke to Reduce Their Risk of Cardiovascular Disease

The role of tobacco smoking as a cause of cardiovascular disease is now unequivocal and well-documented in literally hundreds of epidemiologic and biomedical studies over the past 50 years. Cessation of smoking, on the other hand, swiftly and profoundly reduces the risks of a cardiovascular event. Thus, smoking cessation should be seen as perhaps the most effective lifesaving intervention in the physician's armamentarium. Despite this widely available knowledge, and evidence that most smokers want to quit, relatively few physicians offer cessation support to their smoking patients, even those at high risk for a cardiovascular event. This article reviews the links between tobacco smoking and cardiovascular disease, argues for a greater role for physicians in assisting smokers to quit, and highlights the most effective interventions currently available.     

Smoking behavior among former tuberculosis patients in Indonesia: intervention is needed.

SETTING: Five lung clinics in Jogjakarta Province, Indonesia. OBJECTIVE: To document smoking patterns among tuberculosis (TB) patients before diagnosis and following treatment, to identify smoking-related messages given by health professionals and DOTS providers and to identify predictors of smoking relapse. DESIGN: A cross-sectional survey of 239 male TB patients completed DOTS-based treatment during 2005-2006. Subjects were interviewed at home using a semi-structured questionnaire. Female patients were excluded, as very few smoke. RESULTS: Most TB patients quit smoking when under treatment, but over one third relapsed at 6 months post-treatment. About 30% were never asked about their smoking behavior or advised about quitting. Of relapsed smokers, 60% received only general health messages and not TB-specific smoking messages. DOTS providers are not currently involved in cessation activities. The perception that any level of smoking is harmless for ex-TB patients was a significant predictor for smoking relapse. CONCLUSION: Physicians and DOTS providers should be actively involved in smoking cessation activities among TB and ex-TB patients. Based on these data, the Quit Tobacco Indonesia Project is mounting a pilot intervention to train DOTS providers, who are mostly family members of patients, to deliver smoking cessation messages and reinforce the cessation advice provided by physicians during and following TB treatment.     

Medical Students’ Use of the Stages of Change Model in Tobacco Cessation Counseling

Background Many medical schools have incorporated the Stages of Change Model into their curricula with specific application to tobacco cessation. Objective This study examined the extent to which medical students were prepared to provide stage-based interventions to treat nicotine dependence. Design Using a quasi-experimental design, medical students’ counseling interactions were evaluated with a standardized patient portraying a smoker in either the precontemplation or preparation stage of change. Participants Participants were 147 third-year medical students at the University of California, San Francisco. Measurements Checklists completed by standardized patients evaluated students’ clinical performance. Surveys administered before and after the encounters assessed students’ knowledge, attitudes, confidence and previous experience with treating smoking. Results Most students asked about tobacco use (89%), advised patients of the health benefits of quitting (74%), and assessed the patient’s readiness to quit (76%). The students were more likely to prescribe medications and offer referrals to patients in the preparation than in the precontemplation stage of change (P < 0.001); however, many students had difficulty identifying patients ready to quit, and few encouraged patients to set a quit date or arranged follow-up to assess progress. Students’ tobacco-related knowledge, but not their attitudes, confidence, or previous experience predicted their clinical performance. Conclusions The findings indicated evidence of students tailoring their counseling strategies to the patients’ stage of change; however, they still could do more to assist their patients in quitting. Additional training and integration of cessation counseling into clinical rotations are needed.     

Smoking among diabetes patients in Yogyakarta, Indonesia: cessation efforts are urgently needed

Objectives  To document the prevalence of tobacco use among male diabetes patients in a clinic based population of Yogyakarta Province, Indonesia; to examine patient's perceptions of smoking as a risk factor for diabetes complications; and to investigate whether patients had received cessation messages from their doctors.
Method  Twelve in-depth interviews and five focus groups ( n  = 21) with diabetic patients in 2004–2005, followed by a cross-sectional survey of 778 male diabetic patients in diabetes clinics in 2006–2007.
Results  65% of male diabetes patients smoked before being diagnosed, and 32% smoked in the last 30 days. Most patients incorrectly perceived low level smoking safe for diabetics (mean of 3.6 cigarettes). The median range of cigarettes smoked per day was in excess of this 'safe' amount (4–10 cigarettes). Most respondents did not associate smoking with diabetes and its complications. Only 35% of all patients recalled being asked whether they smoked by their doctors, and there were no differences between smokers and non-smokers. Quit messages received by patients were seen as general health advice and not diabetes specific.
Conclusions  Many diabetic patients continue to smoke despite the hazard of smoking on diabetes complications and mortality. Smoking cessation is not commonly encouraged by health-care providers in Indonesia, and is not a routine part of diabetes counselling despite the risk of smoking to those with diabetes. Project Quit Tobacco International is currently developing cessation services for patients with diabetes and encouraging medical and nursing schools to incorporate disease specific tobacco education in its curriculum and skill based classes in tobacco cessation counselling.     

Cigarette Smoking and Risk Perceptions During the COVID-19 Pandemic Reported by Recently Hospitalized Participants in a Smoking Cessation Trial

BackgroundCigarette smoking is a risk factor for severe COVID-19 disease. Understanding smokers’ responses to the pandemic will help assess its public health impact and inform future public health and provider messages to smokers.ObjectiveTo assess risk perceptions and change in tobacco use among current and former smokers during the COVID-19 pandemic.DesignCross-sectional survey conducted in May–July 2020 (55% response rate)Participants694 current and former daily smokers (mean age 53, 40% male, 78% white) who had been hospitalized pre-COVID-19 and enrolled into a smoking cessation clinical trial at hospitals in Massachusetts, Pennsylvania, and Tennessee.Main MeasuresPerceived risk of COVID-19 due to tobacco use; changes in tobacco consumption and interest in quitting tobacco use; self-reported quitting and relapse since January 2020.Key Results68% (95% CI, 65–72%) of respondents believed that smoking increases the risk of contracting COVID-19 or having a more severe case. In adjusted analyses, perceived risk was higher in Massachusetts where COVID-19 had already surged than in Pennsylvania and Tennessee which were pre-surge during survey administration (AOR 1.56, 95% CI, 1.07–2.28). Higher perceived COVID-19 risk was associated with increased interest in quitting smoking (AOR 1.72, 95% CI 1.01–2.92). During the pandemic, 32% (95% CI, 27–37%) of smokers increased, 37% (95% CI, 33–42%) decreased, and 31% (95% CI, 26–35%) did not change their cigarette consumption. Increased smoking was associated with higher perceived stress (AOR 1.49, 95% CI 1.16–1.91). Overall, 11% (95% CI, 8–14%) of respondents who smoked in January 2020 (pre-COVID-19) had quit smoking at survey (mean, 6 months later) while 28% (95% CI, 22–34%) of former smokers relapsed. Higher perceived COVID-19 risk was associated with higher odds of quitting and lower odds of relapse.ConclusionsMost smokers believed that smoking increased COVID-19 risk. Smokers’ responses to the pandemic varied, with increased smoking related to stress and increased quitting associated with perceived COVID-19 vulnerability.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06913-3.KEY WORDS: cigarette smoking, electronic cigarettes, COVID-19, risk perceptions     

High smoking cessation rate in Crohn's disease patients after physician advice – The TABACROHN Study

IntroductionTobacco smoking has a significant impact on the development of Crohn's disease (CD) and its clinical course, making smoking cessation one of the main goals in CD therapeutic strategy.AimsTo evaluate the effectiveness of an advice-based smoking cessation strategy among CD patients.MethodsWe have performed a prospective multicenter study which enrolled 408 CD smokers. At inclusion all patients were instructed about the risks of smoking and subsequently followed every 3 months. Each center used additional smoking cessation strategies based on available resources. Urinary cotinine and exhaled carbon monoxide levels were evaluated in a subgroup of patients.ResultsMedian study follow up was 18 months. 31% of the patients achieved complete smoking cessation and 23% were smoking-free at the end of their follow up with 8% of smoking relapse. Most patients not achieving smoking cessation did not change their smoking habit with only 5% presenting a decrease in tobacco load. 63% of patients willing to quit smoking received help from another specialist, most frequently the pulmonologist (47%). Surprisingly, most patients (88%) tried to quit smoking with no pharmacological therapy and bupropion, varenicline and nicotine replacement treatment were used in few patients. Urinary cotinine and exhaled CO levels tested in a subgroup of patients proved to have a good correlation with the self-reported smoking habit. No predictors of successful smoking cessation were identified.ConclusionOur results underline that an anti-tobacco strategy mostly based on CD patients´s education and counseling is feasible and effective in helping patients reach complete abstinence.     

Reducing risk in smokers

PURPOSE OF REVIEW: Tobacco smoking is a leading cause of lung cancer and chronic obstructive pulmonary disease. For smokers who want to quit, nicotine replacement therapy and bupropion are frequently recommended. Currently, disagreement surrounds the extent of risk reduction from quitting, the consequences of the change of nicotine replacement therapy to over-the-counter status, and the safety and efficacy of new tobacco products being marketed by tobacco companies. This article reviews the current evidence relevant to these and other developments in smoking interventions and describes the most effective strategies that smokers can use to reduce their risk. RECENT FINDINGS: Although it may take approximately 10 to 30 years of abstinence for former smokers' risk of lung cancer to reach that of never smokers, quitting at any time is substantially less risky than continuing to smoke. Quitting after diagnosis also prolongs survival. Bupropion and nicotine replacement therapy are effective pharmacotherapies, doubling quit rates compared with self-quitting. However, many users of over-the-counter nicotine replacement therapy are using it inappropriately. More research is needed to determine the long-term health effects of modified tobacco products and their efficacy in helping smokers quit. Switching to "low tar" filter cigarettes to reduce lung cancer risk, however, is clearly ineffective. The most effective interventions for quitting continue to be a combination of behavioral and pharmacologic approaches. SUMMARY: Health care practitioners should encourage all smokers to attempt cessation and emphasize pharmacotherapy as an important aid to quitting. Professionals who educate patients on the appropriate use of pharmacotherapy and follow-up on smokers' attempts to quit will help reduce the societal burden and personal risks of smoking.