Proactive, motivationally enhanced smoking cessation counseling among women with elevated cervical cancer risk.

Current treatment guidelines recommend that all smokers be given motivational or action-oriented counseling, as is appropriate to their readiness to quit smoking. The present study assessed the acceptability and impact of a proactively delivered, motivationally tailored phone counseling program targeted to women with elevated risk for cervical cancer. Female smokers with a recent abnormal pap exam or a colposcopy were contacted and invited to participate, regardless of their interest in quitting smoking. Participants were randomly assigned to usual care (UC) or UC plus motivationally enhanced phone counseling (MEC). The intervention was well received: 79% of eligible women enrolled (n = 275), and 90% completed at least three of four calls. Participation did not vary by baseline motivation to quit. Compared with control subjects, counseling participants were more likely to seek additional treatment services and had a higher 7-day point-prevalence abstinence rate at 6 months (20% MEC vs. 12% UC, p<.05). MEC impact was sustained at 12 months, but abstinence increased among the UC group (18% MEC vs. 20% UC, p = ns). There was no difference in repeated point-prevalence abstinence at 6 and 12 months (11% MEC vs. 10% UC, p = ns). Outcomes were similar in a subgroup of 229 women who, at baseline, were interested in quitting in the next 6 months.     

Hypnosis for smoking cessation: a randomized trial

The purpose of this study was to determine whether hypnosis would be more effective in helping smokers quit than standard behavioral counseling when both interventions are combined with nicotine patches (NP). A total of 286 current smokers were enrolled in a randomized controlled smoking cessation trial at the San Francisco Veterans Affairs Medical Center. Participants in both treatment conditions were seen for two 60-min sessions, and received three follow-up phone calls and 2 months of NP. At 6 months, 29% of the hypnosis group reported 7-day point-prevalence abstinence compared with 23% of the behavioral counseling group (relative risk [RR] = 1.27; 95% confidence interval, CI 0.84-1.92). Based on biochemical or proxy confirmation, 26% of the participants in the hypnosis group were abstinent at 6 months compared with 18% of the behavioral group (RR = 1.44; 95% CI 0.91-2.30). At 12 months, the self-reported 7-day point-prevalence quit rate was 24% for the hypnosis group and 16% for the behavioral group (RR = 1.47; 95% CI 0.90-2.40). Based on biochemical or proxy confirmation, 20% of the participants in the hypnosis group were abstinent at 12 months compared with 14% of the behavioral group (RR = 1.40; 95% CI 0.81-2.42). Among participants with a history of depression, hypnosis yielded significantly higher validated point-prevalence quit rates at 6 and 12 months than standard treatment. It was concluded that hypnosis combined with NP compares favorably with standard behavioral counseling in generating long-term quit rates.     

Evaluating the effectiveness of a single telephone contact as an adjunct to a self-help intervention for smoking cessation in a randomized controlled trial.

This study evaluated the effects of including a single brief prequit telephone counseling session in a self-help program for smoking cessation conducted through the mail, by comparison with the effects of the self-help program alone. Volunteer participants from northwestern Spain (N = 228) were randomly assigned to one of two groups: (a) the self-help-only group (n = 110, mean age = 37.4 years, pretreatment cigarette consumption = 26.5 cigarettes/day) or (b) the telephone-support group (n = 118, mean age = 36.8 years, pretreatment cigarette consumption = 27.7 cigarettes/day). Using a conservative data analysis method (missing data considered as treatment failures), we found that the point-prevalence abstinence rate was significantly higher in the telephone-support group than in the self-help-only group at the end of treatment (44.9% vs. 21.8%) and at the 3-month follow-up (39.0% vs. 26.4%). Likewise, sustained abstinence was significantly higher in the telephone-support group at the 3-month follow-up (33.9% vs. 13.6%), the 6-month follow-up (25.4% vs. 12.7%), and the 12-month follow-up (21.2% vs. 9.1%). The results of this randomized controlled trial indicate that both treatments are an effective aid for smoking cessation, and that a single brief telephone call before the quit date is a low-cost and effective procedure for improving abstinence rates in a mailed self-help program.     

Smokers' attitudes and behaviors related to consumer demand for cessation counseling in the medical care setting.

This study describes a new segmentation strategy exploring smokers' interest levels in counseling in the medical care setting in order to understand how public health communications can be designed to increase consumer demand for cessation services within this population. A subsample of 431 smokers from a large, nationally representative mail survey was analyzed and categorized into three cessation-demand groups: Low demand (LD), medium demand (MD), and high demand (HD). HD smokers were most likely to be heavy smokers, to make quitting a high priority, and to have self-efficacy in quitting. MD and LD smokers were less likely than HD smokers to have been told to quit smoking by a health care provider in the past or to believe that counseling is effective. The first step in the regression analysis revealed that age, cigarettes smoked per month, whether smokers were currently trying to quit, and whether they were ever told to quit smoking by their health care provider accounted for 21% of the variance in smokers' interest in smoking cessation counseling, F(4, 234) = 16.49, p<.001. When additional variables on attitudes toward smoking and quitting and perceived effectiveness of receiving counseling in the medical care setting were added to the model, an additional 11% of the variance in smokers' interest in cessation counseling was explained, F(12, 234) = 10.07, p<.001. Results suggest that by categorizing smokers by interest level in cessation counseling, we emerge with three distinct portraits of smokers who might be activated in different ways to increase consumer demand for cessation counseling.     

Smokers' interest in using nicotine replacement to aid smoking reduction.

In recent years the public health community has considered the risks and benefits of encouraging smokers to reduce their smoking, perhaps with the aid of nicotine replacement therapy (NRT). Little is known, however, about whether smokers themselves are interested in smoking reduction; whether they see reduction as an endpoint, or primarily as a route to cessation; or whether they are receptive to the notion of using NRT to achieve reduction. We conducted a population-based national telephone survey of 1,000 current daily cigarette smokers (499 male, 501 female). Most smokers (57%) reported previously trying to reduce their smoking, and many (26%) said that they plan to reduce within the next year. Almost half of those planning to quit in the next 12 months (44%) preferred to quit via gradual cessation and most (68%) indicated that they would consider using a reduction product or medication. Respondents reported that they would prefer a product with a cessation endpoint rather than a reduction endpoint (63% vs. 21%). Interest in reduction was highest among smokers who were less interested in quitting and among heavier smokers. We conclude that many smokers are interested in gradually reducing prior to quitting and that promoting reduction is unlikely to undermine motivation to quit smoking.     

The impact of carotid plaque screening on motivation for smoking cessation.

Showing smokers their own atherosclerotic plaques might increase motivation for smoking cessation, since they underestimate their own risk for smoking-related diseases. To assess the feasibility and optimal processes of studying the impact of carotid atherosclerotic plaque screening in smokers, we enrolled 30 daily cigarette smokers, aged 40-70 years, in an observational pre-post pilot study. All smokers underwent smoking cessation counseling, nicotine replacement therapy, a carotid ultrasound, an educational tutorial on atherosclerosis, baseline and 2-month motivation to change assessment, and assessment of smoking cessation at 2 months. Participants had a mean smoking duration of 34 years (SD = 7). Carotid plaques were present in 22 smokers (73%). Between baseline and 2 months after plaque screening, motivation for smoking cessation increased from 7.4 to 8.4 out of 10 (p = .02), particularly in those with plaques (7.2 to 8.7, p = .008). At 2 months, the smoking quit rate was 63%, with a quit rate of 73% in those with plaques vs. 38% in those without plaques (p = .10). Perceived stress, anxiety, and depression did not increase after screening. 96% of respondents answered correctly at least 80% of questions regarding atherosclerosis knowledge at baseline and after 2 months. In conclusion, studying the process of screening for carotid plaques for the purpose of increasing motivation for smoking cessation, in addition to counseling and drug therapy for smoking cessation in long-term smokers, appears feasible. The impact of carotid plaque screening on smoking cessation should be examined in larger randomized controlled trials with sufficient power to assess the impact on long-term smoking cessation rates.     

Sex differences in long-term smoking cessation rates due to nicotine patch

Compared to men, women may be at greater risk for smoking-related diseases and have greater difficulty quitting smoking. Sex differences in medication response could guide treatment for smoking cessation to improve women's quit rates. We conducted a meta-analysis of the 14 placebo-controlled nicotine patch trials (N = 6,250) for which long-term (6 months) clinical outcome results could be determined separately by sex. This analysis updated a meta-analysis of 11 of these trials that found no significant sex differences due to nicotine patch. The increase in quitting due to the nicotine vs. placebo patch was only about half as large in women as in men. Pooled absolute quit rates at 6 months for nicotine and placebo patch, respectively, were 20.1% and 10.8% in men, and 14.7% and 10.1% in women. The odds ratio for quitting due to nicotine vs. placebo patch was lower in women (OR = 1.61) than in men (OR = 2.20), with an interaction odds ratio of 1.40 (95% CI = 1.02-1.93, p = .04). This sex difference did not vary significantly by whether or not formal counseling was provided. Poorer outcomes in women vs. men treated with nicotine patch suggests that increasing the quit rates of women smokers may require supplementing patch treatment or use of other medications.     

Overcoming barriers to recruitment and retention in adolescent smoking cessation.

Participant recruitment and retention have been identified as challenging aspects of adolescent smoking cessation interventions. Problems associated with low recruitment and retention include identifying smokers, obtaining active parental consent, protecting participants' privacy, respecting participants' autonomy, and making participation relevant and accessible to adolescents. This paper describes nine strategies for minimizing these recruitment and retention problems via a proactive telephone counseling intervention, and reports on their simultaneous implementation among 1,058 smokers from 25 high schools in Washington state. Results are as follows: (a) 85.9% of parents of minor-age seniors provided active consent for their teen's participation, (b) 89.8% of eligible smokers were successfully contacted by counselors, (c) 86.5% of contacted smokers consented to participate in the cessation counseling, (d) 93.8% of consented smokers participated in smoking cessation counseling calls, and (e) 72.2% of participating smokers completed their full intervention. These results demonstrate that older teens who smoke, and their parents, are receptive to confidential cessation counseling that is personally tailored, supportive of their autonomy, and proactively delivered via the telephone.     

Does how you quit affect success? A comparison between abrupt and gradual methods using data from the International Tobacco Control Policy Evaluation Study.

Two recommended quit methods in standard cessation programs involve either gradual reduction of smoking prior to complete abstinence ("cut down") or abrupt abstinence from cigarettes ("cold turkey"). This study examined the reported use, characteristics of users, and the impact of self-selected strategy choice on quitting success and relapse of adult smokers who reported quitting on their own. Data came from the first three waves of the International Tobacco Control Policy Evaluation 4-Country Survey (ITC-4). The ITC-4 is a random-digit-dialed telephone survey of a cohort of more than 8,000 adult smokers from the United Kingdom, the United States, Canada, and Australia, with a 75% follow-up rate. The results indicated that 68.5% of the smokers who had made a quit attempt between waves reported using the cold-turkey method. Of those who used the cold turkey method, 22% and 27% succeeded at Waves 2 and 3, respectively, compared with the 12% and 16%, respectively, who used the cut-down method. Multivariate analyses revealed that cold-turkey users were more likely to be aged 25-39 years, male, from the United Kingdom, and smoking heavily, and had lower perceived dependence. Controlling for sociodemographic and known predictors of quitting including use of medications, we found that smokers who used the cold-turkey method to quit were almost twice as likely to abstain for a month or more in their attempt. Overall, we cautiously conclude that cold turkey should be the recommended strategy for smokers who want to quit on their own.     

American Cancer Society's QuitLink: randomized trial of Internet assistance.

Eligible smokers (N = 6,451) visiting the American Cancer Society's Internet site offering cessation assistance were, with informed consent, randomized to receive access either to a static Internet site with quitting advice or to one of five interactive sites provided by cooperating research partners. Three-month follow-up surveys were conducted via online survey with E-mail prompts, or telephone calls, to assess quitting success; 54% of participants provided follow-up data. Results showed no significant overall difference in cessation rates among participants assigned to the interactive or static sites. We found large differences in the utilization of the five interactive sites. When sites were grouped by level of use, a significantly higher reported 3-month cessation rate was observed among participants assigned to the more highly utilized sites than among those assigned to the less utilized sites (12.2% vs. 10.2% of all randomized participants, 26.0% vs. 22.1% of followed participants). These findings show that interactive Internet sites yielding high levels of utilization can increase quitting success among smokers seeking assistance via the Internet.     

Increasing access to smoking cessation treatment in a low-income, HIV-positive population: the feasibility of using cellular telephones.

This study examined the feasibility of using cellular telephones to improve access to smoking cessation counseling in a low-income, HIV-positive population. Two pilot studies were conducted: (a). A survey of interest and barriers in participating in a smoking cessation intervention (n=49) and (b). a cellular telephone smoking cessation intervention in which participants were provided with free cellular telephones and received six telephone counseling sessions over a 2-week period (n=20). A primary care clinic serving a multiethnic, medically indigent, HIV-positive population served as the setting. Demographics and smoking status were assessed by self-report and expired-air carbon monoxide testing. In study 1, participants reported multiple barriers to participating in a smoking cessation intervention, including transportation, transience, and telephone availability. However, they also reported a high level of interest in participating in a smoking cessation intervention, with the greatest interest in a cellular telephone intervention. In study 2, 19 of the 20 participants successfully completed 2 weeks of smoking cessation counseling with a 93% (106 of 114 calls) contact rate. A total of 19 participants made a quit attempt, and the 2-week end of treatment point-prevalence abstinence rate was 75%. The provision of cellular telephones allowed for the implementation of a proactive telephone smoking cessation intervention providing an underserved population with access to care. Cellular telephones also may provide unique benefits because of the intensity of counseling and support provided as well as the ability to provide counseling in real-world, real-time situations (in vivo counseling).     

Feasibility, cost, and cost-effectiveness of a telephone-based motivational intervention for underserved pregnant smokers.

This study reports on the evaluation of the feasibility, cost, and cost-effectiveness of a proactively provided telephone-based motivational smoking cessation intervention to an underserved population of pregnant smokers who may or may not receive ongoing prenatal care. As part of the New England SCRIPT randomized clinical trial comparing the efficacy of three types of smoking cessation interventions for pregnant smokers, one-third of the women (n = 358) received a motivational telephone counseling intervention (MI) delivered by trained counselors using a semistructured protocol. Although this population was very mobile, the MI counselors were able to reach 86% of the women with at least one call and 46% received all three calls. The group receiving three MI calls had a cotinine-confirmed quit rate of 23%. Cost-effectiveness analyses for those women receiving telephone counseling supported the net benefit in favor of the three phone calls compared with the women who did not receive any telephone calls, with an effectiveness to cost ratio of 1:US dollars 84. Our results suggest that telephone-based motivational smoking cessation counseling may be a feasible and cost-effective method for low-income pregnant smokers enrolled in prenatal care.     

Smoking behavior and risk perception among the parents of infants in the neonatal intensive care unit.

The goal of this study was to explore the prevalence of smoking and attitudes and behaviors relevant to smoking cessation among parents of babies treated in a neonatal intensive care unit (NICU). Participants were 235 mothers and 83 fathers of infants admitted to the NICU of a large, university-based hospital. The 38-item survey included questions that assessed smoking status (current, former, never-smoker), motivation to quit, perceived health risks from smoking, and whether or not they received smoking cessation advice or counseling from a health care provider. A total of 26% of all participants were current smokers. Compared with mothers, fathers were more likely to be current smokers (22% vs. 31%) and smoked more cigarettes per day (11.3% vs. 17.2%). Among participants, 57% reported that smoking affected their own health "a little" or "not at all," and 70% believed that others' smoking would affect the baby's health "a little" or "somewhat." Mothers were more likely than fathers to report health care provider intervention for smoking cessation. Indeed, none of the fathers in this study reported being offered assistance with quitting smoking. More than half of smokers were willing to receive counseling for smoking cessation, and health care provider intervention was positively associated with both motivation to quit and perceived health risk to their infant (p<.01). The NICU may provide a teachable moment in which parents can be assisted with quitting smoking, thus improving their own health and the health of their babies.     

Spirometry as a motivational tool to improve smoking cessation rates: a systematic review of the literature.

Obtaining spirometric testing and providing those results to individuals who smoke has been advocated as a motivational tool to improve smoking cessation. However, its effectiveness is not known. We conducted a systematic review to determine if this approach improves rates of smoking cessation. Data sources included MEDLINE (1966 to October 2005), the Cochrane Library, and experts in the field. Eligible randomized controlled trials (RCTs) enrolled at least 25 smokers per arm, evaluated spirometry with associated counseling or in combination with other treatments, followed subjects at least 6 months, and provided smoking abstinence rates. Results from nonrandomized studies also were summarized. The primary outcome was patient-reported long-term (at least 6 months) sustained abstinence with biological validation. Additional outcomes included self-reported abstinence and point-prevalence abstinence. Seven RCTs (N = 6,052 subjects) met eligibility criteria. Follow-up duration ranged from 9 to 36 months. In six trials, the intervention group received concomitant treatments previously demonstrated to increase cessation independently. The range of abstinence was 3%-14% for control subjects and 7%-39% among intervention groups, statistically significantly in favor of intervention in four studies. The only RCT that assessed the independent contribution of spirometry in combination with counseling demonstrated a nonsignificant 1% improvement in patient-reported point-prevalence abstinence at 12 months in the group that received spirometry plus counseling versus counseling alone (6.5% versus 5.5%). Findings from observational studies were mixed, and the lack of controls makes interpretation problematic. Available evidence is insufficient to determine whether obtaining spirometric values and providing that information to patients improves smoking cessation compared with other smoking cessation methods. Spirometric values are of limited benefit as a predictor of smoking cessation or as a tool to "customize" smoking cessation strategies.     

Which smokers use the smoking cessation Quitline in Hong Kong,and how effective is the Quitline?

Objective: To describe the characteristics of the Chinese subjects who utilised the first telephone smoking cessation service in Hong Kong, and to evaluate its effectiveness.

Methods: The Quitline provided Hong Kong residents with free telephone smoking cessation services which was publicised through a press conference, media reports, pamphlets, and posters at public and private hospitals and clinics. Callers who completed an initial interview from 13 December 2000 to 31 May 2002 were included. Smokers were interviewed using a structured record sheet and provided with stage matched counselling. A follow up interview was carried out after six months. Analysis was conducted by intention-to-treat.

Results: Of the 1120 callers who completed initial assessments, 1047 were current smokers and 872 consented to follow ups. Compared to the general smoking population, the Quitline attracted more of those who were female, younger, single, unemployed, higher educated, smoking more than 20 cigarettes per day, and those with quitting experience. At six months, 12% (95% confidence interval 10% to 15%) of the participants reported that they had not smoked a cigarette for the past seven days. A stepwise logistic regression model showed that the use of nicotine replacement therapy at the present attempt to quit, having made one or more serious attempts to quit in the past, perceiving less difficulties in quitting, and smoking the first cigarette at age 15 years or above were significant predictors of quitting.

Conclusion: This first Quitline in Asia appears to be acceptable to Chinese smokers, with quit rate comparable to those of better funded Quitlines in the West. A low cost Quitline is a promising model for smoking cessation services in the East.

     

Cigarette smoking and quitting behaviors among unemployed adults in the United States.

Little is known about factors associated with smoking among the unemployed. This study estimated the prevalence of smoking and examined sociodemographic factors associated with current, former, and successful quitting among unemployed adults aged 18-64. Cross-sectional data on 13,480 participants in the 1998-1999 and 2001-2002 Tobacco Use Supplements to the Current Population Surveys were analyzed. Multivariate logistic regression analyses were used to examine factors associated with study outcomes (current vs. never, former vs. current, successful quitter vs. other former smoker). Among the unemployed, 35% were current smokers and 13% were former smokers. Of the former smokers, 81% quit successfully for at least 12 months. Participants with family incomes of less than US$25,000 were more likely than those with incomes of $50,000 or more to currently smoke (OR=2.13, 95% CI=1.85-2.46). Service workers and blue-collar workers were less likely than white-collar workers to report former smoking. Participants unemployed for 6 months or more were twice as likely as those unemployed for less than 6 months to quit successfully (OR=2.05, 95% CI=1.07-3.95). Unemployed blue-collar workers had a greater odds ratio of successfully quitting than white-collar workers (OR=1.83, 95% CI=1.17-2.87). Smoking rates were high among the unemployed, and quitting behaviors varied by sociodemographic factors and length of unemployment. Studies are needed to examine the feasibility of cessation interventions for the unemployed.     

How does a failed quit attempt among regular smokers affect their cigarette consumption? Findings from the International Tobacco Control Four-Country Survey (ITC-4).

Recent cross-sectional data suggests that smokers tend to reduce smoking following a failed self-initiated quit attempt, possibly motivated by the need to reduce harms or to facilitate future quitting or both. This study prospectively examined changes in cigarette consumption among adult smokers who relapsed from a quit attempt. It uses data from the first three waves of the International Tobacco Control Four-Country Survey (ITC-4), a random digit-dialed telephone survey of a cohort of over 9,000 adult smokers from the United Kingdom, United States, Canada, and Australia, followed up annually. Compared with those who did not make a quit attempt, relapsers were more likely to reduce consumption (average reduction of 0.7 vs. 3.4, respectively) over a mean period of 7 months between waves 1 and 2. Of the relapsers, 52% reduced their consumption by 5% or more, but 22% increased it. Smokers who smoked heavily at baseline, whose last quit attempt ended more recently, was of longer duration, and quit via a gradual cut-down method were all independently associated with reducing smoking following a failed attempt. These findings were similar across all four countries and were successfully replicated using waves 2-3 data. Change in consumption between waves 1 and 2 (whether increase or decrease) was maintained by a substantial number a year later (wave 3), but change did not undermine nor promote quitting between waves 2 and 3.     

Quitting smoking: why, how, and what might help

OBJECTIVE: To examine reasons for quitting smoking, methods used in quitting, reasons for continuing smoking and potential aids to quitting in the population of Ontario, Canada. DESIGN: Two population-based, telephone interview surveys, conducted by random-digit dialing. SUBJECTS: Adults aged 18 years of age and older in 1983 (n = 1383) and 1991 (n = 1421). MAIN OUTCOME MEASURES: Information was obtained from former smokers on why and how they quit smoking, and from continuing smokers on why they smoked and what might help them quit. RESULTS: The proportion of current smokers in the population decreased from 35.5% in 1983 to 27.2% in 1991. In both surveys, former smokers cited a variety of reasons for quitting, including personal health concerns, social and environmental factors, personal attitude factors, cost, and health education messages. Responses concerning the most important reason also revealed a range of factors; "advice of a physician" was not prominent among them. When questioned about methods used in quitting, most former smokers in both surveys responded that they "just decided to quit". Very few reported using other aids such as cessation clinics or nicotine gum. More smokers in 1991 than in 1983 reported that they continued smoking for enjoyment, to satisfy a craving or addiction, and for relaxation. With regard to what might help them quit, continuing smokers in both surveys cited a wide variety of potential aids, including information on harmful effects, more restrictions on smoking and on sales, cessation clinics, programmes on radio/TV, and higher taxes. CONCLUSIONS: These findings support a multifaceted approach to tobacco control.


     

Efficacy of naltrexone in smoking cessation: a preliminary study and an examination of sex differences.

This double-blinded, placebo-controlled trial evaluated the efficacy of naltrexone as an adjunct to standard smoking cessation treatment. Participants (N = 110) were adult male and female nicotine-dependent smokers who expressed interest in quitting smoking. All subjects received six sessions of behavioral counseling (1 hr/session for 6 weeks), and 1 month of the nicotine patch (21 mg for the first 2 weeks, 14 mg the third week, 7 mg the fourth week). Subjects were randomly assigned to the naltrexone or placebo group. The naltrexone group started at 25 mg daily for 3 days prior to the quit date, and increased to 50 mg/day on the quit date and following 8 weeks. At the end of medication treatment, the naltrexone group had better quit rates versus the placebo group (48% quit on naltrexone vs. 41% on placebo), but this difference was not statistically significant. However, men and women differed on several measures: in the placebo group, women had significantly lower quit rates than men (39% vs. 67%, p<.05), but in the naltrexone group, women had quit rates comparable with those of men (58% vs. 62%, p = ns). Further examination revealed that naltrexone significantly reduced men's and women's cessation-related weight gain and selectively reduced women's urge to smoke to relieve negative affect and withdrawal. The results suggest continued examination of naltrexone as an adjunct in smoking cessation, particularly in female smokers, who have historically shown worse outcomes with traditional treatment methods.