Smoking and Public Health: A Review of Reviews of Interventions to Increase Smoking Cessation, Reduce Smoking Initiation and Prevent Further Uptake of Smoking - Evidence Briefing

This evidence briefing collates review-level evidence of interventions including those targeted at pregnant women and evidence for tackling health inequalities in smoking.

Smoking and Public Health: A Review of Reviews of Interventions to Increase Smoking Cessation, Reduce Smoking Initiation and Prevent Further Uptake of Smoking - Summary

The briefing identifies gaps in primary and review-level research and makes a number of recommendations, including further measures to address health inequalities.

A pilot study combining individual-based smoking cessation counseling, pharmacotherapy, and dental hygiene intervention.

BACKGROUND: Dentists are in a unique position to advise smokers to quit by providing effective counseling on the various aspects of tobacco-induced diseases. The present study assessed the feasibility and acceptability of integrating dentists in a medical smoking cessation intervention. METHODS: Smokers willing to quit underwent an 8-week smoking cessation intervention combining individual-based counseling and nicotine replacement therapy and/or bupropion, provided by a general internist. In addition, a dentist performed a dental exam, followed by an oral hygiene treatment and gave information about chronic effects of smoking on oral health. Outcomes were acceptability, global satisfaction of the dentist's intervention, and smoking abstinence at 6-month. RESULTS: 39 adult smokers were included, and 27 (69%) completed the study. Global acceptability of the dental intervention was very high (94% yes, 6% mostly yes). Annoyances at the dental exam were described as acceptable by participants (61% yes, 23% mostly yes, 6%, mostly no, 10% no). Participants provided very positive qualitative comments about the dentist counseling, the oral exam, and the resulting motivational effect, emphasizing the feeling of oral cleanliness and health that encouraged smoking abstinence. At the end of the intervention (week 8), 17 (44%) participants reported smoking abstinence. After 6 months, 6 (15%, 95% CI 3.5 to 27.2) reported a confirmed continuous smoking abstinence. DISCUSSION: We explored a new multi-disciplinary approach to smoking cessation, which included medical and dental interventions. Despite the small sample size and non-controlled study design, the observed rate was similar to that found in standard medical care. In terms of acceptability and feasibility, our results support further investigations in this field. TRIAL REGISTRATION NUMBER: ISRCTN67470159.

Effectiveness of a low-intensity smoking cessation intervention for hospitalized patients

Résumé en français Contexte Les interventions intensives d'aide à l'arrêt de la cigarette en milieu hospitalier n'ont pas été adoptées à large échelle, peut-être en raison de barrières organisationnelles. Nous évaluons dans cette étude l'efficacité d'une approche moins contraignante. Méthodes Nous avons conçu et réalisé une étude de cohorte avec un groupe de contrôle historique dans le département de médecine d'un hôpital universitaire de 850 lits. Cent dix-sept fumeurs éligibles consécutifs ont bénéficié d'une intervention d'aide à l'arrêt de la cigarette et 113 fumeurs hospitalisés avant l'implémentation de cette intervention ont constitué notre groupe de contrôle. L'intervention d'aide à l'arrêt de la cigarette, d'une durée de 30 minutes, était réalisée par un médecin assistant formé en désaccoutumance au tabac, sans aucun contact ultérieur de suivi. Tous les patients ont ensuite reçu un questionnaire pour évaluer quelles étaient leurs habitudes en matière de tabagisme 6 mois après leur sortie d'hôpital. Nous avons considéré les patients perdus de vue comme fumeurs et l'abstinence tabagique ponctuelle (au moins 7 jours consécutifs) des ex-fumeurs a été validée par leur médecin traitant. Résultats Les taux d'arrêt de la cigarette validés étaient de 23.9% dans le groupe intervention et de 9.7% dans le groupe contrôle (odds ratio 2.9, intervalle de confiance à 95% [IC95] 1.4 à 6.2). Après ajustement pour les facteurs confondants potentiels, l'intervention était toujours efficace, avec un odds ratio ajusté de 2.7 (1095 = 1.0 à 5.0). Conclusion Une intervention d'aide à l'arrêt de la cigarette de faible intensité, sans contact de suivi, est associée avec un plus haut taux d'arrêt de la cigarette à 6 mois en comparaison avec un groupe de contrôle historique.

Factors associated with smoking cessation among outpatients.

RESUME INTRODUCTION Comprendre les déterminants de l'arrêt du tabagisme est un enjeu crucial, tant sur le plan clinique qu'en termes de santé publique. Dans l'étude transversale présentée ici, nous décrivons ce processus au travers de l'expérience d'ex-fumeurs. METHODE Sur une période de 4 mois, nous avons proposé à chaque patient consultant la Policlinique Médicale Universitaire de Lausanne de participer à une étude visant à examiner leur expérience de l'arrêt du tabagisme. Les critères d'inclusion étaient les suivants: (1) âge ≥ 18 ans (2) connaissance minimale de la langue française (capacité de comprendre et répondre aux questions) (3) être un ex-fumeur (défini comme une personne actuellement abstinente mais ayant fumé au moins 100 cigarettes [≥ 5 paquets] pendant > 6 mois dans le passé). Une infirmière formée a mené des entretiens semi-structurés en face-à-face avec les ex-fumeurs recrutés en utilisant un questionnaire explorant les 67 questions parmi les thèmes suivants : caractéristiques démographiques et socioéconomiques ; habitudes antérieures de consommation ; stades de motivation ; influence de l'environnement social ; état de santé et préoccupations au sujet de la santé ; perception des risques et des bénéfices du tabagisme ; perception de la dépendance nicotinique ; offre d'un counseling médical spécifique ; connaissances sur les modalités thérapeutiques disponibles et méthodes utilisées pour arrêter de fumer. Les résultats sont exprimés en nombres absolus, en pourcentages, en moyennes et en dispersion. RÉSULTATS 88 ex-fumeurs ont été inclus dans l'étude. Leurs caractéristiques démographiques et socioéconomiques sont les suivantes : La grande majorité d'entre eux sont des hommes (81%), l'âge moyen de 51 ans (variant de 19 à 81 ans), la moitié sont mariés, 72% de nationalité suisse et une grosse minorité (40%) ont une formation supérieure (universitaire ou équivalente). Leur histoire de consommation montre que l'âge moyen d'initiation du tabagisme est de 18 ans (entre 11 et 30 ans), et 23% ont commencé avant 16 ans. La consommation moyenne était de 26 cigarettes/jour. Presque tous les sujets (92%) étaient en contact fréquent avec des fumeurs à la maison, à l'école, au travail ou avec des amis au moment où ils ont commencé à fumer. La moitié des patients a essayé à une ou deux reprises d'arrêter de fumer avant de parvenir à une réelle abstinence. La durée depuis leur arrêt de consommation de cigarettes était en moyenne 5 ans et seuls 16% des sujets ont fumé occasionnellement depuis l'arrêt de leur consommation régulière. La majorité des ex-fumeurs (93%) dit avoir arrêté de manière abrupte et sans aucune aide thérapeutique (83%). 70 % des patients décrivent l'arrêt comme plutôt ou très difficile. Les problèmes décrits après l'interruption du tabagisme sont une prise pondérale (27%), la dépendance (23%), l'irritabilité (15%), les contacts avec des fumeurs (15%) et le manque de cigarette après les repas (11%). Les motivations principales à arrêter de fumer étaient des préoccupations générales au sujet de la santé (39%), des symptômes (23%) ou des signes cliniques spécifiques (22%), comme des problèmes cardiovasculaires ou respiratoires, ainsi que la conviction que le moment était venu d'arrêter (13%). D'autres motivations (comme les enfants, la grossesse, le coût...) étaient rarement mentionnées alors que 45% d'entre eux ont tout de même ressenti une pression de l'entourage, principalement de la part dé personnes vivant sous le même toit, de leurs famille ou amis. L'effet positif majeur de l'abstinence est, à leurs yeux, une amélioration globale de la santé (48%) ou de leurs problèmes cardiovasculaires ou respiratoires (32%). Trois quarts (74 %) des sujets savent que les cigarettes dites «légères »sont aussi nuisibles que les cigarettes normales, et 90 % sont conscients du fait que la nicotine peut induire une dépendance ; la moitié d'entre eux ne réalisent toutefois pas que le filtre ne protège pas contre les dangers de l'inhalation de fumée. Prés de trois quarts (73%) des ex-fumeurs disent avoir été interrogés sur leur consommation de tabac à l'occasion d'une consultation médicale motivée par un problème de santé et 30% clairement encouragés à arrêter par leur médecin. A ce sujet, 78 % sont d'avis qu'un médecin devrait par principe conseiller un arrêt du tabac. CONCLUSION Les 88 ex-fumeurs de cet échantillon ont, pour la plupart, arrêté la cigarette par leurs propres moyens, après un ou plusieurs échecs. Leurs motivations principales étaient le souci de leur propre santé, globalement ou relativement à des symptômes ou des signes cliniques spécifiques, ce qui reflète le fait que les patients sont relativement bien informés des dangers liés à la consommation de tabac. Enfin, le fumeur est sensible à l'influence de son environnement social, et, dans cette perspective, l'abstinence devrait être encouragée par les autorités sanitaires, les professionnels de la santé et les autres membres de la communauté.

Participation in a population-based physical activity programme as an aid for smoking cessation: a randomised trial.

OBJECTIVES: Exercise combined with nicotine therapy may help smoking cessation and minimise weight gain after quitting. Low participation in vigorous-intensity physical activity programmes precludes their population-wide applicability. In a randomised controlled trial, we tested whether a population-based moderate-intensity physical activity programme increases quit rates among sedentary smokers receiving nicotine therapy. METHODS: Participants (n=481; 57% male; mean age, 42.2 years (SD 10.1); mean cigarette consumption, 27 (SD 10.2) per day) were offered a nine-week smoking cessation programme consisting of a weekly 15-minute counselling session and the prescription of nicotine replacement therapy. In addition, participants in the physical activity group (n=229) also took part in a programme of moderate-intensity physical activity implemented at the national level, and offering nine weekly 60-minute sessions of physical activity. To ensure equal contact conditions, participants in the control group (n=252) attended weekly 60-minute health behaviour education sessions unrelated to physical activity. The primary outcome was continuous CO-verified smoking abstinence rates at 1-year follow-up. RESULTS: Continuous smoking abstinence rates were high and similar in the physical activity group and the control group at the end of the intervention (47% versus 46%, p=0.81) and at 1-year follow-up (27% versus 29%, p=0.71). The mean weight gain after one year was 4.4 kg and 6.2 kg among sustained quitters of the physical activity and control groups, respectively (p=0.06). CONCLUSION: Participation in a population-based moderate-intensity physical activity programme for 9 weeks in addition to a comprehensive smoking cessation programme did not significantly increase smoking cessation rates. A non-significant reduction in weight gain was observed among participants who quit smoking in the physical activity group. TRIAL REGISTRATION: ClinicalTrials.gov; US National Institutes for Health (available online at http://clinicaltrials.gov/; CLINICAL TRIAL REGISTRATION NUMBER: NCT00521391).

Nicotine gum treatment before smoking cessation: a randomized trial.

BACKGROUND: New ways of improving the efficacy of nicotine therapy need to be explored. We tested whether starting nicotine polacrilex gum treatment 4 weeks before the quit date improved smoking abstinence rates compared with starting treatment on the quit date. METHODS: An open randomized trial of 314 daily smokers (mean, 23.7 cigarettes/d) enrolled through the Internet and by physicians in Switzerland from November 2005 to January 2007. In the precessation treatment group, participants received nicotine polacrilex gum (4 mg, unflavored) by mail for 4 weeks before and 8 weeks after their target quit date, and they were instructed to decrease their cigarette consumption by half before quitting. In the usual care group, participants received the same nicotine gum for 8 weeks after their quit date and were instructed to quit abruptly. Instructions were limited to a booklet sent by mail and access to a smoking cessation Web site. Results are expressed as self-reported abstinence rates at the end of treatment and as biochemically verified smoking abstinence (cotinine plus carbon monoxide) after 12 months. RESULTS: Eight weeks after the target quit date, self-reported 4-week abstinence rates were 41.6% in the precessation treatment group and 44.4% in the usual care group (P = .61). One year after the target quit date, biochemically verified 4-week smoking abstinence rates were 20.8% in the precessation treatment group and 19.4% in the usual care group (P = .76). CONCLUSION: Starting nicotine gum treatment 4 weeks before the target quit date was no more effective than starting treatment on the quit date.

Conseit aux fumeurs: mise à jour épidémiologique et clinique [Smoking cessation intervention: 2006 update]

Recent Swiss reports confirmed that several chemical products added to cigarettes may increase the level of dependence and therefore the consumption of cigarettes. Observational studies demonstrated the association between smoking and type II diabetes, that smoking one to four cigarettes daily increases significantly the risk of disease and that the relative risk of breast cancer among non smoking women exposed to passive smoking is increased by 30%. The safety of nicotine replacement therapy for patients with cardiovascular disorders has been confirmed. Among new pharmacological approaches, varenicline, rimonabant, topiramate and nicotine vaccine all appear promising.

Change in physical activity after smoking cessation: the Coronary Artery Risk Development in Young Adults (CARDIA) study.

AIMS: To estimate physical activity trajectories for people who quit smoking, and compare them to what would have been expected had smoking continued. DESIGN, SETTING AND PARTICIPANTS: A total of 5115 participants in the Coronary Artery Risk Development in Young Adults Study (CARDIA) study, a population-based study of African American and European American people recruited at age 18-30 years in 1985/6 and followed over 25 years. MEASUREMENTS: Physical activity was self-reported during clinical examinations at baseline (1985/6) and at years 2, 5, 7, 10, 15, 20 and 25 (2010/11); smoking status was reported each year (at examinations or by telephone, and imputed where missing). We used mixed linear models to estimate trajectories of physical activity under varying smoking conditions, with adjustment for participant characteristics and secular trends. FINDINGS: We found significant interactions by race/sex (P = 0.02 for the interaction with cumulative years of smoking), hence we investigated the subgroups separately. Increasing years of smoking were associated with a decline in physical activity in black and white women and black men [e.g. coefficient for 10 years of smoking: -0.14; 95% confidence interval (CI) = -0.20 to -0.07, P < 0.001 for white women]. An increase in physical activity was associated with years since smoking cessation in white men (coefficient 0.06; 95% CI = 0 to 0.13, P = 0.05). The physical activity trajectory for people who quit diverged progressively towards higher physical activity from the expected trajectory had smoking continued. For example, physical activity was 34% higher (95% CI = 18 to 52%; P < 0.001) for white women 10 years after stopping compared with continuing smoking for those 10 years (P = 0.21 for race/sex differences). CONCLUSIONS: Smokers who quit have progressively higher levels of physical activity in the years after quitting compared with continuing smokers.

Cytochrome P450 1A2 activity and inducibility: impact of smoking, smoking cessation and genetic polymorphisms

Aims: Cytochrome P4501A2 (CYP1A2) is involved in the metabolism of severaldrugs (clozapine, olanzapine, theopylline, caffeine, etc) and is induced by smoking.This can result in decreased plasma levels of drugs metabolized by thisisoenzyme, causing a decrease in therapeutic response. After quitting smoking,increased plasma levels can lead to adverse effects of the concerned drugs, such asconfusion and seizures, described under clozapine treatment. The present studyaimed to examine the variation of CYP1A2 activity in a large group of smokersbefore and after smoking cessation. Moreover, we aimed to determine whethergenetic polymorphisms of CYP1A2 gene could influence the inducibility ofCYP1A2. Methods: CYP1A2 activity was determined by the paraxanthine/caffeineratio in 194 smokers and in 118 of them being abstinent during a 4-weekperiod. Participants were genotyped for CYP1A2*1F (rs762551), *1D(rs35694136) and *1C (rs2069514) polymorphisms. Results: Smokers had higherCYP1A2 activity (1.55-fold; p < 0.0001). Individual change of CYP1A2 activityafter smoking cessation ranged from 1.0-fold (no change) to 7.3-fold decreasedactivity. In five participants with low initial CYP1A2 activity, an increase wasobserved after smoking cessation. During smoking, CYP1A2*1F (p = 0.005), CYP1A2*1D (p = 0.014), the number of cigarettes/day (p = 0.012), contraceptives use(p < 0.001) and - 163A/- 2467T/- 3860G haplotype (p = 0.002) influencedCYP1A2 activity, while after quitting smoking, CYP1A2*1F (p = 0.017) and contraceptives(p = 0.05) did. No influence of CYP1A2 polymorphisms on the inducibilityof CYP1A2 was observed. Conclusion: Higher CYP1A2 activity wasmeasured in smokers, but with a large interindividual variability of its inductionby smoking. Careful clinical management with the help of therapeutic drug monitoringis therefore needed for patients receiving drugs which are metabolized byCYP1A2, who stop or start smoking. Unidentified genetic variations in theCYP1A2 gene and/or in other genes controlling CYP1A2 activity and other environmentalfactors could be responsible of the observed differences in CYP1A2enzymatic activity and inducibility.

Improved smoking cessation in smokers given ultrasound photographs of their own atherosclerotic plaques.

BACKGROUND: We examined whether making smokers aware that they had developed peripheral atherosclerosis would improve smoking cessation. METHODS: Smokers selected from the general population were randomly allocated to undergo high-resolution B-mode ultrasonography of their carotid and femoral arteries. All smokers received quit-smoking counseling. Smokers with > or =1 atherosclerotic plaque were given two photographs of a plaque with a relevant explanation. Quit rates were assessed by telephone 6 months later. RESULTS: Seventy-nine smokers did not undergo ultrasonography (A). Among the 74 smokers submitted to ultrasonography, 20 had no plaque (B) and 54 had > or =1 plaque (C). Quit rates were, respectively, 6.3, 5.0, and 22.2% in groups A, B, and C. Quit rates were higher in smokers submitted to ultrasonography (B + C vs A; P = 0.031) and in those receiving photographs (C vs A + B; P = 0.003). Smoking cessation was independently associated with intervention C (OR = 6.2; 95% CI = 1.8-21) and a white-collar job but not with age or gender. CONCLUSIONS: Providing smokers with photographs demonstrating atherosclerosis on their own person was an effective adjunct to physician's advice to quit smoking. Since ultrasonography is used increasingly often in clinical practice for cardiovascular risk stratification, this can provide an additional opportunity and means to deter smokers from smoking.

Duration of smoking cessation for the prevention of surgical wound healing complications

The study aimed to find scientific evidence about the duration of preoperative smoking cessation required to reduce surgical wound healing complications. An integrative review was performed in the databases, Latin American and Caribbean Literature on Health Sciences (LILACS) and Medical Literature Analysis and Retrieval System Online (MEDLINE), from 08/17/2012 to 09/17/2012, using the keywords: tobacco use cessation and wound healing; tobacco use cessation and preoperative period; tobacco use cessation and perioperative period (LILACS) and tobacco use cessation and perioperative period; tobacco use cessation and wound healing (MEDLINE). Out of the 81 eligible studies, 12 were included. The duration of smoking cessation needed to reduce healing complications was at least four weeks (four studies with level of evidence I, three studies with level of evidence II, two studies with level of evidence IV, and one study with level of evidence VII).

Contributions of auriculotherapy in smoking cessation: a pilot study

Objective To evaluate the contribution of auriculotherapy in smoking cessation. Method Double-blind randomized controlled trial, conducted with 30 smokers allocated into two groups: Experimental Group (21 participants received 10 sessions of auriculotherapy at specific points for smoking) and Control Group (nine participants received auriculotherapy in points that have no effect on the focus of research). Results Auriculotherapy contributed in reducing the number of cigarettes smoked in 61.9% of participants (p=0.002), in reducing the difficult to abstain from smoking in places where it is forbidden by 38% (p=0.050) and in not smoking when ill 23.8% (p=0.025). Conclusion Given the efficacy only in terms of reducing the number of cigarettes smoked and other parameters, we suggest that future studies consider the use of auriculotherapy combined with other treatment methods, in order to achieve better results in cessation/abstinence.

Predictors of Weight Change in Sedentary Smokers Receiving a Standard Smoking Cessation Intervention.

INTRODUCTION: Quitting smoking is associated with weight gain, which may threaten motivation to engage or sustain a quit attempt. The pattern of weight gained by smokers treated according to smoking cessation guidelines has been poorly described. We aimed to determine the weight gained after smoking cessation and its predictors, by smokers receiving individual counseling and nicotine replacement therapies for smoking cessation. METHODS: We performed an ancillary analysis of a randomized controlled trial assessing moderate physical activity as an aid for smoking cessation in addition to standard treatment in sedentary adult smokers. We used mixed longitudinal models to describe the evolution of weight over time, thus allowing us to take every participant into account. We also fitted a model to assess the effect of smoking status and reported use of nicotine replacement therapy at each time point. We adjusted for intervention group, sex, age, nicotine dependence, and education. RESULTS: In the whole cohort, weight increased in the first 3 months, and stabilized afterwards. Mean 1-year weight gain was 3.3kg for women and 3.9kg for men (p = .002). Higher nicotine dependence and male sex were associated with more weight gained during abstinence. Age over median was associated with continuing weight gain during relapse. There was a nonsignificant trend toward slower weight gain with use of nicotine replacement therapies. CONCLUSION: Sedentary smokers receiving a standard smoking cessation intervention experience a moderate weight gain, limited to the first 3 months. Older age, male sex, and higher nicotine dependence are predictors of weight gain.

Leptin and smoking cessation: secondary analyses of a randomized controlled trial assessing physical activity as an aid for smoking cessation.

BACKGROUND: Smokers have a lower body weight compared to non-smokers. Smoking cessation is associated with weight gain in most cases. A hormonal mechanism of action might be implicated in weight variations related to smoking, and leptin might be implicated. We made secondary analyses of an RCT, with a hypothesis-free exploratory approach to study the dynamic of leptin following smoking cessation. METHODS: We measured serum leptin levels among 271 sedentary smokers willing to quit who participated in a randomized controlled trial assessing a 9-week moderate-intensity physical activity intervention as an aid for smoking cessation. We adjusted leptin for body fat levels. We performed linear regressions to test for an association between leptin levels and the study group over time. RESULTS: One year after smoking cessation, the mean serum leptin change was +3.23 mg/l (SD 4.89) in the control group and +1.25 mg/l (SD 4.86) in the intervention group (p of the difference < 0.05). When adjusted for body fat levels, leptin was higher in the control group than in the intervention group (p of the difference < 0.01). The mean weight gain was +2.91 (SD 6.66) Kg in the intervention and +3.33 (SD 4.47) Kg in the control groups, respectively (p not significant). CONCLUSIONS: Serum leptin levels significantly increased after smoking cessation, in spite of substantial weight gain. The leptin dynamic might be different in chronic tobacco users who quit smoking, and physical activity might impact the dynamic of leptin in such a situation. CLINICAL TRIAL REGISTRATION NUMBER: NCT00521391.