Randomized Controlled Trial of a Computer-Based, Tailored Intervention to Increase Smoking Cessation Counseling by Primary Care Physicians

OBJECTIVE: The primary care visit represents an important venue for intervening with a large population of smokers. However, physician adherence to the Smoking Cessation Clinical Guideline (5As) remains low. We evaluated the effectiveness of a computer-tailored intervention designed to increase smoking cessation counseling by primary care physicians. METHODS: Physicians and their patients were randomized to either intervention or control conditions. In addition to brief smoking cessation training, intervention physicians and patients received a one-page report that characterized the patients’ smoking habit and history and offered tailored recommendations. Physician performance of the 5As was assessed via patient exit interviews. Quit rates and smoking behaviors were assessed 6 months postintervention via patient phone interviews. Intervention effects were tested in a sample of 70 physicians and 518 of their patients. Results were analyzed via generalized and mixed linear modeling controlling for clustering. MEASUREMENTS AND MAIN RESULTS: Intervention physicians exceeded controls on “Assess” (OR 5.06; 95% CI 3.22, 7.95), “Advise” (OR 2.79; 95% CI 1.70, 4.59), “Assist–set goals” (OR 4.31; 95% CI 2.59, 7.16), “Assist–provide written materials” (OR 5.14; 95% CI 2.60, 10.14), “Assist–provide referral” (OR 6.48; 95% CI 3.11, 13.49), “Assist–discuss medication” (OR 4.72;95% CI 2.90, 7.68), and “Arrange” (OR 8.14; 95% CI 3.98, 16.68), all p values being < 0.0001. Intervention patients were 1.77 (CI 0.94, 3.34,p = 0.078) times more likely than controls to be abstinent (12 versus 8%), a difference that approached, but did not reach statistical significance, and surpassed controls on number of days quit (18.4 versus 12.2, p < .05) but not on number of quit attempts. CONCLUSIONS: The use of a brief computer-tailored report improved physicians’ implementation of the 5As and had a modest effect on patients’ smoking behaviors 6 months postintervention

Dual use of combustible and electronic cigarettes: patterns and associations between products

Background The use of electronic cigarettes (e-cigarettes) has increased dramatically over the past decade. Although the majority of users report initiating e-cigarette use (vaping) to quit or reduce use of combustible cigarettes (smoking), a substantial proportion become “dual users” of both. Little is known about the patterns of dual use of, and dependence on, these products. This study describes those patterns as well as associations between smoking with vaping variables. Methods During 2016-17, 2894 dual users were recruited into a 2-year longitudinal study testing nicotine cessation interventions. Inclusion criteria required at least weekly use of both products. This report uses baseline questionnaire data collected via mail or Internet before randomization. Descriptive and inferential statistics were calculated. Results Participants' mean age was 29.9 ( SD 11.3) years, and 63% were male. They reported smoking a median of 16-20 cigarettes per day (CPD) for a mean of 13 years before vaping, which was initiated a median of 13-24 months earlier. Smoking declined to 6-10 CPD currently, with 79% reporting decreased and 3% reporting increased smoking. 69% reported daily vaping, with 57% reporting vaping “continuously” or at least 30 times/day. CPD was inversely related to both weekly (days) and daily (uses) vaping frequency ( p s < .001), but positively associated with nicotine dosage of the e-cigarette solution ( p < .001). Duration of vaping was not associated with cigarette use (CPD, time to first cigarette) or dependence, but was positively associated with a measure of e-cigarette dependence ( p < .001). Additional results will be reported. Conclusions The current cross-sectional findings suggest that vaping may reduce and partially replace cigarette use. However, e-cigarette dependence may increase over time without further reduction in smoking among those who maintain dual use. Future results from this longitudinal study should clarify use patterns, with implications for both tobacco intervention and policy

E‐cigarettes and expectancies: why do some users keep smoking?

BACKGROUND AND AIMS: Many smokers who have tried electronic cigarettes (“e-cigarettes”) continue to smoke, perhaps influenced by their beliefs about the outcomes of using e-cigarettes (“e-cigarette expectancies”). The primary aims of this study were to compare expectancies of dual users to former smokers, and to examine the association between expectancies and intentions to quit or reduce “vaping” among former smokers. DESIGN AND SETTING: A large cross-sectional online survey of e-cigarette users conducted in the USA. PARTICIPANTS: We surveyed current e-cigarette users (N=1815), including both current cigarette smokers (“dual users,” n=381) and former smokers (n=1434). We further subdivided former smokers into those with (n=686) and without (n=748) intentions to reduce or quit e-cigarette use. MEASUREMENTS: The primary outcomes were self-reported past-month smoking status and, among former smokers, current intentions to reduce or quit e-cigarette use, both adjusted for potential confounders. E-cigarette expectancy items were primarily derived from a previously validated measure of smoking expectancies. FINDINGS: Dual users reported less positive expectancies than former smokers about e-cigarettes, rating e-cigarettes as more physically irritating (β=−0.10, p<0.001) and addictive (β=0.06, p=0.016), as well as less satisfying (β= −0.11, p<0.001). Former smokers with intentions to quit e-cigarettes also rated e-cigarettes less positively than former smokers without intentions to quit e-cigarettes, rating them more likely to damage health (β=0.16, p<0.001) and cause addiction (β=0.10, p<0.001), but less likely to taste good (β= −0.08, p=0.006). CONCLUSIONS: Positive e-cigarette expectancies among e-cigarette users are associated with a greater likelihood of having quit smoking, but lower likelihood of intention to quit e-cigarette use

E-cigarettes and Expectancies: Why Do Some Users Keep Smoking?

Background and aims: Many smokers who have tried electronic cigarettes (‘e-cigarettes’) continue to smoke, perhaps influenced by their beliefs about the outcomes of using e-cigarettes (‘e-cigarette expectancies’). The primary aims of this study were to compare expectancies of dual users to former smokers, and to examine the association between expectancies and intentions to quit or reduce ‘vaping’ among former smokers. Design and Setting Design and Setting: A large cross-sectional online survey of e-cigarette users conducted in the United States. Participants: We surveyed current e-cigarette users (n = 1815), including both current cigarette smokers (‘dual users’, n = 381) and former smokers (n = 1434). We further subdivided former smokers into those with (n = 686) and without (n = 748) intentions to reduce or quit e-cigarette use. Measurements: The primary outcomes were self-reported past-month smoking status and, among former smokers, current intentions to reduce or quit e-cigarette use, both adjusted for potential confounders. E-cigarette expectancy items were derived primarily from a previously validated measure of smoking expectancies. Findings: Dual users reported less positive expectancies than former smokers about e-cigarettes, rating e-cigarettes as more physically irritating (β = 0.10, P \u3c 0.001) and addictive (β = 0.06, P = 0.016), as well as less satisfying (β = –0.11, P \u3c 0.001). Former smokers with intentions to quit e-cigarettes also rated e-cigarettes less positively than former smokers without intentions to quit e-cigarettes, rating them more likely to damage health (β = 0.16, P \u3c 0.001) and cause addiction (β = 0.10, P \u3c 0.001), but less likely to taste good (β = –0.08, P = 0.006). Conclusions: Positive e-cigarette expectancies among e-cigarette users are associated with a greater likelihood of having quit smoking, but lower likelihood of intention to quit e-cigarette use

Systematic Transcreation of Self-Help Smoking Cessation Materials for Hispanic/Latino Smokers: Improving Cultural Relevance and Acceptability

Smoking-related illnesses are the leading causes of death among Hispanics/Latinos. Yet, there are few smoking cessation interventions targeted for this population. The goal of this study was to “transcreate” an existing, previously validated, English language self-help smoking cessation intervention, titled Forever Free®: Stop Smoking for Good, for Spanish-speaking smokers. Rather than simply translating the materials, our transcreation process involved culturally adapting the intervention to enhance acceptability and receptivity of the information. We utilized a multiphase qualitative approach (focus groups and learner verification interviews) to develop a linguistically and culturally relevant intervention for the diverse sub-ethnic groups of Hispanic/Latino smokers. Focus group findings indicated a need to underscore several additional cultural characteristics and themes such as the need to address familism and unique stressors faced by immigrants and to provide information regarding nicotine replacement therapy. Learner verification findings indicated a need to further emphasize financial and social benefits of quitting smoking and to discuss how family and friends can support the quit attempt. These steps led to the development of a Spanish-language smoking cessation intervention titled, Libre del cigarillo, por mi familia y por mí: Guía para dejar de fumar, that is currently being tested in a national randomized controlled trial

Systematic Transcreation of Self-Help Smoking Cessation Materials for Hispanic/Latino Smokers: Improving Cultural Relevance and Acceptability

Smoking-related illnesses are the leading causes of death among Hispanics/Latinos. Yet, there are few smoking cessation interventions targeted for this population. The goal of this study was to “transcreate” an existing, previously validated, English language self-help smoking cessation intervention, titled Forever Free®: Stop Smoking for Good, for Spanish-speaking smokers. Rather than simply translating the materials, our transcreation process involved culturally adapting the intervention to enhance acceptability and receptivity of the information. We utilized a multiphase qualitative approach (focus groups and learner verification interviews) to develop a linguistically and culturally relevant intervention for the diverse sub-ethnic groups of Hispanic/Latino smokers. Focus group findings indicated a need to underscore several additional cultural characteristics and themes such as the need to address familism and unique stressors faced by immigrants and to provide information regarding nicotine replacement therapy. Learner verification findings indicated a need to further emphasize financial and social benefits of quitting smoking and to discuss how family and friends can support the quit attempt. These steps led to the development of a Spanish-language smoking cessation intervention titled, Libre del cigarillo, por mi familia y por mí: Guía para dejar de fumar, that is currently being tested in a national randomized controlled trial

Reasons for Exclusion from a Smoking Cessation Trial: An Analysis by Race/Ethnicity

The exclusion criteria of tobacco cessation randomized clinical trials (RCTs) may have unintended consequences on inclusion and cessation disparities. We examined racial/ethnic differences in: a) exclusion from a group-based cessation RCT; and b) reasons for exclusion. Quasi-experimental. Inclusion criteria were self-identification as African American/Black, non-Hispanic White, or Hispanic (any race), adults, minimum five cigarettes/day or carbon monoxide reading of ≥ 8 parts per million (ppm), interest in quitting, and spoke/read English. Data were obtained from a parent trial, which is ongoing and will be completed in 2019. Analyses for our present study on participant screening and enrollment were conducted in 2018. Study ineligibility, and reasons for exclusion (contraindications for nicotine patch use, serious mental illness [SMI, eg, bipolar disorder or schizophrenia], alcohol dependence or illicit drug use, current tobacco treatment, attendance barriers [eg, transportation], and other concerns [eg, aggressive, intoxicated, disruptive, visibly ill]). Of 1,206 individuals screened, 36% were ineligible. The most frequent reasons were SMI (28%), alcohol dependence or drug use (10%), and attendance barriers (7%). Ineligibility was greater among African Americans (42%) and Hispanics (37%), compared with Whites (24%; P<.001). Compared with African Americans and Hispanics, Whites were more likely to be excluded for single reasons, including attendance barriers, and medical conditions (P<.05). African Americans were more than twice as likely as Whites to be excluded for 3 or more reasons (12% vs 5% respectively, P<.05). A notable proportion of smokers were ineligible for this RCT, with SMI as the greatest single cause. Racial/ethnic minorities were more likely to be excluded, with African Americans deemed ineligible for multiple reasons. Findings have implications for RCT generalizability, addressing tobacco disparities and health equity

Development of a Self-Help Smoking Cessation Intervention for Dual Users of Tobacco Cigarettes and E-Cigarettes

Most users of electronic cigarettes (e-cigarettes) report initiating use to quit combustible cigarettes. Nevertheless, high levels of dual use (i.e., using both combustible cigarettes and e-cigarettes) occur among adults. Using formative data from in-depth interviews and employing learner verification, we adapted an existing, validated self-help smoking-cessation intervention (Stop Smoking for Good; SSFG) to create a targeted intervention for dual users, If You Vape: A Guide to Quitting Smoking (IYV). In Phase I, in-depth interviews (n = 28) were conducted to assess relevance of the existing SSFG materials (10 booklets, nine pamphlets) and identify new content for the booklets. Next, for Phase II, learner verification interviews (n = 20 dual users) were conducted to assess their appeal and acceptability. Several key themes emerged from the Phase I in-depth interviews. Findings led to the inclusion of e-cigarette-specific strategies used by successful quitters such as gradually reducing nicotine levels, switching from tobacco flavor to alternative flavors, and limiting e-cigarette use to places one would normally smoke (i.e., not expanding use). Suggestions from Phase II learner verification included broadening the visual appeal for a younger, more diverse demographic, expanding tips for quitting smoking via e-cigarettes, and expanding terminology for e-cigarette devices. Beginning with an efficacious self-help intervention, we used a systematic process to develop a version specifically for dual users