Exploratory Analyses of the Popularity and Efficacy of Four Behavioral Methods of Gradual Smoking Cessation

Introduction: Around half of smokers attempt to stop by cutting-down first. Evidence suggests that this results in similar quit rates to abrupt quitting. Evidence for the effectiveness and popularity of different gradual cessation methods is sparse. / Methods: Secondary, exploratory, analyses of a randomized trial of gradual versus abrupt smoking cessation. Gradual participants (N = 342) chose between four methods of cutting-down over 2 weeks: cutting-out the easiest cigarettes first (HR-E); cutting-out the most difficult cigarettes first (HR-D); smoking on an increasing time schedule (SR); and not smoking during particular periods (SFP). Nicotine replacement therapy and behavioral support were provided before and after quit day. We used logistic and linear regression modeling to test whether the method chosen was associated with smoking reduction, quit attempts, and abstinence, while adjusting for potential confounders. / Results: Participants were on average 49 years old, smoked 20 cigarettes per day, and had a Fagerstrom Test for Cigarette Dependence score of 6. 14.9% (51/342) chose HR-E, 2.1% (7/342) HR-D, 46.2% (158/342) SFP, and 36.8% (126/342) SR. We found no evidence of adjusted or unadjusted associations between method and successful 75% reduction in cigarette consumption, reduction in percentage cigarettes per day or exhaled carbon monoxide, quit attempts, or abstinence at 4-week or 6-month follow-up. / Conclusions: Future research and practice could focus more heavily on the SR and SFP methods as these appeared notably more popular than HR. There was substantial imprecision in the efficacy data, which should be treated with caution; however, none of the gradual cessation methods showed clear evidence of being more efficacious than others. Implications: There is evidence that people who would like to quit smoking gradually should be supported to do so. However, as this is relatively new thinking and there is large potential for variation in methods, guidance on the best way to offer support is sparse. This article is an exploratory analysis of the popularity and efficacy of various methods in an attempt to move the topic forward and inform the implementation of gradual smoking cessation methods in practice. The identified popularity of some methods over others signposts directions for future research

Is a combination of varenicline and nicotine patch more effective in helping smokers quit than varenicline alone? A randomised controlled trial

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Potential explanations for conflicting findings on abrupt versus gradual smoking cessation: a population study in England

BACKGROUND AND AIM: Observational and trial evidence conflict on the efficacy of two contrasting behavioural approaches to quitting smoking – gradual and abrupt. Observational data suggests an abrupt approach to quitting is superior to a gradual approach, whilst trials show no difference. One potential explanation is self-selection in observational data, whereby people can choose their quit approach and those who find it harder to quit may be more likely to choose a gradual quit approach. This study aims to investigate potential explanations for these conflicting findings. METHODS: We used observational data from a nationally representative sample of adults in England from November 2006 to February 2020 who reported smoking and had made at least one quit attempt in the past year (n=21,542). We used logistic regression models to assess the association between abrupt versus gradual quit attempts and quit success, adjusting for sociodemographic, smoking and quit attempt characteristics. FINDINGS: Abrupt, versus gradual, attempts were associated with improved quit success in an unadjusted model (OR=2.02, 95% CI=1.86-2.19). This association remained after adjusting for a broad range of relevant confounders (OR=1.75, 95% CI=1.59-1.93). CONCLUSIONS: Among a representative sample of adults who had smoked and made a quit attempt in the past year, there was evidence of an association between abrupt attempts and quit success before and after adjusting for relevant confounders. This suggests that the differences in quit success seen between abrupt and gradual quit attempt types are not completely driven by self-selection in observational data. IMPLICATIONS: We investigated explanations for conflicting findings on the efficacy of gradual versus abrupt approaches to quitting smoking between trial and observational data. Despite adjusting observational data for sociodemographic, smoking and quit attempt characteristics, an association between abrupt quitting and quit success remained. Therefore, differences in quit success were not completely driven by self-selection of a gradual approach by people who found it especially difficult to quit or differences in the use of quitting aids. However, characteristics adjusted for were limited by the data available, and future research should continue to investigate the difference in findings across study types to inform cessation support

Effects on abstinence of nicotine patch treatment prior to quitting smoking: a parallel, two-arm, pragmatic randomised trial

Objectives Standard smoking cessation pharmacotherapy is recommended in the post-quit period, but may also facilitate abstinence if used prior to quitting. The objective was to examine the effectiveness and cost-effectiveness of nicotine patch worn for four weeks before a quit attempt. Design Randomised controlled open-label trial. Setting Primary care and smoking cessation clinics in England enrolled patients between 13/08/2012 and 10/03/2015. Participants 1792 people, mainly middle-aged and of lower socioeconomic status, who were daily smokers with tobacco dependence. Interventions Participants were randomised 1:1, using concealed randomly permuted blocks stratified by centre, to either standard smoking cessation pharmacotherapy and behavioural support or the same treatment supplemented by four weeks of 21mg nicotine patch use prior to quitting: ‘preloading’. Main outcome measures The primary outcome was biochemically confirmed six-month prolonged abstinence and secondary outcomes were prolonged abstinence at four weeks and 12 months. Results 899 people were allocated to the preloading arm and 893 to the control arm. Biochemically validated six-month abstinence, was achieved by 157/899 (17.5%) of the intervention arm and 129/893 (14.4%) of the control arm; difference (95% confidence interval) 3.0% (-0.4% to 6.4%), odds ratio (OR) 1.25 (0.97 to 1.62), p=0.08 in the primary analysis. There was an imbalance between arms in the frequency of use of varenicline for post-cessation medication and planned adjustment for this gave an odds ratio for the effect of pre-loading of 1.34 (1.03, 1.73), p=0.03, difference 3.8% (0.4% to 7.2%). At four weeks, the difference in prolonged abstinence unadjusted for varenicline use was OR 1.21 (1.00 to 1.48), difference 4.3% (0.0% to 8.7%), p=0.05 and adjusted for varenicline use it was OR 1.32 (1.08 to 1.62) p=0.007. At 12 months the OR was 1.28 (0.97 to 1.69), difference 2.7% (-0.4% to 5.8%), p=0.09 unadjusted for varenicline use and after adjustment was OR 1.36 (1.02 to 1.80) p=0.04. 5.9% of participants discontinued preloading because they could not tolerate it. Gastrointestinal symptoms, chiefly nausea, occurred in 4.0% (2.2 to 5.9) more people in the preloading than control arm. There were eight serious adverse events in the preloading arm and eight in the control arm, odds ratio OR of 0.99 (0.36 to 2.75). Conclusions In the primary analysis there was insufficient evidence to confidently demonstrate that nicotine preloading increases subsequent smoking abstinence. The beneficial effect appears to have been masked by a concurrent reduction in the use of varenicline in people using nicotine preloading and future studies should explore ways to mitigate this unintended effect

The effect of individual-level smoking cessation interventions on socioeconomic inequalities in tobacco smoking

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To investigate differences in the effectiveness of individual-level smoking cessation interventions by socioeconomic indicators, to estimate the potential that an intervention might increase or decrease health inequalities due to tobacco use

Biomarkers of potential harm in people switching from smoking tobacco to exclusive e-cigarette use, dual use or abstinence: secondary analysis of Cochrane systematic review of trials of e-cigarettes for smoking cessation

Aims This study aims to compare biomarkers of potential harm between people switching from smoking combustible cigarettes (CC) completely to electronic cigarettes (EC), continuing to smoke CC, using both EC and CC (dual users) and using neither (abstainers), based on behaviour during EC intervention studies. Design Secondary analysis following systematic review, incorporating inverse variance random-effects meta-analysis and effect direction plots. Setting This study was conducted in Greece, Italy, Poland, the United Kingdom and the United States. Participants A total of 1299 adults smoking CC (nine studies) and provided EC. Measurements Measurements were conducted using carbon monoxide (CO) and 26 other biomarkers. Findings In pooled analyses, exhaled CO (eCO) was lower in EC versus EC + CC [mean difference (MD) = −4.40 parts per million (p.p.m.), 95% confidence interval (CI) = −12.04 to 3.24, two studies] and CC (MD = −9.57 p.p.m., 95% CI = −17.30 to −1.83, three studies). eCO was lower in dual users versus CC only (MD = −1.91 p.p.m., 95% CI = −3.38 to −0.45, two studies). Magnitude rather than direction of effect drove substantial statistical heterogeneity. Effect direction plots were used for other biomarkers. Comparing EC with CC, 12 of 13 biomarkers were significantly lower in EC users, with no difference for the 13th. Comparing EC with dual users, 12 of the 25 biomarkers were lower for EC, and five were lower for dual use. For the remaining eight measures, single studies did not detect statistically significant differences, or the multiple studies contributing to the outcome had inconsistent results. Only one study provided data comparing dual use with CC; of the 13 biomarkers measured, 12 were significantly lower in the dual use group, with no statistically significant difference detected for the 13th. Only one study provided data on abstainers. Conclusions Switching from smoking to vaping or dual use appears to reduce levels of biomarkers of potential harm significantly

Mindfulness for smoking cessation (Review)

Review - InterventionBackground Mindfulness-based smoking cessation interventions may aid smoking cessation by teaching individuals to pay attention to, and work mindfully with, negative aFective states, cravings, and other symptoms of nicotine withdrawal. Types of mindfulness-based interventions includemindfulness training,whichinvolves training inmeditation; acceptance andcommitmenttherapy (ACT);distress tolerance training; and yoga. Objectives To assess the eFicacy of mindfulness-based interventions for smoking cessation among people who smoke, and whether these interventions have an eFect on mental health outcomes. Search methods We searched the Cochrane Tobacco Addiction Group's specialised register, CENTRAL, MEDLINE, Embase, PsycINFO, and trial registries to 15 April 2021. We also employed an automated search strategy, developed as part oftheHuman Behaviour Change Project, using MicrosoI Academic. Selection criteria We included randomised controlled trials (RCTs) and cluster-RCTs that compared a mindfulness-based intervention for smoking cessation with another smoking cessation programme or no treatment, and assessed smoking cessation at six months orlonger.We excluded studies that solely recruited pregnant women. Data collection and analysis We followed standard Cochrane methods. We measured smoking cessation at the longest time point, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of intervention and type of comparator. We carried out meta analyses where appropriate, using Mantel-Haenszel random-eFects models. We summarised mental health outcomes narratively. Main results We included 21 studies, with 8186 participants. Mostrecruited adults from the community, and the majority (15 studies) were conducted in the USA. We judged four of the studies to be at low risk of bias, nine at unclear risk, and eight at high risk. Mindfulness-based interventions varied considerably in design and content, as did comparators, therefore, we pooled small groups of relatively comparable studies. We did not detect a clear benefit or harm of mindfulness training interventions on quit rates compared with intensity-matched smoking cessation treatment (RR 0.99, 95% CI 0.67 to 1.46; I 2 = 0%; 3 studies, 542 participants; low-certainty evidence), less intensive smoking cessation treatment (RR 1.19, 95% CI 0.65 to 2.19; I 2 = 60%; 5 studies, 813 participants; very low-certainty evidence), or no treatment (RR 0.81, 95% CI 0.43 to 1.53; 1 study, 325 participants; low-certainty evidence). In each comparison, the 95% CI encompassed benefit (i.e. higher quit rates), harm (i.e. lower quit rates) and no diFerence. In one study of mindfulness-based relapse prevention, we did not detect a clear benefit or harm of the intervention over no treatment (RR 1.43, 95% CI 0.56 to 3.67; 86 participants; very low-certainty evidence). We did not detect a clear benefit or harm of ACT on quit rates compared with less intensive behavioural treatments, including nicotine replacementtherapy alone (RR1.27, 95% CI 0.53 to 3.02; 1 study, 102 participants; low-certainty evidence), brief advice (RR1.27, 95% CI 0.59 to 2.75; 1 study, 144 participants; very low-certainty evidence), or less intensive ACT (RR 1.00, 95% CI 0.50 to 2.01; 1 study, 100 participants; low-certainty evidence). There was a high level of heterogeneity (I 2 = 82%) across studies comparing ACT with intensity-matched smoking cessation treatments, meaning it was not appropriate to report a pooled result. We did not detect a clear benefit or harm of distress tolerance training on quit rates compared with intensity-matched smoking cessation treatment (RR 0.87, 95% CI 0.26 to 2.98; 1 study, 69 participants; low-certainty evidence) or less intensive smoking cessation treatment (RR 1.63, 95% CI 0.33 to 8.08; 1 study, 49 participants; low-certainty evidence). We did not detect a clear benefit or harm of yoga on quit rates compared with intensity-matched smoking cessation treatment (RR 1.44, 95% CI 0.40 to 5.16; 1 study, 55 participants; very low-certainty evidence). Excluding studies at high risk of bias did not substantially alterthe results, nor did using complete case data as opposed to using data from all participants randomised. Nine studies reported on changes in mental health and well-being, including depression, anxiety, perceived stress, and negative and positive aFect. Variation in measures and methodological diFerences between studies meant we could not meta-analyse these data. One study found a greater reduction in perceived stress in participants who received a face-to-face mindfulness training programme versus an intensity-matched programme.However,the remaining eight studies found no clinically meaningful diFerences in mental health and well being between participantswho received mindfulness-based treatments and participantswho received anothertreatment or no treatment (very low-certainty evidence). Authors' conclusions We did not detect a clear benefit of mindfulness-based smoking cessation interventions for increasing smoking quit rates or changing mental health and well-being. This was the case when compared with intensity-matched smoking cessation treatment, less intensive smoking cessation treatment, or no treatment. However, the evidence was of low and very low certainty due to risk of bias, inconsistency, and imprecision, meaning future evidence may very likely change our interpretation of the results. Further RCTs of mindfulness-based interventions for smoking cessation compared with active comparators are needed. There is also a need for more consistent reporting of mental health and well-being outcomes in studies of mindfulness-based interventions for smoking cessation

Electronic cigarettes and subsequent cigarette smoking in young people

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To assess the evidence on the relationship between the use and availability of e-cigarettes and subsequent cigarette smoking in young people (aged 29 years or less), and whether the relationship differs by socioeconomic status, gender, or other demographic characteristics

Longer-term use of electronic cigarettes when provided as a stop smoking aid: Systematic review with meta-analyses.

Moderate certainty evidence supports use of nicotine electronic cigarettes to quit smoking combustible cigarettes. However, there is less certainty regarding how long people continue to use e-cigarettes after smoking cessation attempts. We set out to synthesise data on the proportion of people still using e-cigarettes or other study products at 6 months or longer in studies of e-cigarettes for smoking cessation. We updated Cochrane searches (November 2021). For the first time, we meta-analysed prevalence of continued e-cigarette use among individuals allocated to e-cigarette conditions, and among those individuals who had successfully quit smoking. We updated meta-analyses comparing proportions continuing product use among individuals allocated to use nicotine e-cigarettes and other treatments. We included 19 studies (n = 7787). The pooled prevalence of continued e-cigarette use at 6 months or longer was 54% (95% CI: 46% to 61%, I2 86%, N = 1482) in participants assigned to e-cigarette conditions. Of participants who had quit combustible cigarettes overall 70% were still using e-cigarettes at six months or longer (95% CI: 53% to 82%, I2 73%, N = 215). Heterogeneity in direction of effect precluded meta-analysis comparing long-term use of nicotine e-cigarettes with NRT. More people were using nicotine e-cigarettes at longest follow-up compared to non-nicotine e-cigarettes, but CIs included no difference (risk ratio 1.15, 95% CI: 0.94 to 1.41, n = 601). The levels of continued e-cigarette use observed may reflect the success of e-cigarettes as a quitting tool. Further research is needed to establish drivers of variation in and implications of continued use of e-cigarettes