BabyBreathe trial: protocol for a randomised controlled trial of a complex intervention to prevent postpartum return to smoking.

INTRODUCTION: Many people quit smoking during pregnancy, but postpartum smoking relapse is common. Maintaining smoking abstinence achieved during pregnancy is key to improving maternal and child health. There are no evidence-based interventions for preventing postpartum smoking relapse. This trial aims to determine whether an intervention to prevent postpartum relapse is effective and cost-effective. METHODS AND ANALYSIS: A randomised controlled trial of a complex intervention to prevent postpartum smoking relapse (BabyBreathe), with internal pilot, economic and process evaluations. Participants are adults who are pregnant and who report having quit smoking in the 12 months before, or during pregnancy. Participants are eligible if they read and understand English, and provide informed consent. Following consent and biochemical validation of smoking abstinence, participants are randomised to intervention or usual care/control (no specific relapse prevention support). The BabyBreathe intervention consists of manualised advice from a trained member of the health visiting service, health information leaflets for participants and partners, access to the BabyBreathe website and app. At the time of birth, participants are posted the BabyBreathe box and support is provided by text message for up to 12 months postpartum. Target sample size is 880, recruiting across midwifery services at four hubs in England and Scotland and through remote advertising in England, Scotland, Wales and Northern Ireland. Outcomes are collected at 6 and 12 months. The primary outcome is self-reported sustained smoking abstinence at 12 months, carbon monoxide verified. Secondary outcomes include self-reported abstinence, time to relapse, partner smoking status and quality of life. ETHICS AND DISSEMINATION: The trial was approved by the North West Preston Research Ethics committee (21/NW/0017). Dissemination will include publication in peer-reviewed journals, presentation at academic and public conferences including patient and public involvement and to policymakers and practitioners. TRIAL REGISTRATION NUMBER: ISRCTN70307341.

Effectiveness of school-based interventions for preventing tobacco smoking initiation among young people in low- and middle-income countries: a systematic review protocol.

BACKGROUND: Despite the commendable progress made globally in tobacco control, the world is falling short of achieving a 30% relative reduction in current tobacco use by 2025. The African region remains the least in the efforts in fighting the tobacco epidemic and is most exploited by the tobacco industry. Schools have been continuously used for over three decades as a setting for delivering youth smoking prevention programmes; however, the evidence of the effectiveness of those school-based interventions provides varying outcomes. Also, interventions that proved to be effective, in high-income countries (HICs), may not necessarily be effective in the African region as a result of cultural differences and other contrasting factors. An existing systematic review that explored school-based tobacco prevention programmes among the youth in African countries from 2000 to 2016 showed partial effectiveness. This review will address the gap by updating the 2016 review to examine studies in LMICs to generate findings to help target resources which have the potential to save lives by preventing smoking initiation among young people. METHODS: The JBI methodology for systematic reviews of effectiveness will guide the conduct of this review. A comprehensive strategic search will be developed to retrieve both published and unpublished studies that evaluate school-based interventions to prevent tobacco smoking initiation among in-school young people in LMICs compared to non-intervention programmes. Published studies would be from databases such as MEDLINE via Ovid, CINAHL via EBSCO, Embase, PsycINFO, PsycEXTRA, and the Cochrane Central Register of Controlled Trials. Sources of grey literature would be ProQuest Dissertations and Theses, MedNar, EBSCO Open Dissertations, Open Access Theses and Dissertations, and Trove. The databases will be searched for published studies in the English language. The processes of study selection, critical appraisal, data extraction, and data synthesis will be in accordance with the JBI approach for reviews of effectiveness with a minimum of two reviewers at each stage. The primary outcome of the review will be the non-initiation of tobacco smoking by the youth. DISCUSSION: The review will provide synthesized evidence on the effectiveness of school-based smoking initiation prevention among young people in LMICs. The findings of the review would support policymakers and programme implementers to develop targeted interventions for effective tobacco control initiatives. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021246206.

Determinants of tobacco smoking abstinence one year after major noncardiac surgery: a secondary analysis of the VISION study.

BACKGROUND: Tobacco smoking is a leading preventable cause of death and increases perioperative risk. Determinants of smoking abstinence after noncardiac surgery and the association between smoking and 1-yr vascular outcomes are not fully elucidated. METHODS: We did a prospective cohort study of 40 004 patients, aged ≥45 yr, enrolled between August 2007 and November 2013, and followed for 1 yr after surgery. Patients were categorised as never smokers, ex-smokers (quit >4 weeks preoperatively), and current smokers (smoking ≤4 weeks preoperatively). Primary outcome was abstinence at 1 yr. Secondary outcome was a composite of all-cause death, non-fatal myocardial infarction, and non-fatal stroke at 1 yr. RESULTS: Of 4658 current smokers, 1838 (39.5%) were abstinent 1 yr after surgery. Median (inter-quartile range) time to resumption was 7 (3-23) days post-surgery. Perioperatively, 7.2% of current smokers obtained smoking cessation pharmacotherapy. Older age (adjusted risk ratio [aRR] 1.21; 95% confidence interval [CI]: 1.12-1.32); having recent coronary artery disease (aRR 1.41; 95% CI: 1.29-1.55); cancer (aRR 1.37; 95% CI: 1.18-1.59); and undergoing major vascular (aRR 1.20; 95% CI: 1.02-1.41), urgent/emergent (aRR 1.14; 95% CI: 1.05-1.23), or thoracic (aRR 1.41; 95% CI: 1.26-1.56) surgeries increased abstinence. One-year abstinence was less likely when patients stopped smoking 0-1 day (aRR 0.53; 95% CI: 0.43-0.66) and 2-14 days (aRR 0.76; 95% CI: 0.71-0.82) before surgery compared with >14 days before surgery. Current smokers (adjusted hazard ratio [aHR] 1.14; 95% CI: 1.01-1.29) and ex-smokers (aHR 1.11; 95% CI: 1.03-1.21) had higher risk of the 1-yr vascular outcome compared with never smokers. CONCLUSIONS: Long-term tobacco abstinence is more likely after major surgery in those with serious medical comorbidities. Interventions to prevent smoking resumption after surgery remain a priority. Clinical trial registration NCT00512109.

The Effectiveness of Health Education Using Audiovisual on the Santri Smokers' Motivation to Stop Smoking.

BACKGROUND AND OBJECTIVE: Low motivation to quit smoking affects individual smoking behavior. Health education using audiovisual media can increase smokers' motivation to quit smoking. The objective of this study was to determine the effectiveness of health education using audiovisuals on the Santri smokers' motivation to stop smoking. METHODS: This quasi-experimental study was carried out using a pretest-posttest design. The sample in this study included Santri smokers studying at the Traditional Islamic Boarding School in Aceh Besar . This study consisted of 4 groups. Three groups were given intervention (audiovisual health education with different themes) and one group received just health education. Groups were compered in terms of difference in the mean smokers' motivation to quit smoking. The data analysis was done by running paired t-test and one-way ANOVA. RESULTS: The results of statistical tests showed that there was a difference in the mean motivation to quit smoking before and after the intervention in each group (mean ± SD for group 1 to 4 was 11.52 ± 4.76, 15.39 ± 6.06, 22.57 ± 6.23, and 9.84 ± 6.42, respectively). The highest increase in the mean motivation to quit smoking was allocated to group 3 who received audiovisual health education with the theme of risk of developing cancer due to smoking. CONCLUSION: Health education using audiovisuals could increase the motivation of students to quit smoking, especially interventions on the risk of developing cancer due to smoking. Therefore, health workers are suggested to use audiovisuals to implement various intervention in order to change smoking behavior in students.

An evaluation of Indigenous Tobacco Program smoking prevention workshops with First Nations youth in Ontario, Canada.

SETTING: The Indigenous Tobacco Program (ITP) operated by the Indigenous Cancer Care Unit at Cancer Care Ontario provides customized tobacco prevention workshops to First Nations youth across Ontario, in partnership with First Nations communities and partner organizations. INTERVENTION: First Nations youth in Canada are more likely than non-Indigenous youth to be smokers. The ITP aims to address the negative health impacts of commercial tobacco, using culturally relevant approaches, tools and resources while remaining respectful to the significance of sacred tobacco. This paper aims to determine whether a culturally tailored tobacco prevention workshop increases tobacco-related knowledge among First Nations youth in Ontario. OUTCOMES: The workshops exhibited promise in impacting First Nations youth knowledge on the harms of commercial tobacco, as after the workshop intervention, all indicators showed improved knowledge. Building strong and ongoing relationships with communities and partner organizations is vital to the success of the program. IMPLICATIONS: Culturally tailored workshops grounded in traditional knowledge and values provide an opportunity to increase the knowledge of the harms of commercial tobacco among First Nations youth in Ontario. With commercial tobacco use and exposure having tremendous health consequences, such interventions are essential.

RéSUMé: CADRE: Le Programme pour la lutte contre le tabagisme chez les peuples autochtones (PLTPA) administré par l'Unité des soins de cancérologie chez les peuples autochtones à Cancer Care Ontario dispense des ateliers personnalisés de prévention du tabagisme aux jeunes Autochtones dans tout l'Ontario, en partenariat avec les communautés et organismes partenaires des Premières Nations. INTERVENTION: Les jeunes des Premières Nations canadiennes sont plus susceptibles de fumer que les jeunes non autochtones. Le PLTPA vise à remédier aux effets négatifs sur la santé du tabac commercial à l'aide d'approches, d'outils et de ressources pertinents sur le plan culturel, tout en demeurant respectueux de l'importance du tabac sacré. Cet article vise à déterminer si un atelier de prévention adapté sur le plan culturel permet d'accroître les connaissances relatives au tabac parmi les jeunes des Premières Nations de l'Ontario. RéSULTATS: Les ateliers ont eu des répercussions prometteuses sur les connaissances des jeunes des Premières Nations ayant trait aux effets néfastes du tabac commercial, puisqu'à la suite de l'atelier d'intervention, tous les indicateurs dénotaient une amélioration des connaissances à ce sujet. L'entretien de relations solides et continues avec les communautés et organismes partenaires est essentiel à la réussite du programme. IMPLICATIONS: Les ateliers culturellement adaptés et fondés sur des connaissances et des valeurs traditionnelles permettent d'accroître les connaissances des jeunes des Premières Nations ontariennes ayant trait aux effets néfastes du tabac commercial. Au vu des impacts énormes sur la santé, liés à la consommation de tabac commercial et à l'exposition à celui-ci, de telles interventions sont essentielles.

Bupropion for postpartum smoking relapse: A remote protocol for a two-arm, double-blind, placebo-controlled randomized clinical trial.

Cigarette smoking among postpartum women remains a significant public health problem despite known health risks to women and their newborns. It is estimated that over 50% of women quit smoking during pregnancy but 90% relapse by one year. Safe and effective postpartum relapse prevention strategies are urgently needed. In an attempt to address this deficit, we will investigate the efficacy of bupropion vs. placebo as a smoking relapse prevention aid in postpartum women. The objective of this paper is to detail an approach to investigate bupropion's efficacy for preventing postpartum smoking relapse among women who quit smoking during pregnancy. Specifically, we designed a two-arm, double-blind, placebo-controlled randomized trial testing the efficacy of bupropion vs. placebo as a relapse prevention tool. Mothers of healthy infants who quit smoking while pregnant will be stratified based on current or past history of major depressive disorder or persistent depressive disorder and randomized to receive either active (bupropion XL 300 mg/day) or placebo medication for 12 weeks. To respond to safety concerns associated with participant and staff exposure to COVID-19, we revised our original protocol and present procedures which allow our trial to be conducted entirely remotely. Primary and secondary outcomes will be assessed at weeks 12, 24, 36 and 52 post-randomization. The primary outcome is 7-day point prevalence abstinence at 24 weeks. Results of this work have the potential to positively impact women and their children by promoting lifelong cessation, eliminating secondhand smoke exposure, and modelling of abstinence to children.

Impact of the Revised European Tobacco Product Directive on the Quality of E-cigarette Refill Liquids in Belgium.

INTRODUCTION: Since its introduction, the e-cigarette has become a commonly used consumer product. In this study, we investigate whether regulatory changes had an impact on the quality of refill liquids (e-liquids) available on the Belgian market through analysis of their chemical composition. Hence, the nicotine concentration accuracy was investigated in samples before, during and after the implementation of the revised Tobacco Product Directive (TPD) as an indicator of good manufacturing practices. This is, however, not enough to assure the quality. Therefore, extra criteria were also assessed based on TPD requirements. METHODS: By using in-house validated methods, a total of 246 e-liquids purchased prior (2013-2015), during (2016) and after (2017-2018) the implementation of the TPD revisions, were analyzed for the presence of nicotine, nicotine-related impurities, volatile organic compounds (VOCs), caffeine and taurine, and the flavors diacetyl and acetylpropionyl. RESULTS: Although not all manufacturers managed to produce and label their products accurately, nicotine labeling discrepancies have decreased over time. Moreover, also the number of e-liquids, containing high-risk VOCs (10% in 2016 vs. none of the samples in 2017-2018), caffeine (16% in 2017 vs. 5% in 2018), and diacetyl and acetylpropionyl (50% in 2017 vs. 27% in 2018 of sweet-flavored samples) diminished over time. CONCLUSION: Our results demonstrate that the overall quality of the e-liquids has improved after the implementation of the revised TPD. However, the results also show that periodic quality control might be required to ensure further compliance to the TPD. IMPLICATIONS: This study clearly demonstrates that the implementation of the revised TPD has improved the quality of the e-liquids on the Belgian market. However, there are still e-liquids that are not in agreement with the TPD due to nicotine concentration label discrepancies, presence of e-liquid impurities and controversial flavors diacetyl and acetylpropionyl or the additive caffeine.

Vaping Restrictions: Is Priority to the Young Justified?

The vast majority of smokers become dependent on nicotine in youth. Preventing dependence has therefore been crucial to the recent decline in youth smoking. The advent of vaping creates an opportunity for harm reduction to existing smokers (mostly adults) but simultaneously also undermines prevention efforts by becoming a new vehicle for young people to become dependent on nicotine, creating an ethical dilemma. Restrictions to access to some vaping products enacted in response to the increase in vaping among youth observed in the United States since 2018 have arguably prioritized prevention of new cases of dependence-protecting the young-over harm reduction to already dependent adults. Can this prioritization of the young be justified? This article surveys the main bioethical arguments for prioritizing giving health benefits to the young and finds that none can justify prioritizing dependence prevention over harm reduction: any reasons for prioritizing the current cohort of young people at risk from vaping will equally apply to current adult smokers, who are overwhelmingly likely to have become nicotine-dependent in their own youth. Public health authorities' current tendency to prioritize the young, therefore, does not seem to be ethically justified. IMPLICATIONS: This article argues that commonsense reasons for prioritizing the young do not apply to the ethical dilemma surrounding restricting access to vaping products.

Testing Augmented Reality for Eliciting Cue-Provoked Urges to Smoke: Toward Moving Cue-Exposure Into the Real World.

BACKGROUND: Cue exposure for extinguishing conditioned urges to smoking cues has been promising in the laboratory, but difficult to implement in natural environments. The recent availability of augmented reality (AR) via smartphone provides an opportunity to overcome this limitation. Testing the ability of AR to elicit cue-provoked urges to smoke (ie, cue reactivity [CR]) is the first step to systemically testing the efficacy of AR for cue exposure therapy. OBJECTIVES: To test CR to smoking-related AR cues compared to neutral AR cues, and compared to in vivo cues. METHODS: A 2 × 2 within-subject design comparing cue content (smoking vs. neutral) and presentation modality (AR vs. in vivo) on urge response. Seventeen smokers viewed six smoking-related and six neutral cues via AR smartphone app and also six smoking and six neutral in vivo cues. Participants rated their urge to smoke and reality/co-existence of the cue. RESULTS: Average urge to smoke was higher following smoking-related AR images (Median = 7.50) than neutral images (Median = 3.33) (Z = -3.44; p = .001; d = 1.37). Similarly, average urge ratings for in vivo smoking-related cues (Median = 8.12) were higher than for neutral cues (Median = 2.12) (Z = -3.44; p = .001; d = 1.64). Also, greater CR was observed for in vivo cues than for AR cues (Z = -2.67, p = .008; d = .36). AR cues were generally perceived as being realistic and well-integrated. CONCLUSIONS: CR was demonstrated with very large effect sizes in response to AR smoking cues, although slightly smaller than with in vivo smoking cues. This satisfies the first criterion for the potential use of AR for exposure therapy. IMPLICATIONS: This study introduces AR as a novel modality for presenting smoking-related stimuli to provoke cue reactivity, and ultimately to conduct extinction-based therapy. AR cues presented via a smartphone have the advantage over other modes of cue presentation (pictures, virtual reality, in vivo, etc.) of being easily transportable, affordable, and realistic, and they can be inserted in a smokers' natural environment rather than being limited to laboratory and clinic settings. These AR features may overcome the generalizability barriers of other methods, thus increasing clinical utility for cue exposure therapies.

Patterns of tobacco and alcohol misuse among presumptive TB Patients in Myanmar: prevalence and sociodemographic associations.

This study aimed to assess the prevalence and patterns of tobacco and alcohol use and the associations with socio-demographic variables among presumptive TB patients. A cross-sectional study was conducted among 397 presumptive TB patients in a tertiary hospital in Myanmar. Global Adult Tobacco Survey (GATS) questionnaire and AUDIT-C were used to measure daily tobacco use (single, any or dual use of smoked and smokeless tobacco) and harmful alcohol use, respectively. Multiple and multinomial logistic regression were used to examine the associations with socio-demographic factors. The prevalence of daily use of dual tobacco and any tobacco was 28.2% and 65.7%, respectively. Harmful alcohol use was also high (44.8%). While single use of daily tobacco and harmful alcohol was 28.2% and 7.3%, respectively, concurrent tobacco and alcohol use was 37.5%. While being male and having low education were associated with tobacco use, concurrent tobacco and harmful alcohol use were associated with male gender, low education, and occupation with the government or a company. Due to the high prevalence of tobacco and alcohol misuse, identifying those at risk of tobacco and alcohol misuse and providing integrated care services in a health facility should be considered as a joint activity in national TB and tobacco control programmes.

[Dialogue between general practitioner and patient regarding tobacco and alcohol consumption, from the patient's standpoint]. / Dialogue entre médecin généraliste et patient : les consommations de tabac et d'alcool en question, du point de vue du patient.

BACKGROUND: General practitioners (GP) are key players in screening and counselling for smokers and alcohol drinkers exceeding French guidelines for low-risk consumption thresholds. Tackling the subject from the patients' perspective, the authors aim at estimating the proportion of the population having discussed their smoking and alcohol consumption with their GPs, and to pinpoint the factors associated with their having done so. METHODS: The data (n=6346) are derived from nationwide representative phone survey in mainland France conducted by the French public health monitoring center Baromètre de Santé publique France. RESULTS: Among the persons aged 18-75 having consulted a GP over the last 12 months (82.5%), 36.7% stated that smoking had been discussed in consultation while 16.8% had talked about alcohol use. For both substances, being a man, a smoker, an excessive alcohol user and having a chronic illness were not only independently associated with being questioned by one's doctor, but also with more frequent patient initiative. About 87% considered it normal to be asked by their GP about their alcohol intake, this proportion being higher among men and people with high incomes. CONCLUSION: Even though a large portion of the population would deem it normal to discuss smoking and alcohol intake in consultation with a GP, the subjects are rarely broached. Our results underline the need to bolster efforts at systematic screening for substance use by GPs.

Targeting mailed nicotine patch distribution interventions to rural regions of Canada: protocol for a randomized controlled trial.

BACKGROUND: Quitting smoking is the most effective way of reducing the risk of cancer among smokers. One way of helping people stop smoking is to provide them with free Nicotine Replacement Therapy (NRT), such as when NRT is sent to people by postal mail as part of a mass distribution initiative. Our previous research indicated that there may be a substantial impact on increasing quit rates of a mailed NRT intervention in rural areas. The current research seeks to confirm this finding and to understand the social determinants of health driving these anticipated large effects. METHODS/DESIGN: Telephone numbers will be randomly selected from across rural regions of Canada in order to recruit adult smokers interested in completing a smoking survey and willing to be interviewed again in 6 months. The survey will ask participants about their smoking history, demographic characteristics, and a hypothetical question: would they be interested in receiving nicotine patches if they were provided to them free of charge? Half of the smokers interested in receiving nicotine patches will be selected by chance and offered the NRT package. The other half of smokers will not be offered the nicotine patches. In addition, the municipality where each participant lives will be identified and, once the relevant general population data becomes available, attempts will be made to link participant data to relevant municipal characteristics (e.g., smoking rates, availability of health services). Characteristics of the participants and the municipalities in which they live will be used to explain why the nicotine patch intervention may have a larger impact in some rural regions compared to others. DISCUSSION: The findings from the proposed RCT are timely and of high relevance as the distribution of nicotine patches has substantial potential to combat the public health problem of cigarette related cancer, other diseases, and premature death from tobacco use. Targeting such tobacco cessation initiatives to rural regions may substantially increase the impact of this intervention, helping to optimize the use of limited prevention resources while aiming to save the maximum number of lives. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov NCT04606797 , October, 27, 2020.

Reported patterns of vaping to support long-term abstinence from smoking: a cross-sectional survey of a convenience sample of vapers.

BACKGROUND: E-cigarettes are the most popular aid to smoking cessation attempts in England and the USA. This research examined associations between e-cigarette device characteristics and patterns of use, tobacco-smoking relapse, and smoking abstinence. METHODS: A convenience sample of 371 participants with experience of vaping, and tobacco-smoking abstinence and/or relapse completed an online cross-sectional survey about e-cigarettes. Factors associated with smoking relapse were examined using multiple linear and logistic regression models. RESULTS: Most participants were self-reported long-term abstinent smokers (86.3%) intending to continue vaping. Most initiated e-cigarette use with a vape pen (45.8%) or cig-a-like (38.7%) before moving onto a tank device (89%). Due to missing data, managed through pairwise deletion, only around 70 participants were included in some of the main analyses. Those using a tank or vape pen appeared less likely to relapse than those using a cig-a-like (tank vs. cig-a-like OR = 0.06, 95% CI 0.01-0.64, p = 0.019). There was an inverse association between starting self-reported e-cigarette liquid nicotine concentration and relapse, interacting with device type (OR = 0.79, 95% CI 0.63-0.99, p = 0.047), suggesting that risk of relapse may have been greater if starting with a low e-cigarette liquid nicotine concentration and/or cig-a-like device. Participants reported moving from tobacco-flavored cig-a-likes to fruit/sweet/food flavors with tank devices. CONCLUSIONS: Knowledge of how people have successfully maintained tobacco-smoking abstinence using vaping could help other tobacco smokers wishing to quit tobacco smoking through vaping.