Twenty Years of the Cochrane Tobacco Addiction Group: Past, Present, and Future.

Implications: This review provides an overview of the work of Cochrane TAG. Readers will gain an insight into the origins of the group, its impact on evidence-based medicine relating to tobacco addiction, and the goals of the group moving forward. This supports the group's aim to encourage knowledge of Cochrane's work within the field, and thereby the wider use of and contribution to high-quality systematic reviews and meta-analyses of the literature to improve policy and clinical practice.

Gradual Versus Abrupt Smoking Cessation: A Randomized, Controlled Noninferiority Trial.

BACKGROUND: Most smoking cessation guidelines advise quitting abruptly. However, many quit attempts involve gradual cessation. If gradual cessation is as successful, smokers can be advised to quit either way. OBJECTIVE: To examine the success of quitting smoking by gradual compared with abrupt quitting. DESIGN: Randomized, controlled noninferiority trial. (International Standardized Randomized Controlled Trial Number Register: ISRCTN22526020). SETTING: Primary care clinics in England. PARTICIPANTS: 697 adult smokers with tobacco addiction. INTERVENTION: Participants quit smoking abruptly or reduced smoking gradually by 75% in the 2 weeks before quitting. Both groups received behavioral support from nurses and used nicotine replacement before and after quit day. MEASUREMENTS: The primary outcome measure was prolonged validated abstinence from smoking 4 weeks after quit day. The secondary outcome was prolonged, validated, 6-month abstinence. RESULTS: At 4 weeks, 39.2% (95% CI, 34.0% to 44.4%) of the participants in the gradual-cessation group were abstinent compared with 49.0% (CI, 43.8% to 54.2%) in the abrupt-cessation group (relative risk, 0.80 [CI, 0.66 to 0.93]). At 6 months, 15.5% (CI, 12.0% to 19.7%) of the participants in the gradual-cessation group were abstinent compared with 22.0% (CI, 18.0% to 26.6%) in the abrupt-cessation group (relative risk, 0.71 [CI, 0.46 to 0.91]). Participants who preferred gradual cessation were significantly less likely to be abstinent at 4 weeks than those who preferred abrupt cessation (38.3% vs 52.2%; P = 0.007). LIMITATIONS: Blinding was impossible. Most participants were white. CONCLUSION: Quitting smoking abruptly is more likely to lead to lasting abstinence than cutting down first, even for smokers who initially prefer to quit by gradual reduction. PRIMARY FUNDING SOURCE: British Heart Foundation.

Nicotine receptor partial agonists for smoking cessation.

BACKGROUND: Nicotine receptor partial agonists may help people to stop smoking by a combination of maintaining moderate levels of dopamine to counteract withdrawal symptoms (acting as an agonist) and reducing smoking satisfaction (acting as an antagonist). OBJECTIVES: To review the efficacy of nicotine receptor partial agonists, including varenicline and cytisine, for smoking cessation. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group's specialised register for trials, using the terms ('cytisine' or 'Tabex' or 'dianicline' or 'varenicline' or 'nicotine receptor partial agonist') in the title or abstract, or as keywords. The register is compiled from searches of MEDLINE, EMBASE, and PsycINFO using MeSH terms and free text to identify controlled trials of interventions for smoking cessation and prevention. We contacted authors of trial reports for additional information where necessary. The latest update of the specialised register was in May 2015, although we have included a few key trials published after this date. We also searched online clinical trials registers. SELECTION CRITERIA: We included randomised controlled trials which compared the treatment drug with placebo. We also included comparisons with bupropion and nicotine patches where available. We excluded trials which did not report a minimum follow-up period of six months from start of treatment. DATA COLLECTION AND ANALYSIS: We extracted data on the type of participants, the dose and duration of treatment, the outcome measures, the randomisation procedure, concealment of allocation, and completeness of follow-up.The main outcome measured was abstinence from smoking at longest follow-up. We used the most rigorous definition of abstinence, and preferred biochemically validated rates where they were reported. Where appropriate we pooled risk ratios (RRs), using the Mantel-Haenszel fixed-effect model. MAIN RESULTS: Two trials of cytisine (937 people) found that more participants taking cytisine stopped smoking compared with placebo at longest follow-up, with a pooled risk ratio (RR) of 3.98 (95% confidence interval (CI) 2.01 to 7.87; low-quality evidence). One recent trial comparing cytisine with NRT in 1310 people found a benefit for cytisine at six months (RR 1.43, 95% CI 1.13 to 1.80).One trial of dianicline (602 people) failed to find evidence that it was effective (RR 1.20, 95% CI 0.82 to 1.75). This drug is no longer in development.We identified 39 trials that tested varenicline, 27 of which contributed to the primary analysis (varenicline versus placebo). Five of these trials also included a bupropion treatment arm. Eight trials compared varenicline with nicotine replacement therapy (NRT). Nine studies tested variations in varenicline dosage, and 13 tested usage in disease-specific subgroups of patients. The included studies covered 25,290 participants, 11,801 of whom used varenicline.The pooled RR for continuous or sustained abstinence at six months or longer for varenicline at standard dosage versus placebo was 2.24 (95% CI 2.06 to 2.43; 27 trials, 12,625 people; high-quality evidence). Varenicline at lower or variable doses was also shown to be effective, with an RR of 2.08 (95% CI 1.56 to 2.78; 4 trials, 1266 people). The pooled RR for varenicline versus bupropion at six months was 1.39 (95% CI 1.25 to 1.54; 5 trials, 5877 people; high-quality evidence). The RR for varenicline versus NRT for abstinence at 24 weeks was 1.25 (95% CI 1.14 to 1.37; 8 trials, 6264 people; moderate-quality evidence). Four trials which tested the use of varenicline beyond the 12-week standard regimen found the drug to be well-tolerated during long-term use. The number needed to treat with varenicline for an additional beneficial outcome, based on the weighted mean control rate, is 11 (95% CI 9 to 13). The most commonly reported adverse effect of varenicline was nausea, which was mostly at mild to moderate levels and usually subsided over time. Our analysis of reported serious adverse events occurring during or after active treatment suggests there may be a 25% increase in the chance of SAEs among people using varenicline (RR 1.25; 95% CI 1.04 to 1.49; 29 trials, 15,370 people; high-quality evidence). These events include comorbidities such as infections, cancers and injuries, and most were considered by the trialists to be unrelated to the treatments. There is also evidence of higher losses to follow-up in the control groups compared with the intervention groups, leading to a likely underascertainment of the true rate of SAEs among the controls. Early concerns about a possible association between varenicline and depressed mood, agitation, and suicidal behaviour or ideation led to the addition of a boxed warning to the labelling in 2008. However, subsequent observational cohort studies and meta-analyses have not confirmed these fears, and the findings of the EAGLES trial do not support a causal link between varenicline and neuropsychiatric disorders, including suicidal ideation and suicidal behaviour. The evidence is not conclusive, however, in people with past or current psychiatric disorders. Concerns have also been raised that varenicline may slightly increase cardiovascular events in people already at increased risk of those illnesses. Current evidence neither supports nor refutes such an association, but we await the findings of the CATS trial, which should establish whether or not this is a valid concern. AUTHORS' CONCLUSIONS: Cytisine increases the chances of quitting, although absolute quit rates were modest in two recent trials. Varenicline at standard dose increased the chances of successful long-term smoking cessation between two- and three-fold compared with pharmacologically unassisted quit attempts. Lower dose regimens also conferred benefits for cessation, while reducing the incidence of adverse events. More participants quit successfully with varenicline than with bupropion or with NRT. Limited evidence suggests that varenicline may have a role to play in relapse prevention. The most frequently recorded adverse effect of varenicline is nausea, but mostly at mild to moderate levels and tending to subside over time. Early reports of possible links to suicidal ideation and behaviour have not been confirmed by current research.Future trials of cytisine may test extended regimens and more intensive behavioural support.

Interventions to reduce harm from continued tobacco use.

BACKGROUND: Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced-exposure tobacco products (PREPs), as an alternative to cigarettes. OBJECTIVES: To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long-term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco? SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free-text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. SELECTION CRITERIA: Randomized or quasi-randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention. DATA COLLECTION AND ANALYSIS: We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long-term smoking abstinence), using fixed-effect models. Where it was not possible to meta-analyse data, we summarized findings narratively. MAIN RESULTS: Twenty-four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically-heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as 'low' or 'very low', due to imprecision and indirectness. A 'low' grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A 'very low' grade means we are very uncertain about the estimate. AUTHORS' CONCLUSIONS: People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking. This could simply be due to the lack of high-quality studies (our confidence in cessation outcomes for these aids is rated 'low' or 'very low' due to imprecision by GRADE standards), meaning that we may have missed a worthwhile effect, or due to a lack of effect on reduction or quit rates. It is therefore important that more high-quality RCTs are conducted, and that these also measure the long-term health effects of treatments.

Does reduced smoking if you can't stop make any difference?

BACKGROUND: Promoting and supporting smoking reduction in smokers with no immediate intention of stopping smoking is controversial given existing fears that this will deter cessation and that reduction itself may not improve health outcomes. DISCUSSION: Evidence shows that smokers who reduce the number of daily cigarettes smoked are more likely to attempt and actually achieve smoking cessation. Further, clinical trials have shown that nicotine replacement therapy benefits both reduction and cessation. Worldwide data suggests that 'non-medical' nicotine is more attractive to people who smoke, with electronic cigarettes now being widely used. Nevertheless, only one small trial has examined the use of electronic cigarettes to promote reduction, with direct evidence remaining inconclusive. It has been suggested that long-term reduced smoking may directly benefit health, although the benefits are small compared with cessation. SUMMARY: The combined data imply that smoking reduction is a promising intervention, particularly when supported by clean nicotine; however, the benefits are only observed when it leads to permanent cessation.

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 quit smoking. OBJECTIVES: To determine whether or not motivational interviewing (MI) promotes smoking cessation. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialized 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. Date of the most recent search: August 2014. SELECTION CRITERIA: Randomized controlled trials in which motivational interviewing or its variants were offered to tobacco users to assist cessation. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate. The main outcome measure was abstinence from smoking after at least six months follow-up. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. We counted participants lost to follow-up as continuing smoking or relapsed. We performed meta-analysis using a fixed-effect Mantel-Haenszel model. MAIN RESULTS: We identified 28 studies published between 1997 and 2014, involving over 16,000 participants. MI was conducted in one to six sessions, with the duration of each session ranging from 10 to 60 minutes. Interventions were delivered by primary care physicians, hospital clinicians, nurses or counsellors. Our meta-analysis of MI versus brief advice or usual care yielded a modest but significant increase in quitting (risk ratio (RR) 1.26; 95% confidence interval (CI) 1.16 to 1.36; 28 studies; N = 16,803). Subgroup analyses found that MI delivered by primary care physicians resulted in an RR of 3.49 (95% CI 1.53 to 7.94; 2 trials; N = 736). When delivered by counsellors the RR was smaller (1.25; 95% CI 1.15 to 1.63; 22 trials; N = 13,593) but MI still resulted in higher quit rates than brief advice or usual care. When we compared MI interventions conducted through shorter sessions (less than 20 minutes per session) to controls, this resulted in an RR of 1.69 (95% CI 1.34 to 2.12; 9 trials; N = 3651). Single-session treatments might increase the likelihood of quitting over multiple sessions, but both regimens produced positive outcomes. Evidence is unclear at present on the optimal number of follow-up calls.There was variation across the trials in treatment fidelity. All trials used some variant of motivational interviewing. Critical details in how it was modified for the particular study population, the training of therapists and the content of the counselling were sometimes lacking from trial reports.   AUTHORS' CONCLUSIONS: Motivational interviewing may assist people to quit smoking. However, the results should be interpreted with caution, due to variations in study quality, treatment fidelity, between-study heterogeneity and the possibility of publication or selective reporting bias.

Interventions to increase adherence to medications for tobacco dependence.

BACKGROUND: Pharmacological treatments for tobacco dependence, such as nicotine replacement therapy (NRT), have been shown to be safe and effective interventions for smoking cessation. Higher levels of adherence to these medications increase the likelihood of sustained smoking cessation, but many smokers use them at a lower dose and for less time than is optimal. It is therefore important to determine the effectiveness of interventions designed specifically to increase medication adherence. Such interventions may include further educating individuals about the value of taking medications and providing additional support to overcome problems with maintaining adherence. OBJECTIVES: The primary objective of this review was to assess the effectiveness of interventions to increase adherence to medications for smoking cessation, such as NRT, bupropion, nortriptyline and varenicline (and combination regimens). This was considered in comparison to a control group, typically representing standard care. Secondary objectives were to i) assess which intervention approaches are most effective; ii) determine the impact of interventions on potential precursors of adherence, such as understanding of the treatment and efficacy perceptions; and iii) evaluate key outcomes influenced by prior adherence, principally smoking cessation. SEARCH METHODS: We searched the following databases using keywords and medical subject headings: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (OVID SP) (1946 to July Week 3 2014), EMBASE (OVID SP) (1980 to Week 29 2014), and PsycINFO (OVID SP) (1806 to July Week 4 2014). The Cochrane Tobacco Addiction Group Specialized Register was searched on 9th July 2014. We conducted forward and backward citation searches. SELECTION CRITERIA: Randomised, cluster-randomised or quasi-randomised studies in which participants using active pharmacological treatment for smoking cessation are allocated to an intervention arm or a control arm. Eligible participants were adult (18+) smokers. Eligible interventions comprised any intervention that differed from standard care, and where the intervention content had a clear principal focus on increasing adherence to medications for tobacco dependence. Acceptable comparison groups were those that provided standard care, which depending on setting may comprise minimal support or varying degrees of behavioural support. Included studies used a measure of adherence behaviour that allowed some assessment of the degree of adherence. DATA COLLECTION AND ANALYSIS: Two review authors searched for studies and independently extracted data for included studies. Risk of bias was assessed according to the Cochrane Handbook guidance. For continuous outcome measures, we report effect sizes as standardised mean differences (SMDs). For dichotomous outcome measures, we report effect sizes as relative risks (RRs). We obtained pooled effect sizes with 95% confidence intervals (CIs) using the fixed effects model. MAIN RESULTS: Our search strategy retrieved 3165 unique references and we identified 31 studies as potentially eligible for inclusion. Of these, 23 studies were excluded at full-text screening stage or identified as studies awaiting classification subject to further information. We included eight studies involving 3336 randomised participants. The interventions were all additional to standard behavioural support and typically provided further information on the rationale for, and emphasised the importance of, adherence to medication, and supported the development of strategies to overcome problems with maintaining adherence.Five studies reported on whether or not participants achieved a specified satisfactory level of adherence to medication. There was evidence that adherence interventions led to modest improvements in adherence, with a relative risk (RR) of 1.14 (95% CI, 1.02 to 1.28, P = 0.02, n = 1630). Four studies reported continuous measures of adherence to medication. Although the standardised mean difference (SMD) favoured adherence interventions, the effect was small and not statistically significant (SMD 0.07, 95% CI, -0.03 to 0.17, n = 1529). Applying the GRADE system, the quality of evidence for these results was assessed as moderate and low, respectively.There was evidence that adherence interventions led to modest improvements in rates of cessation. The relative risk for achieving abstinence was similar to that for improved adherence. It was not significant in meta-analysis of four studies providing short-term abstinence: RR = 1.07 (95% CI 0.95 to 1.21, n = 1755), but there was statistically significant evidence of improved abstinence at six months or more from a different set of four studies: RR = 1.16 (95% CI, 1.01 to 1.34, P = 0.03, n = 3049). Applying the GRADE system, the quality of evidence for these results was assessed as low for both.As interventions were similar in nature and the number of studies was low, it was not possible to investigate whether different types of intervention approaches were more effective than others. Relevant outcomes other than adherence or cessation were not reported.There was no evidence that interventions to increase adherence to medication led to any adverse events. All included studies were assessed as at high or unclear risk of bias. This was often due to a lack of clarity in reporting - meaning assessments were unclear - rather than clear evidence of failing to sufficiently safeguard against the risk of bias. AUTHORS' CONCLUSIONS: There is some evidence that interventions that devote special attention to improving adherence to smoking cessation medication through providing information and facilitating problem-solving can improve adherence, though the evidence for this is not strong and is limited in both quality and quantity. There is some evidence that such interventions improve the chances of achieving abstinence but again the evidence for this is relatively weak.

Gradual reduction vs abrupt cessation as a smoking cessation strategy in smokers who want to quit.

CLINICAL QUESTION: Is gradual smoking cessation associated with poorer success rates than abrupt cessation in smokers who want to quit? BOTTOM LINE: Gradual reduction may not be associated with a clinically significant difference in smoking cessation rates compared with abrupt cessation.

Reduction versus abrupt cessation in smokers who want to quit.

BACKGROUND: The standard way to stop smoking is to quit abruptly on a designated quit day. A number of smokers have tried unsuccessfully to quit this way. Reducing smoking before quitting could be an alternative approach to cessation. Before this method is adopted it is important to determine whether it is at least as successful as abrupt quitting. OBJECTIVES: 1. To compare the success of reducing smoking to quit and abrupt quitting interventions. 2. To compare adverse events between arms in studies that used pharmacotherapy to aid reduction. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Review Group specialised register using topic specific terms. The register contains reports of trials of tobacco addiction interventions identified from searches of MEDLINE, EMBASE and PsycInfo. We also searched reference lists of relevant papers and contacted authors of ongoing trials. Date of most recent search: July 2012. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that recruited adults who wanted to quit smoking. Studies included at least one condition which instructed participants to reduce their smoking and then quit and one condition which instructed participants to quit abruptly. DATA COLLECTION AND ANALYSIS: The outcome measure was abstinence from smoking after at least six months follow-up. We pooled the included trials using a Mantel-Haenszel fixed-effect model. Trials were split for two sub-group analyses: pharmacotherapy vs no pharmacotherapy, self help therapy vs behavioural support. Adverse events were summarised as a narrative. It was not possible to compare them quantitatively as there was variation in the nature and depth of reporting across studies. MAIN RESULTS: Ten studies were relevant for inclusion, with a total of 3760 participants included in the meta-analysis. Three of these studies used pharmacotherapy as part of the interventions. Five studies included behavioural support in the intervention, four included self-help therapy, and the remaining study had arms which included behavioural support and arms which included self-help therapy. Neither reduction or abrupt quitting had superior abstinence rates when all the studies were combined in the main analysis (RR= 0.94, 95% CI= 0.79 to 1.13), whether pharmacotherapy was used (RR= 0.87, 95% CI= 0.65 to 1.22), or not (RR= 0.97, 95% CI= 0.78 to 1.21), whether studies included behavioural support (RR= 0.87, 95% CI= 0.64 to 1.17) or self-help therapy (RR= 0.98, 95% CI= 0.78 to1.23). We were unable to draw conclusions about the difference in adverse events between interventions, however recent studies suggest that pre-quit NRT does not increase adverse events. AUTHORS' CONCLUSIONS: Reducing cigarettes smoked before quit day and quitting abruptly, with no prior reduction, produced comparable quit rates, therefore patients can be given the choice to quit in either of these ways. Reduction interventions can be carried out using self-help materials or aided by behavioural support, and can be carried out with the aid of pre-quit NRT. Further research needs to investigate which method of reduction before quitting is the most effective, and which categories of smokers benefit the most from each method, to inform future policy and intervention development.

Does cigarette reduction while using nicotine replacement therapy prior to a quit attempt predict abstinence following quit date?

BACKGROUND AND AIMS: Previous studies have reported that people who use a smoking cessation medication while smoking and reduce cigarette consumption spontaneously are three times more likely to stop smoking after a quit date. The aim was to replicate this and assess whether it arises because of willed effortful reduction rather than unwilled reduced drive to smoke caused by medication. DESIGN: Secondary analysis of a trial where participants were randomised to smoke as normal or reduce by 75% over 2 weeks prior to quit date, using nicotine replacement therapy (NRT) in both arms. SETTING: Thirty-one UK primary care practices. PARTICIPANTS: A total of 517 adult smokers seeking quitting support in the carbon monoxide (CO) analyses and 421 in the cigarettes/day analyses. MEASUREMENTS: Russell Standard abstinence was recorded 4 weeks after quit date. The randomized groups were combined and the association between reduction and abstinence examined. The second analysis assessed whether this association differed by whether smokers were, or were not, instructed to reduce. FINDINGS: In all participants, there was no evidence that reducing cigarettes/day or CO by at least half compared with not reducing predicted abstinence at 4 weeks [risk ratio (RR) = 0.88; 95% confidence interval (CI) = 0.68-1.14 and RR = 1.20; 95% CI = 1.00-1.44, respectively]. However, in smokers instructed to reduce, CO reduction was associated with 4-week abstinence (RR = 1.52; 95% CI = 1.16-2.00), but not among people advised not to reduce (RR = 0.91; 95% CI = 0.67-1.24). CONCLUSIONS: Smoking reduction prior to a target quit date while on a smoking cessation medication may only predict subsequent abstinence when smokers are consciously attempting to reduce.

Future orientation and smoking cessation: secondary analysis of data from a smoking cessation trial.

AIMS: To examine the association between future orientation (how individuals consider and value outcomes in the future) and smoking cessation at 4 weeks and 6 months post quit-date in individuals enrolled in a smoking cessation study. DESIGN: Cohort analysis of randomized controlled trial data. SETTING: UK primary care. PARTICIPANTS: Adults aged ≥18 years smoking ≥15 cigarettes daily, prepared to quit in the next 2 weeks. MEASUREMENTS: Future orientation was measured prior to quitting and at 4 weeks post-quitting using the Consideration of Future Consequences Scale. Smoking cessation at 4 weeks and 6 months was confirmed biochemically. Those lost to follow-up were assumed to not be abstinent. Potential confounders adjusted for were: age, gender, educational attainment, nicotine dependence and longest previous period quit. FINDINGS: A total of 697 participants provided data at baseline; 422 provided information on future orientation at 4 weeks. There was no evidence of an association between future orientation at baseline and abstinence at 4 weeks [adjusted odds ratio (aOR) = 1.05, 95% confidence intervals (CI) 0.80-1.38] or 6 months (aOR = 0.85, 95% CI = 0.60-1.20). There was no change in future orientation from baseline to 4 weeks and no evidence that the change differed between those who were and were not quit at 4 weeks (adjusted regression coefficient = -0.04, 95% CI = -0.16 to 0.08). CONCLUSIONS: In smokers who are prepared to quit in the next 2 weeks, the extent of future orientation is unlikely to be a strong predictor of quitting over 4 weeks or 6 months and any increase in future orientation following quitting is likely to be small.

Change in mental health after smoking cessation: systematic review and meta-analysis.

OBJECTIVE: To investigate change in mental health after smoking cessation compared with continuing to smoke. DESIGN: Systematic review and meta-analysis of observational studies. DATA SOURCES: Web of Science, Cochrane Central Register of Controlled Trials, Medline, Embase, and PsycINFO for relevant studies from inception to April 2012. Reference lists of included studies were hand searched, and authors were contacted when insufficient data were reported. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Longitudinal studies of adults that assessed mental health before smoking cessation and at least six weeks after cessation or baseline in healthy and clinical populations. RESULTS: 26 studies that assessed mental health with questionnaires designed to measure anxiety, depression, mixed anxiety and depression, psychological quality of life, positive affect, and stress were included. Follow-up mental health scores were measured between seven weeks and nine years after baseline. Anxiety, depression, mixed anxiety and depression, and stress significantly decreased between baseline and follow-up in quitters compared with continuing smokers: the standardised mean differences (95% confidence intervals) were anxiety -0.37 (95% confidence interval -0.70 to -0.03); depression -0.25 (-0.37 to -0.12); mixed anxiety and depression -0.31 (-0.47 to -0.14); stress -0.27 (-0.40 to -0.13). Both psychological quality of life and positive affect significantly increased between baseline and follow-up in quitters compared with continuing smokers 0.22 (0.09 to 0.36) and 0.40 (0.09 to 0.71), respectively). There was no evidence that the effect size differed between the general population and populations with physical or psychiatric disorders. CONCLUSIONS: Smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke. The effect size seems as large for those with psychiatric disorders as those without. The effect sizes are equal or larger than those of antidepressant treatment for mood and anxiety disorders.

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.

The importance of practitioner smoking status: a survey of NHS Stop Smoking Service practitioners.

OBJECTIVE: To investigate the smoking status of stop smoking practitioners, the impact of this on their practice, and clients' quit rates. METHODS: Smoking cessation practitioners in the UK NHS Stop Smoking Service were asked about their smoking status, client quit rates and practitioner-client interaction, using an online survey. Associations between responses were investigated using logistic regression. RESULTS: 51% of the sample (N=484) were ex-smokers. Most practitioners had been questioned about their smoking status by clients, with more never than ex-smokers claiming that this reduced their confidence when advising. Never smokers more frequently reported that clients questioned their ability as a practitioner, but no significant difference in quit rates was reported between never and ex-smokers. CONCLUSION: Although evidence suggests smokers believe many practitioners are never smokers, this survey found that this is not true. Research investigating how many smokers might not be seeking support to quit because of this could be beneficial. PRACTICE IMPLICATIONS: Raising awareness of the similarity of quit rates achieved by never and former smoker practitioners, and the experience practitioners draw upon when offering advice, might encourage greater use of the NHS SSS. It could also be beneficial to improve training in never smokers to address confidence issues.