Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial

Objective To evaluate the impact of telling patients their estimated spirometric lung age as an incentive to quit smoking.Design Randomised controlled trial.Setting Five general practices in Hertfordshire, England.Participants 561 current smokers aged over 35.Intervention All participants were offered spirometric assessment of lung function. Participants in intervention group received their results in terms of "lung age" (the age of the average healthy individual who would perform similar to them on spirometry). Those in the control group received a raw figure for forced expiratory volume at one second (FEV1). Both groups were advised to quit and offered referral to local NHS smoking cessation services.Main outcome measures The primary outcome measure was verified cessation of smoking by salivary cotinine testing 12 months after recruitment. Secondary outcomes were reported changes in daily consumption of cigarettes and identification of new diagnoses of chronic obstructive lung disease.Results Follow-up was 89%. Independently verified quit rates at 12 months in the intervention and control groups, respectively, were 13.6% and 6.4% (difference 7.2%, P=0.005, 95% confidence interval 2.2% to 12.1%; number needed to treat 14). People with worse spirometric lung age were no more likely to have quit than those with normal lung age in either group. Cost per successful quitter was estimated at 280 pound ((euro) 365, $556). A new diagnosis of obstructive lung disease was made in 17% in the intervention group and 14% in the control group; a total of 16% (89/561) of participants.Conclusion Telling smokers their lung age significantly improves the likelihood of them quitting smoking, but the mechanism by which this intervention achieves its effect is unclear.Trial registration National Research Register N0096173751

Hard-core Smokers, the Hardening Hypothesis and Harm Reduction: Implications for Australian Tobacco Control Policy

Background: The prevalence of cigarette smoking has decreased considerably in many developed countries over the past few decades. However, in Australia, the rate of the decrease has been slowing, and between 2013-2016, appeared to stall. This is important because cigarette smoking remains a major public health issue, and is – for example – the leading cause of cancer-related mortality in Australia. The slowing decline in smoking prevalence has prompted calls to address the interrelated issues of hardening and hard-core smoking. The hardening hypothesis proposes that, as smoking rates decline, the remaining smokers will become hard-core (i.e., more resistant to quitting). This group of hard-core smokers may require more tailored approaches to cessation and/or product-based tobacco harm reduction (THR). Although hardening and hard-core smoking are often discussed and investigated, the literature is plagued by inconsistencies in how these terms are defined and operationalised. As a result, many aspects of the nature of hardening and hard-core smoking remain unclear. Alternate nicotine delivery systems (ANDS), such as e-cigarettes, have been proposed as an option to achieve further reductions in smoking prevalence rates in Australia. This is because ANDS may support hard-core smokers to quit or (as a form of THR) transition smokers away from combustible cigarettes. The Australian regulatory environment for ANDS, together with a robust tobacco control environment, means that hard-core smoking and hardening research conducted in other countries may not be transferable to the Australian context. As such, there is a significant knowledge gap about the contemporary nature of hard-core smoking in Australia. This thesis aims to examine the existence and nature of hardening and hard-core smoking in an Australian context. In doing so, this thesis will also address important theoretical issues relating to the definitions and operationalisations of these concepts. This includes the application of the Precaution Adoption Process Model as a theoretical framework to understand hard-core smoking. This thesis is comprised of three empirical studies and two policy focused commentary papers which address the gaps in the literature to account for: i) contemporary evidence supporting claims of hardening amongst Australian and international smokers (Paper1); ii) identification of the extent of hard-core smoking rates in Australia (Paper 2); iii) an understanding of the characteristics of hard-core smokers (Papers 2 and 3); iv) exploration of a stage-based behaviour change model that may account for smokers who do not want to change their smoking behaviour (Paper 3); v) a review of the status of smoke-free spaces in Australia as a key component of non-product-based THR (Paper 4); and v) a review of Australian tobacco dependence treatment policy (Paper 5). Method: Paper 1 was a systematic review to identify and summarise studies on hard-core smoking and hardening to: i) determine the degree of variability in definitions of hard-core smoking and hardening; ii) assess the evidence for claims that smokers are becoming increasingly hardened; and iii) identify the determining characteristics of a hard-core smoker. We searched five electronic databases from 1970 to mid-April 2018 using the search term “smok* AND hard* AND (tobacco OR cigar* OR nicotin*)”. We included studies if they included a definition of hard-core smokers and/or hardening and provided a prevalence rate for hard-core smokers or empirical evidence for hardening. Paper 2 tested the hardening hypothesis by analysing the rates of hard-core smoking in the Australian smoking population between 2010 and 2016. Data were drawn from three waves of the National Drug Strategy Household Survey (NDSHS) in 2010, 2013 and 2016. Two different definitions were used to assess hard-core smoking to arrive at an upper and lower rate. Logistic regression models assessed hard-core smoker characteristics for both definitions of hard-core smoking. Paper 3 applied the Precaution Adoption Process Model (PAPM) to a community-based sample of smokers (n=336) to determine whether it provides a useful approach to identifying hard-core smokers. Australian smokers were recruited through social media and an online data collection agency. Paper 4 and Paper 5 reviewed the status of smoke-free spaces and tobacco dependence treatment as key THR approaches in Australia and outlined the need for renewed focus on implementing comprehensive, robust and evidence-based tobacco control polices to reduce population level harm and drive cessation in the face of lobbying by industry for widespread availability of ANDS products. Results: Paper 1 indicated there is considerable variability in how hard-core smoking is defined and operationalised in the literature. This variability was associated with inconsistencies in reported prevalence rates of hard-core smoking. The three empirical papers indicated there was little evidence of a crisis of hard-core smokers posing a credible threat to achieving further smoking prevalence reductions in Australia. Paper 1 suggested that hardening was not evident in the general smoking population, although there was evidence of softening occurring in smoking populations. In Paper 2, the most inclusive definition of hard-core smoking (i.e. a smoker with no plan to quit) showed a significant decline in hard-core smoking between 2010 and 2016 (5.49%–4.85%). The prevalence of hard-core smoking using the most stringent definition (i.e. a current daily smoker of at least 15 cigarettes per day, aged 26 years or over, with no intention to quit, a lifetime consumption of at least 100 cigarettes, and no quit attempt in the past 12 months) did not change significantly between 2010 and 2016. In Paper 3, 11.9% of smokers were in Stage 4 of the PAPM – i.e. had decided not to quit. These smokers were more resistant to quitting and exhibited similar characteristics to hard-core smokers. Conclusions: The present thesis demonstrates that the Australian smoking population is not hardening, nor are Australian smokers becoming increasingly hard-core. As such, further reductions in smoking prevalence are achievable by further strengthening and funding a comprehensive approach to tobacco control. This should include improvements in the delivery of tobacco dependence treatment (TDT) to improve quit outcomes amongst the majority of Australian smokers who are motivated to quit. ANDS may be of benefit to some smokers who have been unable to quit using evidence-based combination pharmacotherapy and behavioural support. However, they may create population level harm if they increase rates of youth smoking

The impact of population tobacco control interventions on socioeconomic inequalities in smoking: a systematic review and appraisal of future research directions

BACKGROUND: While price increases and targeted cessation support have been found to reduce inequalities in smoking by socioeconomic status (SES), evidence on other measures is mixed. We aimed to update the most recent (2014) previous review by identifying and appraising evidence published since 2013 on the equity impact of population tobacco control measures. METHODS: Systematic searching of 10 electronic databases and hand-searching of four key journals identified 68 primary research articles published since 2013 that sought to examine the equity impact of population tobacco control measures in high-income countries with a negative socioeconomic gradient in smoking. Reported equity impacts were categorised as positive (greater impact among lower SES), neutral (no difference by SES), negative (greater impact among higher SES) or mixed/unclear. RESULTS: There was substantial growth in research seeking to evaluate the equity impact of tobacco control interventions, but the majority of new studies showed mixed/unclear results. Findings for price increases and targeted cessation support continue to suggest an equity-positive impact, but limitations in the available evidence make further assessment difficult. Substantial differences in the context, scale and implementation of tobacco control policies make straightforward comparison of findings from the previous 2014 and current reviews problematic. CONCLUSION: Researchers need to adopt more sophisticated, multidisciplinary approaches in evaluating the equity impact of tobacco control measures—developing robust measures of equity effect and using frameworks that take account of context, existing systems/processes and the likely mechanisms of action. Socioeconomic differences in intervention impact within low-income and middle-income countries require evaluation

Identifying and eliminating tobacco-related disparities : key outcome indicators for evaluating comprehensive tobacco control programs

The Centers for Disease Control and Prevention\u2019s (CDC\u2019s) Office on Smoking and Health (OSH) developed this publication to assist state and territorial commercial tobacco control programs evaluate efforts to reduce tobacco-related health disparities. The primary audiences for this publication consist of planners, managers, and evaluators of tobacco control programs.This publication is the fourth in a series of key outcome indicator guides released by OSH and the first to specifically focus on tobacco-related disparities. This guide can be used in combination with outcome indicators from the three other guides: Preventing Initiation of Tobacco Use: Outcome Indicators for Comprehensive Tobacco Control Programs\u20142014, Promoting Quitting Among Adults and Young People: Outcome Indicators for Comprehensive Tobacco Control Programs\u20142015, and Eliminating Exposure to Secondhand Smoke: Outcome Indicators for Comprehensive Tobacco Control Programs\u20132017.Many indicators in the present guide align closely with those in previously published guides with the addition of information specific to tobacco-related disparities. This indicator guide supports evaluation of the National Tobacco Control Program (NTCP), which aims to reduce tobacco-related disease, disability, and death. The NTCP seeks to achieve these goals by working in four areas:1. Preventing initiation among youth and young adults.2. Eliminating exposure to secondhand smoke.3. Promoting quitting among adults and youth.4. Identifying and eliminating tobacco-related disparities.A logic model with corresponding indicators for Goal Area 4 of the NTCP (Identifying and Eliminating Tobacco-Related Disparities) is included in the present guide, which contains indepth information on indicators that can be used to measure progress toward various outcomes. Consumer Reports\uae\u2013type ratings are included to allow for tailored selection of indicators by state and territorial tobacco control programs. Moreover, this guidance document highlights how to use indicators to integrate program and evaluation planning.This guide supports and complements broader monitoring and evaluation efforts to identify and eliminate tobacco-related disparities. It supports application of CDC\u2019s Framework for Program Evaluation in Public Health Practice4 and may be used in coordination with CDC\u2019s workbook, Developing an Effective Evaluation Plan: Setting the Course for Effective Program Evaluation, 5 and other OSH surveillance and evaluation resources. Tobacco prevention and control program managers and evaluators can use the indicators in this document to focus their evaluations, inform the selection of indicators, link these to intended outcomes, and assist in gathering credible evidence.Suggested Citation: Centers for Disease Control and Prevention. Identifying and Eliminating Tobacco-Related Disparities: Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs\u20142022. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2021.Publication date from documemt properties.2022-koi-guide-508.pd

A pilot randomised trial of a brief virtual reality scenario in smokers unmotivated to quit: Assessing the feasibility of recruitment

Individual-level interventions for smokers unmotivated to quit remain scarce and have had limited success. Little is known about the potential of virtual reality (VR) for delivering messaging to smokers unmotivated to quit. This pilot trial aimed to assess the feasibility of recruitment and acceptability of a brief, theory-informed VR scenario and estimate proximal quitting outcomes. Unmotivated smokers (recruited between February-August 2021) aged 18+ years who had access to, or were willing to receive via post, a VR headset were randomly assigned (1:1) using block randomisation to view the intervention (i.e., a hospital-based scenario with motivational stop smoking messaging) or a ‘sham’ VR scenario (i.e., a scenario about the human body without any smoking-specific messaging) with a researcher present via teleconferencing software. The primary outcome was feasibility of recruitment (i.e., achieving the target sample size of 60 participants within 3 months of recruitment). Secondary outcomes included acceptability (i.e., positive affective and cognitive attitudes), quitting self-efficacy and intention to stop smoking (i.e., clicking on a weblink with additional stop smoking information). We report point estimates and 95% confidence intervals (CIs). The study protocol was pre-registered (osf.io/95tus). A total of 60 participants were randomised within 6 months (intervention: n = 30; control: n = 30), 37 of whom were recruited within a 2-month period of active recruitment following an amendment to gift inexpensive (£7) cardboard VR headsets via post. The mean (SD) age of participants was 34.4 (12.1) years, with 46.7% identifying as female. The mean (SD) cigarettes smoked per day was 9.8 (7.2). The intervention (86.7%, 95% CI = 69.3%-96.2%) and control (93.3%, 95% CI = 77.9%-99.2%) scenarios were rated as acceptable. Quitting self-efficacy and intention to stop smoking in the intervention (13.3%, 95% CI = 3.7%-30.7%; 3.3%, 95% CI = 0.1%-17.2%) and control (26.7%, 95% CI = 12.3%-45.9%; 0%, 95% CI = 0%-11.6%) arm were comparable. The target sample size was not achieved within the feasibility window; however, an amendment to gift inexpensive headsets via post appeared feasible. The brief VR scenario appeared acceptable to smokers unmotivated to quit

An Evaluation of the State Tobacco Activities Tracking and Evaluation (STATE) System: Cross-Promoting Healthy People 2020

The State Tobacco Activities Tracking and Evaluation (STATE) System is an interactive web-based application and data tool providing up-to-date state-level information related to tobacco use. Indicators in STATE present data related to current and former tobacco use, smoking cessation, funding, tobacco-related health costs, and tobacco control policies. The STATE System also serves as a primary data source for many objectives in Healthy People 2020’s Tobacco Use chapter. Currently, there is no common thread between access to information pertaining to Healthy People 2020 objectives and STATE System data. For this reason, a comprehensive evaluation was conducted of the STATE System’s individual reports and static web-content as it relates to Healthy People 2020 objectives. Implications for research and evaluation are intended to educate the Office on Smoking and Health’s staff & colleagues in the states, networks, and territories on identifiable, cross-promotional opportunities that highlight both state and national data

Operator-based approaches to harm minimisation in gambling: summary, review and future directions

In this report we give critical consideration to the nature and effectiveness of harm minimisation in gambling. We identify gambling-related harm as both personal (e.g., health, wellbeing, relationships) and economic (e.g., financial) harm that occurs from exceeding one’s disposable income or disposable leisure time. We have elected to use the term ‘harm minimisation’ as the most appropriate term for reducing the impact of problem gambling, given its breadth in regard to the range of goals it seeks to achieve, and the range of means by which they may be achieved. The extent to which an employee can proactively identify a problem gambler in a gambling venue is uncertain. Research suggests that indicators do exist, such as sessional information (e.g., duration or frequency of play) and negative emotional responses to gambling losses. However, the practical implications of requiring employees to identify and interact with customers suspected of experiencing harm are questionable, particularly as the employees may not possess the clinical intervention skills which may be necessary. Based on emerging evidence, behavioural indicators identifiable in industryheld data, could be used to identify customers experiencing harm. A programme of research is underway in Great Britain and in other jurisdiction

The organisation and delivery of health improvement in general practice and primary care: a scoping study

Background This project examines the organisation and delivery of health improvement activities by and within general practice and the primary health-care team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices, how individual practices and the primary health-care team organise such public health activities, and how these contribute to health improvement. Our focus was on health promotion and ill-health prevention activities. Aims The aim of this scoping exercise was to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary health-care team. The key objectives were to provide an overview of the range and type of health improvement activities, identify gaps in knowledge and areas for further empirical research. Our specific research objectives were to map the range and type of health improvement activity undertaken by general practice staff and the primary health-care team based within general practice; to scope the literature on health improvement in general practice or undertaken by health-care staff based in general practice and identify gaps in the evidence base; to synthesise the literature and identify effective approaches to the delivery and organisation of health improvement interventions in a general practice setting; and to identify the priority areas for research as defined by those working in general practice. Methods We undertook a comprehensive search of the literature. We followed a staged selection process involving reviews of titles and abstracts. This resulted in the identification of 1140 papers for data extraction, with 658 of these papers selected for inclusion in the review, of which 347 were included in the evidence synthesis. We also undertook 45 individual and two group interviews with primary health-care staff. Findings Many of the research studies reviewed had some details about the type, process or location, or who provided the intervention. Generally, however, little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches, with practices engaging in both primary and secondary prevention. The range of activities suggests that general practitioners do not take a population approach but focus on individual patients. However, it is clear that many general practitioners see health promotion as an integral part of practice, whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Our key conclusion is that there is currently insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care more widely. Future Research Future research on health improvement in general practice and by the primary health-care team needs to move beyond clinical research to include delivery systems and be conducted in a primary care setting. More research needs to examine areas where there are chronic disease burdens – cancer, dementia and other disabilities of old age. Reviews should be commissioned that examine the whole prevention pathway for health problems that are managed within primary care drawing together research from general practice, pharmacy, community engagement, etc

Self-Exempting Beliefs and Intention to Quit Smoking within a Socially Disadvantaged Australian Sample of Smokers

An investigation of beliefs used to rationalise smoking will have important implications for the content of anti-smoking programs targeted at socioeconomically disadvantaged groups, who show the lowest rates of cessation in the population. This study aimed to assess the types of self-exempting beliefs reported by a sample of socioeconomically disadvantaged smokers, and identify associations between these beliefs and other smoking-related factors with quit intentions. A cross-sectional survey was conducted from March–December 2012 with smokers seeking welfare assistance in New South Wales (NSW), Australia (n= 354; response rate 79%). Responses to a 16-item self-exempting beliefs scale and intention to quit, smoker identity, and enjoyment of smoking were assessed. Most participants earned <AUD$400/week (70%), and had not completed secondary schooling (64%). All “jungle” beliefs (normalising the dangers of smoking due to ubiquity of risk) and selected “skeptic” beliefs were endorsed by 25%–47% of the sample, indicating these smokers may not fully understand the extensive risks associated with smoking. Smokers with limited quit intentions held significantly stronger self-exempting beliefs than those contemplating or preparing to quit (all p< 0.01). After adjusting for smoking-related variables only “skeptic” beliefs were significantly associated with intention to quit (p= 0.02). Some of these beliefs are incorrect and could be addressed in anti-smoking campaigns