Are waterpipe users interested in quitting?

Waterpipe smoking has increased dramatically worldwide in recent years, with an estimated 100 million daily users. Research on this traditional Middle Eastern tobacco use method is in its infancy, and little is known about users' cessation-related attitudes and experiences. A random sample of 268 narghile (waterpipe) smokers (40% female; mean age = 30 years; range = 18-68) was obtained from cafes and restaurants in Aleppo, Syria. The majority of users (86.5%) believed they could quit using waterpipes at any time, but that belief was inversely related to perceived dependence, with only 48.7% of those who thought they were "very hooked" believing they could quit. Interest in quitting was expressed by 28.4% of subjects, with the majority (89.2%) reporting health concerns as a primary reason, and 59.2% having made an unsuccessful quit attempt in the past year. In a logistic regression model, independent predictors of interest in quitting included being married, having smoked for fewer years, not increasing the frequency of smoking over time, and having family members who do not smoke a waterpipe and disapprove of its use. Results indicate that a sizable percentage of waterpipe users express interest in quitting and have tried unsuccessfully in the past to quit. Waterpipe use needs to be considered in developing effective tobacco use cessation programs in the Middle East.     

Tobacco education in U.S. schools of pharmacy.

This study is the first to characterize tobacco-related content in pharmacy school curricula in the United States. A national survey mailed to 83 U.S. schools of pharmacy assessed the extent to which tobacco is addressed in required coursework, educational methods of instruction, perceived importance of addressing tobacco in the doctor of pharmacy degree program, perceived adequacy of current levels of tobacco education in curricula, and perceived barriers to enhancing the tobacco-related content. A total of 82 surveys (98.8% response) revealed a median of 170 min of tobacco education throughout the doctor of pharmacy program. The most heavily emphasized topics are aids for cessation, assisting patients with quitting, nicotine pharmacology and principles of addiction, and drug interactions with smoking, yet more than 40% of respondents believed that each of these topics was covered inadequately. Key barriers to enhancing tobacco training are lack of curriculum time and lack of clinical clerkship sites focusing on tobacco interventions. Pharmacy faculty members perceive tobacco cessation training to be important, yet a mismatch exists between the perceived importance and the perceived adequacy of current levels of training in pharmacy school curricula. The results of this study will serve as a baseline measure against which future, parallel assessments will be compared as faculty at schools of pharmacy across the United States work together toward enhancing the tobacco cessation training of student pharmacists.     

Homelessness and smoking cessation: insights from focus groups.

Smoking prevalence among homeless persons is approximately 70%, yet little is known about tobacco use patterns or smoking cessation practices in this population. We assessed smoking attitudes and behaviors, psychosocial and environmental influences on smoking, barriers to and interest in quitting, and preferred methods for cessation among some homeless smokers. Six 90-min focus groups of current smokers (N = 62) were conducted at homeless service facilities. Participants had a mean age of 41.5 years (SD = 9.3), were predominantly male (69.4%) and African American (59%), and smoked an average of 18.3 cigarettes/day. Although most reported that they were motivated to quit, a number of barriers to quitting were identified. Participants reported that the pervasiveness and social acceptance of tobacco use in homeless settings contributed to smoking more cigarettes per day, adopting alternative smoking behaviors such as smoking cigarette butts and making their own cigarettes, and experiencing difficulty in quitting. High levels of boredom and stress also were cited as reasons for continued smoking. Smoking frequently occurred in combination with alcohol or illicit drug use or to achieve a substitute "high." Most participants (76%) reported that they planned to quit smoking in the next 6 months. Many were interested in using pharmacotherapy in combination with behavioral treatments. Results suggest that, although motivated to quit smoking, homeless smokers are faced with unique social and environmental barriers that make quitting more difficult. Interventions must be flexible and innovative to address the unique needs of homeless smokers. Smoking restrictions at homeless service facilities and funding for smoking cessation assistance in this underserved population may help to reduce prevalence.     

Activities and perceptions of pharmacists providing tobacco control services in community pharmacy in Thailand.

Community pharmacists' involvement in tobacco control and their perceived role and barriers were assessed. In part I, a self-administered questionnaire was mailed to 164 community pharmacists who applied for community pharmacy accreditation from the Thai Pharmacy Council in 2003. In part II, an in-depth interview was conducted among 13 community pharmacists who participated in the 1-day smoking cessation services training. Main outcome measures were tobacco control-related activities, perceived tobacco control role, and perceived barriers. The questionnaire response rate was 51% (83/164 pharmacists), with half of the respondents (42/83, 51%) reporting active tobacco control activities. Of these pharmacists, seven (7/42, 17%) reported participating in public or policy advocacy by campaigning against smoking in the community. Thirty-four (34/42, 81%) and thirty-six (36/42, 86%) reported engaging in activities in their own pharmacies by providing educational materials and smoking cessation services, respectively. Even though the perceived roles in tobacco control of these pharmacists were high, they also reported several barriers, especially in five categories: lack of client demand, lack of educational materials, lack of smoking cessation products, lack of knowledge and skill, and lack of follow-up visits. On the other hand, lack of time and lack of reimbursement were not indicated as important barriers. Data from in-depth interviews confirmed these findings. This study revealed that Thai community pharmacists were engaged in various levels of tobacco control-related activities. Most of them perceived the significance of tobacco control activities. However, several barriers were also reported and need to be addressed further.     

Smoking cessation in general practice: the effects of a quitline.

This cross-sectional study assessed changes between 1999 and 2003 in attitudes among Swedish general practitioners (GPs) toward smoking cessation activities and also assessed the effect of a nationwide quitline on GPs' smoking cessation activities. A random sample of 621 Swedish GPs answered a questionnaire mailed to their home addresses in spring 2003. When possible, the results of the present study were compared with results from a similar study conducted in 1999. Main outcome measures were GPs' self-reported activities, perceived barriers to engaging in smoking cessation, and referrals to the quitline. Between 1999 and 2003, GPs increased their overall smoking cessation activities and were more aware of the complexity of smoking cessation support. Significantly more GPs experienced smoking cessation support as "too time consuming" and preferred to refer smokers to counselors specializing in smoking cessation. GPs referring patients to the quitline were more likely to be active in other smoking cessation activities. One out of five GPs had advised their patients to use oral smokeless tobacco as a means to stop smoking. A paradigm shift regarding awareness of the complexity of smoking cessation support may be ongoing amongst Swedish GPs. The nationwide smoking cessation quitline appears to have had a positive effect on GPs' engagement in smoking cessation.     

Regulatory strategies to reduce tobacco addiction in youth

Preventing tobacco addiction and achieving cessation in established users are the cornerstones of efforts to reduce tobacco use and disease. It has been increasingly recognised that reducing tobacco toxin exposure has theoretical potential to reduce disease in continuing tobacco users. This has been controversial because such approaches also carry the potential to undermine prevention and cessation. As complicated as harm reduction issues are for adults, they are still more complicated for youth. Harm reduction is not a singular approach, but rather a concept that encompasses an extremely diverse array of potential approaches. These carry equally diverse potential risks and benefits. The regulatory framework (for example, whether or not the Food and Drug Administration regulates the approach) is also predicted to be a major factor in determining the consequences of harm reduction approaches. This paper examines the various issues and potential approaches concerning the application of harm reduction to youth. We conclude that although some carry great risk, others may actually support broader tobacco control efforts to prevent tobacco use and foster cessation in youth and adults.     

Military tobacco use: a synthesis of the literature on prevalence, factors related to use, and cessation interventions

Tobacco use remains the number one cause of preventable morbidity and premature death in the United States. As a result, military leaders are recognizing that tobacco can adversely affect military fitness levels, deployment readiness, and safety and can increase health care costs. Yet military members continue to use tobacco. Tobacco may be viewed as part of the military culture since military members have used tobacco for many decades for pleasure, comfort, and currency and as a morale booster. Most recently, the military has seen an increase in tobacco use among young military members. A number of research studies have examined the prevalence of tobacco and factors related to use in the military, and several have evaluated cessation and prevention interventions. This article provides a brief historical perspective of military tobacco use in the 20th century and a critical review of the literature published between 1991 and 2006 describing prevalence of tobacco use, factors influencing use, and cessation interventions in the military. Recommendations for future research and for interventions are provided.     

The demand for health insurance coverage for tobacco dependence treatments: support for a benefit mandate and willingness to pay.

One solution for reducing tobacco use is to expand health insurance coverage for tobacco dependence treatments (TDTs), but the public demand for a coverage mandate is unknown. This study finds that demand for coverage of TDTs among a random sample of adult Californians with employer-sponsored health insurance is strong, with 62% indicating that health insurers should be required to offer coverage as part of their standard plans and a majority (56%) indicating a willingness to pay $3 more for their annual health insurance premium to finance cessation coverage. Compared to never smokers, current and former smokers are no more likely to support a benefit mandate to require coverage of cessation treatments, but the adjusted odds are approximately three times greater that current and former smokers are willing to pay $3 more toward their annual premium to finance cessation coverage. Liberals had higher adjusted odds of supporting a benefit mandate and of being willing to pay a higher premium compared to conservatives. Non-whites had higher adjusted odds of supporting a mandate compared to whites, with no differences by race/ethnicity in willingness to pay a higher premium. There were no differences in preferences for a benefit mandate or willingness to pay a higher premium as a function of age, gender or income. These findings have important policy implications for a state health insurance mandate to cover tobacco dependence treatments.     

Nicotine lozenges for the treatment of smokeless tobacco use.

Nicotine lozenges have been shown to increase tobacco abstinence rates in cigarette smokers, but they have not been evaluated in smokeless tobacco (ST) users. We conducted an open-label, one-arm, phase II clinical trial to evaluate the efficacy of the 4-mg nicotine lozenge for the treatment of withdrawal and craving associated with tobacco abstinence among ST users. Eligible subjects received 4-mg nicotine lozenges for 6 weeks followed by a 6-week taper. Subjects completed daily tobacco withdrawal diaries, and data on lozenge use, adverse events, and lozenge acceptability were collected. Urine anabasine was collected at 3 and 6 months for biochemical confirmation of self-reported tobacco abstinence. Participants were 30 ST users with a mean age of 35.4 years (SD=6.5) using an average of 4.2 cans or pouches (SD=3.2) of ST per week for a mean of 15.1 years (SD=6.5). Among subjects continuously tobacco abstinent for the first 2 weeks, no significant increases in composite withdrawal symptoms were observed, compared with baseline symptoms, whereas craving decreased significantly. Biochemically confirmed 7-day point-prevalence tobacco abstinence was 53% (95% CI=34%-72%) at 12 weeks (end of treatment) and 47% (95% CI=28%-66%) at 6 months. Few adverse events attributable to the nicotine lozenge occurred, and the lozenge was perceived as helpful in assisting subjects quit ST. The use of the 4-mg nicotine lozenge appears promising for the clinical treatment of withdrawal symptoms and craving associated with tobacco abstinence in ST users. Future phase III clinical trials investigating the efficacy of nicotine lozenges are warranted.     

Predictors of crop diversification: a survey of tobacco farmers in North Carolina (USA)

OBJECTIVE: To assess the attitudes and behaviours of North Carolina tobacco farmers around crop diversification. DESIGN: Cross-sectional telephone survey. PARTICIPANTS: Active tobacco farmers in 14 North Carolina counties (n = 1236), interviewed between January and April 1997 (91% response rate). OUTCOME MEASURES: Interest in, experience with, and perceived barriers to diversification. RESULTS: Most farmers (95%) grew/raised a commodity other than tobacco (mean = 2.8). A total of 60% of farmers expressed interest in trying other on-farm activities to supplement their tobacco and 60% reported taking action in the past year around supplementation. Younger age and college education were positively associated with interest. College education, off-farm income, and larger farm size were associated with the number of actions taken. For perceived external barriers to diversification, use of tobacco, percent income from tobacco, lack of college education, and younger age were most strongly associated with the number of barriers. For internal barriers (personal factors), percent income from tobacco, use of tobacco, and lack of college education were most strongly associated with the number of barriers. CONCLUSIONS: Most farmers were involved in diverse operations and expressed interest in continuing to diversify, although the breadth of diversification was narrow. Farmers noted many barriers to diversifying. If conventional production and marketing techniques are employed for non-tobacco alternatives, these alternatives may not provide the sustainable profitability that tobacco has afforded. Competition from foreign tobacco growers is the primary threat to the future of American growers and tobacco dependent communities.     

A meta-analysis of acupuncture techniques for smoking cessation

OBJECTIVE: To determine the effectiveness of acupuncture for smoking cessation and to examine whether any individual aspect of trials is associated with an effect. DATA SOURCES: All randomised controlled trials of acupuncture for smoking cessation that were listed in computerised databases or reference lists of relevant articles. STUDY SELECTION: All randomised single-blind studies that compared acupuncture with sham acupuncture. DATA EXTRACTION: Methodological data were extracted for quality assessment. Outcome data were extracted for rates of total smoking cessation at three intervals: early after treatment and after six and 12 months follow up. DATA SYNTHESIS: Results were expressed as odds ratios of success over failure in intervention over control groups. The combined odds ratio for all studies was calculated. Repeated meta-analyses were subsequently performed on subsets of studies combined according to defined characteristics: acupuncture technique, number of attendances, country of origin, status of journal, and control procedure. The overall quality of studies was poor. The combined odds ratio for smoking cessation calculated for the earliest results after the end of treatment was 1.20 (95% confidence intervals (95% CIs) = 0.98 to 1.48). The combined odds ratio for smoking cessation after six months was 1.29 (95% CI = 0.82 to 2.01), and after 12 months was 1.03 (95% CI = 0.73 to 1.46). There were no significant effects of relevance among subsets of studies grouped according to defined characteristics. CONCLUSIONS: Acupuncture was not superior to sham acupuncture for smoking cessation; no particular aspect of acupuncture technique was associated with a positive effect. The conclusions are limited by methodological inadequacies of studies and by the absence of testable hypotheses; design of future trials should avoid these deficiencies.     

Tobacco use and acculturation among Californians of Korean descent: a behavioral epidemiological analysis.

This study presents population estimates of cigarette use among adults of Korean descent residing in California. Data were drawn from telephone interviews with adults (N=2,830) developed from a random sampling of listed persons in California with Korean surnames. A total of 86% of attempted interviews were completed, and 85% of the interviews were conducted in Korean. Less acculturated men and more acculturated women reported higher present and predicted future rates of smoking after multivariate statistical controls were applied. Sharply divergent rates of cigarette use were found between the genders. Although men did not smoke their first cigarette or smoke cigarettes regularly earlier than women, both groups began smoking later than adults born in the United States. To be effective, tobacco intervention efforts must be tailored specifically to cultures of each minority. Results suggest that acculturation processes influence tobacco use differentially by gender, and future research is needed to identify the implications of processes in tobacco initiation and cessation.     

Self-help cessation programs for smokeless tobacco users: long-term follow-up of a randomized trial.

This paper presents long-term outcomes of the largest clinical trial of smokeless tobacco (SLT) cessation reported to date. SLT users in five northwestern states were recruited to call a toll-free number, and 1,069 users were randomized to one of two self-help conditions: either a manual-only condition or an assisted self-help condition, which included the manual, a targeted video, and two support phone calls. Significant between-group differences were not found for either the 12- or 18-month point-prevalence measure of abstinence from either SLT only or all tobacco products using outcomes based on either the responder or intention-to-treat outcomes. However, using a repeated point-prevalence measure across all three assessment points, we found that significantly more assisted self-help participants reported abstinence, compared with manual-only participants. Compared with manual-only participants, those in the assisted self-help condition were significantly more likely to use recommended cessation techniques. Results demonstrate that low-cost, minimal interventions delivered by mail and phone can help a sizable proportion of individuals quit using SLT.     

Understanding tobacco use among Filipino American men.

Although lung cancer is the top cancer killer among Filipino American men, data on tobacco-related knowledge and attitudes, cessation efforts, and preferences for smoking cessation programs among this population are lacking. We interviewed a community sample of 318 Filipino American men (110 current, 108 former, and 100 never-smokers, all immigrants) aged 40-75 years in Los Angeles County in English and Tagalog, to gain a better understanding of their tobacco use as a first step toward developing a culturally tailored smoking cessation program. In our sample, smokers had lower levels of education and income compared with nonsmokers and were less acculturated based on language use and English fluency. Smokers were more likely than nonsmokers to agree that smoking can alleviate stress, depression, and boredom, and that it is part of social interactions, growing up, being a man, and looking mature. These beliefs were summarized in a Smoking Beliefs Scale (Cronbach's alpha = .84), which predicted current smoking in a multivariate analysis, together with perceived risk of getting smoking-related diseases and peer norms. The most preferred smoking cessation intervention formats were educational small group sessions with other Filipino men (32%), followed by one-on-one consultations by a health professional (26%), video (20%), pamphlet (17%), and toll-free telephone number (6%). More than half of the current smokers requested these smoking cessation activities in Tagalog (34%) or a combination of Tagalog and English (24%). Based on these findings, we make specific recommendations for a smoking cessation program for Filipino men.     

Tobacco quitlines: looking back and looking ahead

Telephone based tobacco cessation services, or quitlines, have become central components of many comprehensive tobacco control programmes. This paper provides an overview of their history, noting milestones in the growth of quitlines. Key factors in their worldwide adoption were solid evidence from clinical trials with large community samples and strong backing from public health officials. Quitlines are now available throughout most of North America, Europe, Australia and in many other locations around the world. The paper also offers several recommendations for future directions in quitline practice and research. Benchmarks should be established for key areas of quitline implementation, such as accessibility, quality and cost efficiency. Advances in pharmacotherapy, telephony and web based applications should be investigated for opportunities to expand service offerings. Research and development are needed to determine how best to serve a diverse clientele in the most cost effective manner. Funding should be expanded and diversified to enable quitlines to serve much larger numbers of users. Healthcare providers should be targeted for quitline promotion, to engage them in a broad effort to increase the number of patients receiving cessation messages from clinicians. The goal of quitline promotion should expand to include an increase in unaided quit attempts in the population. Early research findings were quickly adopted in quitline practice, and future research to answer questions that have arisen through the implementation of quitlines will probably also find quick adoption.     

The development of tobacco use in adolescence among "snus starters" and "cigarette starters": an analysis of the Swedish "BROMS" cohort

Whether the use of smokeless tobacco can facilitate the transition to cigarette smoking and/or to prolonged tobacco use in adolescence is unclear. We analyzed data from a cohort of 2,938 Swedish adolescents, with six follow-up assessments of tobacco use between the ages of 11 and 18 years. The majority of tobacco users (70%) started by smoking cigarettes, 11% took up snus before smoking, and 19% used both tobacco types close in time. Ever users of tobacco at baseline had a higher risk of being current smokers and/or smokeless tobacco users at the end of follow-up compared with never users, with the highest excess relative risk for "mixed users." Adolescents who initiated tobacco use with cigarettes had a non-significantly increased probability to end up as current smokers compared with snus starters (adjusted OR=1.42; 95% CI 0.98-2.10) The OR of smoking for "mixed starters" was 2.54 (95% CI 1.68-3.91). The risk of becoming current user of any tobacco was also significantly enhanced for "mixed starters." Marked sex differences were observed in these associations, as initiation with cigarettes rather than with snus predicted current smoking or tobacco use only among females. Progression of tobacco use in adolescence is not predicted by onset with snus or cigarettes, but rather by initiation with both tobacco types close in time and/or at young age. The proportion of adolescent smoking prevalence attributable to a potential induction effect of snus is likely small.     

Bupropion and cognitive-behavioral treatment for depression in smoking cessation.

This study is a randomized, double-blind, placebo-controlled clinical trial examining the effects of an intensive cognitive-behavioral mood management treatment (CBTD) and of bupropion, both singularly and in combination, on smoking cessation in adult smokers. As an extension of our previous work, we planned to examine the synergistic effects of CBTD and bupropion on smoking cessation outcomes in general and among smokers with depression vulnerability factors. Participants were 524 smokers (47.5% female, M (age) = 44.27 years) who were randomized to one of four 12-week treatments: (a) standard, cognitive-behavioral smoking cessation treatment (ST) plus bupropion (BUP), (b) ST plus placebo (PLAC), (c) standard cessation treatment combined with cognitive-behavioral treatment for depression (CBTD) plus BUP, and (d) CBTD plus PLAC. Follow-up assessments were conducted 2, 6, and 12 months after treatment, and self-reported abstinence was verified biochemically. Consistent with previous studies, bupropion, in comparison with placebo, resulted in better smoking outcomes in both intensive group treatments. Adding CBTD to standard intensive group treatment did not result in improved smoking cessation outcomes. In addition, neither CBTD nor bupropion, either alone or in combination, was differentially effective for smokers with single-past-episode major depressive disorder (MDD), recurrent MDD, or elevated depressive symptoms. However, findings with regard to recurrent MDD and elevated depressive symptoms should be interpreted with caution given the low rate of recurrent MDD and the low level of depressive symptoms in our sample. An a priori test of treatment effects in smokers with these depression vulnerability factors is warranted in future clinical trials.