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

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

Motivational interviewing for smoking cessation.

BACKGROUND: Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to stop smoking. OBJECTIVES: To evaluate the efficacy of MI for smoking cessation compared with no treatment, in addition to another form of smoking cessation treatment, and compared with other types of smoking cessation treatment. We also investigated whether more intensive MI is more effective than less intensive MI for smoking cessation. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialised Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. We also searched trial registries to identify unpublished studies. Date of the most recent search: August 2018. SELECTION CRITERIA: Randomised controlled trials in which MI or its variants were offered to smokers to assist smoking cessation. We excluded trials that did not assess cessation as an outcome, with follow-up less than six months, and with additional non-MI intervention components not matched between arms. We excluded trials in pregnant women as these are covered elsewhere. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RR) and 95% confidence intervals (CI) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models. We extracted data on mental health outcomes and quality of life and summarised these narratively. MAIN RESULTS: We identified 37 eligible studies involving over 15,000 participants who smoked tobacco. The majority of studies recruited participants with particular characteristics, often from groups of people who are less likely to seek support to stop smoking than the general population. Although a few studies recruited participants who intended to stop smoking soon or had no intentions to quit, most recruited a population without regard to their intention to quit. MI was conducted in one to 12 sessions, with the total duration of MI ranging from five to 315 minutes across studies. We judged four of the 37 studies to be at low risk of bias, and 11 to be at high risk, but restricting the analysis only to those studies at low or unclear risk did not significantly alter results, apart from in one case - our analysis comparing higher to lower intensity MI.We found low-certainty evidence, limited by risk of bias and imprecision, comparing the effect of MI to no treatment for smoking cessation (RR = 0.84, 95% CI 0.63 to 1.12; I2 = 0%; adjusted N = 684). One study was excluded from this analysis as the participants recruited (incarcerated men) were not comparable to the other participants included in the analysis, resulting in substantial statistical heterogeneity when all studies were pooled (I2 = 87%). Enhancing existing smoking cessation support with additional MI, compared with existing support alone, gave an RR of 1.07 (95% CI 0.85 to 1.36; adjusted N = 4167; I2 = 47%), and MI compared with other forms of smoking cessation support gave an RR of 1.24 (95% CI 0.91 to 1.69; I2 = 54%; N = 5192). We judged both of these estimates to be of low certainty due to heterogeneity and imprecision. Low-certainty evidence detected a benefit of higher intensity MI when compared with lower intensity MI (RR 1.23, 95% CI 1.11 to 1.37; adjusted N = 5620; I2 = 0%). The evidence was limited because three of the five studies in this comparison were at risk of bias. Excluding them gave an RR of 1.00 (95% CI 0.65 to 1.54; I2 = n/a; N = 482), changing the interpretation of the results.Mental health and quality of life outcomes were reported in only one study, providing little evidence on whether MI improves mental well-being. AUTHORS' CONCLUSIONS: There is insufficient evidence to show whether or not MI helps people to stop smoking compared with no intervention, as an addition to other types of behavioural support for smoking cessation, or compared with other types of behavioural support for smoking cessation. It is also unclear whether more intensive MI is more effective than less intensive MI. All estimates of treatment effect were of low certainty because of concerns about bias in the trials, imprecision and inconsistency. Consequently, future trials are likely to change these conclusions. There is almost no evidence on whether MI for smoking cessation improves mental well-being

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

Attitudes of parents towards the ‘Fit Together’ childhood obesity prevention programme: a qualitative study

Background: The latest available data for England show that childhood obesity continues to be a major public health concern with 9.3% of 4–5 years old and 18.9% of 10–11 years old children found to be obese (1). The aim of the study was to explore attitudes towards a community based childhood obesity prevention project among parents participating in the programme. Methods: The ‘Fit Together’ programme was provided in socio-economically deprived areas of Leeds which, at the time of the research study, was in its final year of running. The programme was delivered for 2 hours each week over a six week period by community health educators, and involved health education and cooking sessions. A convenience sample of parents who had attended at least one session of the Fit Together programme, delivered between November-December 2014, were recruited from a children’s centre (where families access health advice and related activities with their children aged 0– 5yr) and a primary school. Semi-structured interviews were conducted using a topic schedule with prompts, and were digitally recorded. A short screening questionnaire was completed to obtain demographic information. Three parents were present in each of the two Fit Together sessions allocated for recruitment. These six parents were recruited to the study and were interviewed. Interviews were transcribed verbatim, transcripts manually coded and thematic analysis conducted using a framework approach. Ethical approval for the study was obtained from the Faculty of Health & Social Sciences Local Research Ethics Coordinator, Leeds Beckett University. Results: Participants were all mothers with 1–3 children, and mean age was 27 years. Four participants self-defined their ethnicity as White British and the remaining two as Pakistani. Themes emerging from the interview data suggested that participants’ appraisal of the programme was positive and they reported benefits in behaviour change relevant to addressing childhood obesity. Parents felt the programme was logistically suitable, and had appropriate content and leaders. All participants would recommend the programme and highlighted the development of their cooking skills, which related to an increase in home cooking and in fruit and vegetable consumption. The opportunity to involve their children and spend time with them learning skills was a strongly held view among respondents. Parents felt the programme had also increased their awareness of nutrition content and children’s dietary habits. However, the view that an extended programme and subsequent follow-up were needed was commonly held. Additional benefits beyond behaviour change were also expressed. For example, the importance of social interaction was clear, with respondents reporting the alleviation of boredom and isolation while attending the programme, as this participant states: “Something to do ain’t it? Gets you out. There’s nothing else to go to” (White British, 23yr, 2 children). Participants also reported exchanging cultural beliefs and learning new styles of cooking from people from different backgrounds. Discussion: The findings of this first exploration of parents’ attitudes to Fit Together supports existing literature on the value of community educators in delivering health interventions (2). Beneficial behaviour change such as increased homecooking was consistent with previous programmes (3). Conclusion: Attitudes towards Fit Together were positive, with mothers viewing the programme as acceptable and bene- ficial. References 1. Stevens. L., & Nelson, M. The contribution of school meals and packed lunch to food consumption and nutrient intakes in UK primary school children from a low income population. Journal of Human Nutrition and Dietetics, 24; 223–232. 2011. 2. Evans, C., & Harper, C. A History and Review of school meals standards in the UK. Journal of Human Nutrition and Dietetics, 89–99. 2009. 3. Lop ez Nomdedeu, C. Agencia Espanola de Seguridad Alimentaria y Nutricion. Ministerio de Sanidad y Consum. La alimentacion de tus ni nos. Nutrici ~ on Saludable de la Infan- cia a la Adolescencia. Madrid: Fiselgraf, S.L. 2002

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

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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Nicotine patch preloading for smoking cessation (the preloading trial): study protocol for a randomized controlled trial

Background: The use of nicotine replacement therapy before quitting smoking is called nicotine preloading. Standard smoking cessation protocols suggest commencing nicotine replacement therapy only on the first day of quitting smoking (quit day) aiming to reduce withdrawal symptoms and craving. However, other, more successful smoking cessation pharmacotherapies are used prior to the quit day as well as after. Nicotine preloading could improve quit rates by reducing satisfaction from smoking prior to quitting and breaking the association between smoking and reward. A systematic literature review suggests that evidence for the effectiveness of preloading is inconclusive and further trials are needed. Methods/Design: This is a study protocol for a multicenter, non-blinded, randomized controlled trial based in the United Kingdom, enrolling 1786 smokers who want to quit, funded by the National Institute for Health Research, Health Technology Assessment program, and sponsored by the University of Oxford. Participants will primarily be recruited through general practices and smoking cessation clinics, and randomized (1:1) either to use 21 mg nicotine patches, or not, for four weeks before quitting, whilst smoking as normal. All participants will be referred to receive standard smoking cessation service support. Follow-ups will take place at one week, four weeks, six months and 12 months after quit day. The primary outcome will be prolonged, biochemically verified six-month abstinence. Additional outcomes will include point prevalence abstinence and abstinence of four-week and 12-month duration, side effects, costs of treatment, and markers of potential mediators and moderators of the preloading effect. Discussion: This large trial will add substantially to evidence on the effectiveness of nicotine preloading, but also on its cost effectiveness and potential mediators, which have not been investigated in detail previously. A range of recruitment strategies have been considered to try and compensate for any challenges encountered in recruiting the large sample, and the multicentre design means that knowledge can be shared between recruitment teams. The pragmatic study design means that results will give a realistic estimate of the success of the intervention if it were to be rolled out as part of standard smoking cessation service practice. Trial registration: Current Controlled Trials ISRCTN33031001. Registered 27 April 2012