Effect of narrative videos and mini-VR games in nursing smoking cessation training on empathy and self-efficacy of smoking cessation counseling: A randomized controlled trial.

BACKGROUND: Empathy and self-efficacy for smoking cessation counseling can be enhanced through smoking cessation training. Narrative videos and virtual reality (VR) games have been applied in medical education, but their application in smoking cessation training is limited and understudied. OBJECTIVES: To evaluate the effect of smokers' narrative videos and mini-VR games on nursing students' empathy towards smokers (State Empathy Scale), confidence in practicing empathy, self-efficacy in smoking cessation counseling, and learning satisfaction. DESIGN: An open-labeled randomized controlled trial, registration number: NCT05440877 (ClinicalTrials.gov). SETTING AND PARTICIPANTS: Master of nursing students from the University in Hong Kong who enrolled in a smoking cessation course. METHODS: All students attended a tutorial including case-based discussions and role-play. The intervention group could additionally access the narrative videos and mini-VR games of smokers' cases. Linear mixed models and Cohen's d were used to evaluate the intervention effect on the self-reported learning outcomes after the intervention. RESULTS: 26 students enrolled in this trial, with 13 in each trial arm. All completed the trial. Post-test state empathy scores were significantly higher in the control group than in the intervention group (Cohen's d = 0.814, p = 0.049). No significant group differences were observed in the change of confidence in practicing empathy (ß = -11.154, p = 0.073), self-efficacy (ß = 4.846, p = 0.096), and students' learning satisfaction (Cohen's d = 0.041, p = 0.917). Both groups showed a significant increase in self-efficacy post-test (p < 0.001). CONCLUSIONS: Narrative videos showing smoking scenes and reluctance to quit, and our mini-VR games may weaken nursing students' empathy towards smokers. Smoking cessation training involving narrative videos should be modified. Debriefing and guidance to understand smokers' difficulties and express empathy are needed. VR games for smoking cessation training can involve more frame stories and challenging tasks to increase engagement.

Engagement With a Mobile Chat-Based Intervention for Smoking Cessation: A Secondary Analysis of a Randomized Clinical Trial.

Importance: Determining how individuals engage with digital health interventions over time is crucial to understand and optimize intervention outcomes. Objective: To identify the engagement trajectories with a mobile chat-based smoking cessation intervention and examine its association with biochemically validated abstinence. Design, Setting, and Participants: A secondary analysis of a pragmatic, cluster randomized clinical trial conducted in Hong Kong with 6-month follow-up. From June 18 to September 30, 2017, 624 adult daily smokers were recruited from 34 community sites randomized to the intervention group. Data were analyzed from March 6 to October 30, 2023. Intervention: Chat-based cessation support delivered by a live counselor via a mobile instant messaging app for 3 months from baseline. Main Outcomes and Measures: Group-based trajectory modeling was used to identify engagement trajectories using the participants' weekly responses to the messages from the counselor over the 3-month intervention period. The outcome measures were biochemically validated tobacco abstinence at 3-month (end of treatment) and 6-month follow-ups. Covariates included sex, age, educational level, nicotine dependence, past quit attempt, and intention to quit at baseline. Results: Of 624 participants included in the analysis, 479 were male (76.8%), and the mean (SD) age was 42.1 (16.2) years. Four distinct engagement trajectories were identified: low engagement group (447 [71.6%]), where participants maintained very low engagement throughout; rapid-declining group (86 [13.8%]), where participants began with moderate engagement and rapidly decreased to a low level; gradual-declining group (58 [9.3%]), where participants had high initial engagement and gradually decreased to a moderate level; and high engagement group (58 [5.3%]), where participants maintained high engagement throughout. Compared with the low engagement group, the 6-month validated abstinence rates were significantly higher in the rapid-declining group (adjusted relative risk [ARR], 3.30; 95% CI, 1.39-7.81), gradual-declining group (ARR, 5.17; 95% CI, 2.21-12.11), and high engagement group (ARR, 4.98; 95% CI, 1.82-13.60). The corresponding ARRs (95% CI) of 3-month validated abstinence were 4.03 (95% CI, 1.53-10.59), 5.25 (95% CI, 1.98-13.88), and 9.23 (95% CI, 3.29-25.86). Conclusions and Relevance: The findings of this study suggest that higher levels of engagement with the chat-based smoking cessation intervention were associated with greater biochemically validated tobacco abstinence. Improving engagement with digital interventions may increase intervention benefits. Trial Registration: ClinicalTrials.gov Identifier: NCT03182790.

Effectiveness of Very Brief Advice on Tobacco Cessation: A Systematic Review and Meta-Analysis.

BACKGROUND: Very brief advice (VBA; ≤ 3 min) on quitting is practical and scalable during brief medical interactions with patients who smoke. This study aims to synthesize the effectiveness of VBA for smoking cessation and summarize the implementation strategies. METHODS: We searched randomized controlled trials aiming at tobacco abstinence and comparing VBA versus no smoking advice or no contact from Medline, Embase, CINAHL, Cochrane Library, PsycInfo databases, six Chinese databases, two trial registries ClinicalTrials.gov and WHO-ICTRP from inception to September 30, 2023. Grading of Recommendations, Assessment, Development, and Evaluations framework was used to assess the certainty of the evidence of the meta-analytic findings. The outcomes were self-reported long-term tobacco abstinence at least 6 months after treatment initiation, earlier than 6 months after treatment initiation, and quit attempts. Effect sizes were computed as risk ratio (RR) with 95% CI using frequentist random-effect models. DATA SYNTHESIS: Thirteen randomized controlled trials from 15 articles (n = 26,437) were included. There was moderate-certainty evidence that VBA significantly increased self-reported tobacco abstinence at ≥ 6 months in the adjusted model (adjusted risk ratio ARR 1.17, 95% CI: 1.07-1.27) compared with controls. The sensitivity analysis showed similar results when abstinence was verified by biochemical validation (n = 6 studies, RR 1.53, 95% CI 0.98-2.40). There was high-certainty evidence that VBA significantly increased abstinence at < 6 months (ARR 1.22, 95% CI: 1.01-1.47). Evidence of effect on quit attempts (ARR 1.03, 95% CI 0.97-1.08) was of very low certainty. DISCUSSION: VBA delivered in a clinical setting is effective in increasing self-reported tobacco abstinence, which provides support for wider adoption in clinical practice.

Effect of Adding Personalized Instant Messaging Apps to a Brief Smoking Cessation Model in Community Smokers in Hong Kong: Pragmatic Randomized Clinical Trial.

BACKGROUND: While text messaging has proven effective for smoking cessation (SC), engagement in the intervention remains suboptimal. OBJECTIVE: This study aims to evaluate whether using more interactive and adaptive instant messaging (IM) apps on smartphones, which enable personalization and chatting with SC advisors, can enhance SC outcomes beyond the provision of brief SC advice and active referral (AR) to SC services. METHODS: From December 2018 to November 2019, we proactively recruited 700 adult Chinese daily cigarette users in Hong Kong. Participants were randomized in a 1:1 ratio. At baseline, all participants received face-to-face brief advice on SC. Additionally, they were introduced to local SC services and assisted in selecting one. The intervention group received an additional 26 personalized regular messages and access to interactive chatting through IM apps for 3 months. The regular messages aimed to enhance self-efficacy, social support, and behavioral capacity for quitting, as well as to clarify outcome expectations related to cessation. We developed 3 sets of messages tailored to the planned quit date (within 30 days, 60 days, and undecided). Participants in the intervention group could initiate chatting with SC advisors on IM themselves or through prompts from regular messages or proactive inquiries from SC advisors. The control group received 26 SMS text messages focusing on general health. The primary outcomes were smoking abstinence validated by carbon monoxide levels of <4 parts per million at 6 and 12 months after the start of the intervention. RESULTS: Of the participants, 505/700 (72.1%) were male, and 450/648 (69.4%) were aged 40 or above. Planning to quit within 30 days was reported by 500/648 (77.2%) participants, with fewer intervention group members (124/332, 37.3%) reporting previous quit attempts compared with the control group (152/335, 45.4%; P=.04). At the 6- and 12-month follow-ups (with retention rates of 456/700, 65.1%, and 446/700, 63.7%, respectively), validated abstinence rates were comparable between the intervention (14/350, 4.0%, and 19/350, 5.4%) and control (11/350, 3.1% and 21/350, 6.0%) groups. Compared with the control group, the intervention group reported greater utilization of SC services at 12 months (RR 1.26, 95% CI 1.01-1.56). Within the intervention group, engaging in chat sessions with SC advisors predicted better validated abstinence at 6 months (RR 3.29, 95% CI 1.13-9.63) and any use of SC services (RR 1.66, 95% CI 1.14-2.43 at 6 months; RR 1.67, 95% CI 1.26-2.23 at 12 months). CONCLUSIONS: An IM-based intervention, providing support and assistance alongside brief SC advice and AR, did not yield further increases in quitting rates but did encourage the utilization of SC services. Future research could explore whether enhanced SC service utilization leads to improved long-term SC outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT03800719; https://clinicaltrials.gov/ct2/show/NCT03800719.

Efficacy of simple and very brief handgrip and isometric exercises for reducing withdrawal symptoms in cigarette smokers: A pilot randomized controlled trial.

INTRODUCTION: Withdrawal symptoms lead to smoking relapse and reduce the intention to quit. The present pilot RCT examined the effect of simple and very brief handgrip and isometric exercises on reducing withdrawal symptoms, measured by the strength of tobacco craving, Questionnaire of Smoking Urges-Brief (QSU-B), Mood and Physical Symptoms Scale (MPSS), and Positive and Negative Affect Schedule (PANAS). METHODS: In this 2-arm, open-labeled pilot RCT, 30 current smokers who had abstained from tobacco for at least 9 hours were randomly assigned (allocation ratio 1:1) to either the intervention group that watched a 5-minute video and did 5-minute handgrip and isometric exercises (pulling and pushing) or control group that watched 10-minute healthy-diet videos. Measurements were taken before, immediately after, and 10 minutes post-intervention. Outcomes were self-reported strength of tobacco craving, QSU-B, MPSS, and PANAS scores. The effect size for group-by-time interaction was assessed using Cohen's f2 (small=0.02, medium=0.15, large=0.35). RESULTS: Group-by-time interactions showed that the intervention group showed larger reductions than the control group in the strength of tobacco craving (Cohen's f2=0.54, 95% CI: 0.52-0.57), QSU-B (Cohen's f2=0.77; 95% CI: 0.74-0.80), and MPSS (Cohen's f2=0.51; 95% CI: 0.46-0.56) over the three measurement points. CONCLUSIONS: This RCT showed that simple and brief handgrip and isometric exercises could immediately reduce withdrawal symptoms and up to 10 minutes. CLINICAL TRIAL REGISTRATION: in https://clinicaltrials.gov/. IDENTIFIER: NCT04059497.

Patterns and socioeconomic differences in secondhand exposure to cigarettes, e-cigarettes, and heated tobacco products at home in Hong Kong adolescents.

INTRODUCTION: Smoke or aerosols from cigarettes, e-cigarettes (ECs), or heated tobacco products (HTPs) are harmful. Yet, there is little knowledge about the specific patterns of secondhand tobacco exposure by source within household settings and the socioeconomic status (SES) differences in adolescents. METHODS: We used territory-representative student data from a cross-sectional school-based survey in 2020-2021 to calculate the weighted prevalence of secondhand exposure to cigarettes, e-cigarettes, and HTPs in the past seven days. Parental education and perceived family affluence were used as indicators of socioeconomic status. Generalized linear mixed models were used to analyze associations. RESULTS: Among 22039 participants, 29.8% reported any secondhand tobacco exposure (SH-Any) at home, primarily from cigarettes (27.4%), followed by e-cigarettes (4.0%) and HTPs (0.9%). Tertiary parental education level was associated with lower SH-Any exposure (Adjusted odds ratio, AOR=0.49; 95% CI: 0.45-0.53, p<0.001), fewer exposure days (ß= -0.685, p<0.001), lower exposure to cigarettes (SH-CC) (AOR=0.49; 95% CI: 0.45-0.54, p<0.001) and to e-cigarettes or HTPs (SH-EC/HTP) (AOR=0.57; 95% CI: 0.45-0.71, p<0.001). 'Poor' family affluence was associated with higher exposures [AOR(SH-Any) =1.14; 95% CI: 1.06-1.22, p=0.001; ß(days)=0.160, p<0.001; AOR(SH-CC) =1.15; 95% CI: 1.07-1.24, p<0.001], except for SH-EC/HTP exposure, which was higher in students in an affluent family (AOR =1.66; 95% CI: 1.25-2.21, p<0.001). Significant SES differences in SH-EC/HTP exposure were found only in groups with low parental education level. Dose-response relationships were found between lower SH-Any and SH-CC and higher SES categories (p for trend<0.001). CONCLUSIONS: Adolescents experienced a high prevalence of tobacco smoke exposure at home, primarily from cigarettes. Higher SES was associated with lower tobacco exposure, except for SH-EC/HTP, which was higher among adolescents from affluent families. Additionally, high parental education level was protective against exposure to SH-EC/HTP. Comprehensive control measures to reduce the use of these tobacco products are needed to protect adolescents of diverse socioeconomic backgrounds.

Association between tobacco industry denormalisation beliefs and support for tobacco endgame policies: a population-based study in Hong Kong.

OBJECTIVES: To examine the associations between tobacco industry denormalisation (TID) beliefs and support for tobacco endgame policies. METHODS: A total of 2810 randomly selected adult respondents of population-based tobacco policy-related surveys (2018-2019) were included. TID beliefs (agree vs disagree/unsure) were measured by seven items: tobacco manufacturers ignore health, induce addiction, hide harm, spread false information, lure smoking, interfere with tobacco control policies and should be responsible for health problems. Score of each item was summed up and dichotomised (median=5, >5 strong beliefs; ≤5 weak beliefs). Support for tobacco endgame policies on total bans of tobacco sales (yes/no) and use (yes/no) was reported. Associations between TID beliefs and tobacco endgame policies support across various smoking status were analysed, adjusting for sociodemographics. RESULTS: Fewer smokers (23.3%) had strong beliefs of TID than ex-smokers (48.4%) and never smokers (48.5%) (p<0.001). Support for total bans on tobacco sales (74.6%) and use (76.9%) was lower in smokers (33.3% and 35.3%) than ex-smokers (74.3% and 77.9%) and never smokers (76.0% and 78.3%) (all p values<0.001). An increase in the number of TID beliefs supported was positively associated with support for a total ban on sales (adjusted risk ratio 1.06, 95% CI 1.05 to 1.08, p<0.001) and use (1.06, 95% CI 1.05 to 1.07, p<0.001). The corresponding associations were stronger in smokers than non-smokers (sales: 1.87 vs 1.25, p value for interaction=0.03; use: 1.78 vs 1.21, p value for interaction=0.03). CONCLUSION: Stronger TID belief was associated with greater support for total bans on tobacco sales and use. TID intervention may increase support for tobacco endgame, especially in current smokers.

The learning outcomes of smoking cessation training in undergraduate nursing students: A systematic review.

AIM: To systematically evaluate the effect of smoking cessation training on nursing students' learning outcomes. DESIGN: This systematic review followed the PRISMA guidelines and was registered with PROSPERO (CRD42022373280). METHODS: Ten electronic English and Chinese databases were searched to identify articles on nursing students' smoking cessation training from inception to October 2022. Medical Education Research Study Quality Instrument was used to assess the methodological quality of eligible studies. RESULTS: Twelve moderate methodological quality studies (three randomized controlled trials and nine quasi-experimental studies) with 2114 undergraduate nursing students were included. Teaching strategies included didactic lectures, collaborative learning, blended learning and the service-learning approach. Eight studies showed that the training significantly increased nursing students' knowledge of smoking cessation (p < 0.05) and three of them showed a large effect size (Cohen's d: 0.83-1.31). Seven studies showed that training enhanced students' attitudes/motivation towards smoking cessation interventions significantly (p < 0.05) and two of them showed a large effect size (Cohen's d: 1.11-1.84). Nine studies reported that students' self-efficacy improved significantly after training (p < 0.05) and six of them showed a large effect size (Cohen's d: 0.98-2.18). Two one-group pre-post studies showed training significantly improved students' practice of 5 A's behavior (p < 0.05), with a small effect size (Cohen's d < 0.50). CONCLUSIONS: This review showed that smoking cessation training had a positive and large effect on undergraduate nursing students' knowledge, attitudes/motivation and self-efficacy towards smoking cessation intervention, but the effect of changing the practice of 5 A's was modest. We noted that very few RCTs were done and most studies only used subjective measures. More robust experimental studies with long-term follow-up are warranted in evaluating nursing students' practice/behavior of smoking cessation intervention and patients' quitting outcomes. Blended and collaborative learning are recommended in smoking cessation education.

Corrigendum: Risk perceptions and changes in tobacco use in relation to Coronavirus Disease 2019 pandemic: A qualitative study on adolescent tobacco users in Hong Kong.

[This corrects the article DOI: 10.18332/tid/167479.].

Effectiveness of personalized smoking cessation intervention based on ecological momentary assessment for smokers who prefer unaided quitting: protocol for a randomized controlled trial.

Introduction: Ecological momentary assessment (EMA)-based smoking cessation intervention may help personalize intervention for smokers who prefer to quit smoking unaided. This study aims to evaluate the effectiveness of EMA-based phone counseling and instant messaging for smoking cessation. Methods/design: This is a two-arm, accessor-blinded, simple individual randomized controlled trial (allocation ratio 1:1). Participants will be recruited from community sites and online platforms in Hong Kong. Interventions will be delivered via a phone call and instant messaging. Current adult smokers who (1) self-report no intention to use smoking cessation services and medication in the coming month and (2) have not used smoking cessation services or nicotine replacement therapy in the past 7 days will be recruited. Recruited participants will be randomized to intervention or control groups via an online randomizer. All participants will be required to complete EMAs (five times per day for 7 consecutive days). The intervention group (n = 220) will receive a nurse-led brief phone counseling immediately after the 1-week EMAs and 10-week EMA-based advice via instant messaging applications (e.g., WhatsApp, WeChat). The 10-week EMA-based advice covers a summary of the 1-week EMAs, and tailored cessation support focused on personalized smoking triggers. The control group (n = 220) will not receive any intervention during the same period. The primary outcomes are participants' progression toward smoking cessation assessed by the Incremental Behavior Change toward Smoking Cessation (IBC-S) and biochemically validated abstinence at the 3-month follow-up. Secondary outcomes include self-reported and biochemically validated tobacco abstinence at the 6-month follow-up. Discussion: The findings will provide evidence that the EMA-based tailored smoking cessation intervention can be adapted as a new health promotion strategy for current smokers who are unwilling to use smoking cessation aids. Clinical trial registration: https://classic.clinicaltrials.gov/ct2/show/NCT05212220, identifier: NCT05212220.

Risk perceptions and changes in tobacco use in relation to Coronavirus Disease 2019 pandemic: A qualitative study on adolescent tobacco users in Hong Kong.

INTRODUCTION: Tobacco use is associated with an increased risk of Coronavirus Disease 2019 (COVID-19) infection, severe COVID-19 outcomes requiring intensive care, and mortality. We investigated the perceived risk of and changes in cigarette, e-cigarette (EC) and heated tobacco product (HTP) use in relation to COVID-19 in Hong Kong adolescent tobacco users. METHODS: We conducted semi-structured telephone interviews from January to April 2021 and in February 2022 on 40 adolescents (65% boys, Secondary school grades 2-6) who participated in our previous smoking surveys and were using cigarettes, ECs or HTPs before the first wave of the COVID-19 pandemic in January 2020. RESULTS: Adolescents generally perceived higher risks of contracting and having more severe COVID-19 from using cigarettes than ECs/HTPs, but they had limited knowledge of COVID-19 risks from EC/HTP use, particularly. Both increased and reduced consumption were found in tobacco, with EC use being the less affected product. Changes also included switching to ECs for convenience and lower cost and shifting from smoking cigarettes outside to mainly at home or in hidden areas. COVID-related policies, fear of infection, non-COVID-related health concerns, less social opportunities and pocket money, and limited access to tobacco products were barriers to tobacco use. In contrast, greater freedom at home versus school and negative emotions due to social distancing were facilitators. Family/peer influence had mixed impacts. CONCLUSIONS: Adolescent tobacco users perceived lower COVID risks associated with HTPs and ECs than cigarettes, and various changes in tobacco use were found amid the pandemic in Hong Kong. COVID-19 and related social changes may both facilitate or deter adolescent tobacco use.

Impact of mandatory masking amid the COVID-19 pandemic on outdoor smoking: an interrupted time-series analysis of a 33-month unobtrusive observational study.

Background: Mask-wearing in outdoor public places in Hong Kong was mandated on 29 July 2020, amid the COVID-19 pandemic. We aimed to evaluate the impact of mandatory masking with no exemption for smoking on outdoor smoking. Methods: We conducted 253 unobtrusive observations at 10 outdoor smoking hotspots in 33 months from July 2019 to March 2022 and counted smokers and non-smoking pedestrians in fixed boundaries. We conducted interrupted time-series analyses on the monthly mean volume of smokers (persons per hour) using generalized linear models. The independent variables were as follows: time since the first observation, implementation of the mask regulation, time since the regulation, seasonality, and waves 1-5 outbreaks. We checked the robustness of the association using the daily mean volume of smokers as the dependent variable. Two sensitivity analyses were conducted to include the hotspot location or the number of all pedestrians as an offset. Results: Monthly outdoor smoking decreased immediately after the regulation (incidence rate ratio [IRR]: 0.505, 95% confidence interval [CI]: 0.374 to 0.680, P < 0.001). Daily smoking analysis and the two sensitivity analyses supported the results. However, monthly outdoor smoking increased by 11% since the regulation (IRR: 1.110, 95% CI: 1.074 to 1.147, P < 0.001). An exception was observed at the most severe wave 5 outbreak when monthly outdoor smoking decreased (IRR: 0.415, 95% CI: 0.327 to 0.525, P < 0.001). Conclusion: Outdoor smoking fell immediately after mandatory masking, rebounded to pre-pandemic levels, and decreased again at the most severe wave 5.

Effect of mobile interventions with nicotine replacement therapy sampling on long-term smoking cessation in community smokers: A pragmatic randomized clinical trial.

INTRODUCTION: Mobile interventions enable personalized behavioral support that could improve smoking cessation (SC) in smokers ready to quit. Scalable interventions, including unmotivated smokers, are needed. We evaluated the effect of personalized behavioral support through mobile interventions plus nicotine replacement therapy sampling (NRT-S) on SC in Hong Kong community smokers. METHODS: A total of 664 adult daily cigarette smokers (74.4% male, 51.7% not ready to quit in 30 days) were proactively recruited from smoking hotspots and individually randomized (1:1) to the intervention and control groups (each, n=332). Both groups received brief advice and active referral to SC services. The intervention group received 1-week NRT-S at baseline and 12-week personalized behavioral support through SC advisor-delivered Instant Messaging (IM) and a fully automated chatbot. The control group received regular text messages regarding general health at a similar frequency. Primary outcomes were carbon monoxide-validated smoking abstinence at 6 and 12 months post-treatment initiation. Secondary outcomes included self-reported 7-day point-prevalence and 24-week continuous abstinence, quit attempts, smoking reduction, and SC service use at 6 and 12 months. RESULTS: By intention-to-treat, the intervention group did not significantly increase validated abstinence at 6 months (3.9% vs 3.0%, OR=1.31; 95% CI: 0.57-3.04) and 12 months (5.4% vs 4.5%, OR=1.21; 95% CI: 0.60-2.45), as were self-reported 7-day point-prevalence abstinence, smoking reduction, and SC service use at 6 and 12 months. More participants in the intervention than control group made a quit attempt by 6 months (47.0% vs 38.0%, OR=1.45; 95% CI: 1.06-1.97). Intervention engagement rates were low, but engagement in IM alone or combined with chatbot showed higher abstinence at 6 months (adjusted odds ratios, AORs=4.71 and 8.95, both p<0.05). CONCLUSIONS: Personalized behavioral support through mobile interventions plus NRT-S did not significantly improve abstinence in community smokers compared to text only messaging. The suboptimal intervention engagement needs to be addressed in future studies. TRIAL REGISTRATION: ClinicalTrials.gov NCT04001972.

Cigarettes, heated tobacco products and dual use: exhaled carbon monoxide, saliva cotinine and total tobacco consumed by Hong Kong tobacco users.

BACKGROUND: Independent studies on exhaled carbon monoxide (CO) and saliva cotinine levels in regular heated tobacco product (HTP) users, and how they compare with conventional cigarette (CC) smokers, are lacking. METHODS: A total of 3294 current users of CCs, HTPs or electronic cigarettes (ECs) from a household survey and a smoking hotspot survey were classified into seven groups: exclusive users of CCs, HTPs, ECs; dual users of CCs and HTPs, CCs and ECs, HTPs and ECs; and triple users. We measured exhaled CO level using the piCo Smokerlyzer (n=780) and saliva cotinine using NicAlert cotinine test strips (n=620). Among the seven groups, the differences in (1) CO and cotinine levels were examined using Kruskal-Wallis test, and (2) the average daily tobacco consumption in the past 30 days was examined using multivariable linear regression. RESULTS: Both exclusive and dual users of CCs had a higher CO level than exclusive HTP or EC users (p<0.05). Exhaled CO levels were similar between HTP and EC users, as were saliva cotinine levels among the seven groups. Compared with exclusive CC users, those who also used HTPs or ECs smoked fewer CCs (CCs+HTPs: adjusted coefficient -2.79, 95% CI -3.90 to -1.69; CCs+ECs: -1.34, 95% CI -2.34 to -0.34), but consumed more tobacco sticks equivalent in total (2.79 (95% CI 1.61 to 3.96); 1.95 (95% CI 0.79 to 3.12)). CONCLUSIONS: HTP or EC use showed lower exhaled CO but similar saliva cotinine levels compared with CC use. Dual users of CCs and HTPs/ECs smoked fewer CCs than exclusive CC users, but consumed more tobacco in total.

Mobile Chat Messaging for Preventing Smoking Relapse Amid the COVID-19 Pandemic: A Pilot Randomized Controlled Trial.

INTRODUCTION: The ongoing COVID-19 pandemic had reduced access to traditional, in-person smoking cessation treatment. We examined the feasibility, acceptability, and potential effectiveness of mobile chat messaging in preventing smoking relapse in smokers who have recently quit smoking. METHODS: In this assessor-blinded, pilot randomized controlled trial in five cessation clinics, we recruited adult daily smokers who had been receiving cessation treatments and abstained for 3 to 30 days. The intervention group received real-time, personalized chat messaging on relapse prevention via WhatsApp for 3 months. The control group received generic text messaging on the harms of smoking and benefits of quitting for 3 months. The primary outcome was carbon monoxide-validated abstinence at 6 months post-treatment initiation. The trial was registered with ClinicalTrials.gov (NCT04409496). RESULTS: From June to July 2020, 108 of 130 (83%) eligible subjects were randomized to the intervention (N = 54) or control (N = 54) groups. The retention rate was 93% at 3 months (end of treatment) and 85% at 6 months. In the intervention group, 80% of participants responded to the chat messages at least once; 43% continuously engaged with the intervention over the 3-month intervention period. By intention-to-treat, validated abstinence at 6 months was higher in the intervention than control group (31% vs. 22%), with a relative risk of 1.72 (95% CI = 0.91% to 3.23%; p = .09) after adjusting for pre-quit nicotine dependence, duration of abstinence, and cessation treatment at baseline. CONCLUSIONS: This pilot trial showed the feasibility and acceptability of mobile chat messaging for relapse prevention with preliminary evidence on its effectiveness in increasing validated abstinence. IMPLICATIONS: Smoking relapse is the most likely outcome of smoking cessation attempts and an undertreated problem. This pilot trial showed the feasibility and acceptability of personalized chat messaging via WhatsApp for relapse prevention in recent abstainers amid the COVID-19 pandemic. The higher carbon monoxide-validated abstinence rate in participants who received chat messaging than controls showed preliminary evidence on the effectiveness of the intervention. Fully powered trials are warranted to test the intervention.

Perception of heated tobacco products and support for regulations: a cross-sectional study in Hong Kong.

BACKGROUND: Hong Kong has proposed banning the sale of heated tobacco products (HTPs). Perceptions of reduced harms and effectiveness for quitting combustible cigarettes (CCs) of HTPs due to their promotions may erode public support for regulations. We assessed the associations between perceptions of HTPs and support for regulations in Hong Kong. METHODS: In two population-based landline surveys conducted in 2018-2019, 1985 respondents (51.4% male; 22.7% aged 60+ years) reported perceived relative harm of HTPs to CCs and effectiveness for quitting CCs, and support for five HTP regulations (ban on promotion and advertisements, use in smoke-free areas, sales to minors, registration before sale, sale licence) and a total ban on sale. Current and former smokers were oversampled due to low prevalence. Descriptive statistics were weighted to the general population. Associations were analysed, adjusting for sociodemographic characteristics, smoking status and ever HTP use. RESULTS: 27.4% (N=515) of respondents perceived HTPs as less harmful, and 18.8% (N=1299) perceived them as effective for quitting CCs. Support was generally high (at least one regulation, 99.1%, N=1959; all five regulations, 66.8%, N=1114; total ban, 63.5%, N=946). Perceptions of reduced harm were associated with lower support for all five regulations (adjusted risk ratio 0.85, 0.75 to 0.96) and a total ban on sale (0.58, 0.51 to 0.66). Results were similar for perceptions of effectiveness for quitting. CONCLUSIONS: Lower support for HTP regulations and a total ban on sale were associated with perceptions of reduced harm and effectiveness for quitting CCs of HTPs in Hong Kong.

Changes in tobacco use at the early stage of the COVID-19 pandemic: Results of four cross-sectional surveys in Hong Kong.

INTRODUCTION: Changes in tobacco use since the COVID-19 outbreak differed by countries and little is known about changes in the use of specific tobacco products. METHODS: We analyzed data from four cross-sectional telephone/online surveys from April to June 2020 to investigate such changes since the 1st and 2nd wave outbreaks (February to April 2020) in Hong Kong. The respondents were 1595 adults (83.2% male) who used tobacco before the COVID-19 outbreak from our previous intervention study and surveys. We investigated the changes in tobacco use, intention to quit and quit attempts during the outbreak. RESULTS: About two-thirds (65.3%) of respondents reported no change in overall tobacco use, while 23.1% used less (including cessation) and 11.6% used more, resulting in a net decrease of 11.5 percentage points. A greater net decrease was observed for cigarettes (14.3% points) than heated tobacco products (HTPs, 3.3% points) and electronic cigarettes (e-cigarettes, 2.5% points). Decreased use was mainly due to the more extended stay at home (63.2%), health considerations (52.6%) and mask-wearing (47.4%), while increased use was for passing time (75.0%) and releasing stress (46.4%). Eight percent of cigarette, HTP and e-cigarette users reported a higher intention to quit since the pandemic outbreak. Nineteen percent of tobacco users (176/948) attempted to quit during the pandemic. Only 2.9% (46/1569) were abstinent at the time of the survey. CONCLUSIONS: Overall tobacco use decreased after the first two waves of the COVID-19 outbreak in Hong Kong. A greater proportion of cigarette users decreased use than HTP and e-cigarette users. Given the different methods used in the four surveys, future studies should aim for a large and representative sample.

First Report on Smoking and Infection Control Behaviours at Outdoor Hotspots during the COVID-19 Pandemic: An Unobtrusive Observational Study.

This study was to observe smoking behaviours and infection control behaviours in smokers at outdoor smoking hotspots during the COVID-19 pandemic in Hong Kong. We conducted unobtrusive observations at nine hotspots during 1 July 2019-31 January 2020 (pre-outbreak, 39 observations), 1 February-30 April 2020 (outbreak, eight observations), and 1 May-11 June 2020 (since-outbreak, 20 observations). Sex, age group, type of tobacco products used, duration of stay, group smoking behaviours, face mask wearing and infection control behaviours of smokers, and mask wearing of non-smoking pedestrians were observed. Compared with pre-outbreak, lower volumes of smokers were observed during outbreak and since-outbreak. Smokers gathered more in a group (24.5% and 25.8% vs. 13.4%, respectively) and stayed longer (91.5% and 83.6% vs. 80.6% stayed ≥1 min) during outbreak and since-outbreak than pre-outbreak. Ninety-six percent smokers possessed a face mask. While smoking, 81.6% of smokers put the mask under the chin and 13.8% carried it in the hand, 32.4% did not wear a mask immediately after smoking, 98.0% did not sanitize hands, and 74.3% did not keep a distance of at least one metre. During the COVID-19 pandemic, smokers gathered closely and stayed longer at the hotspots, and few practised hand hygiene, all of which may increase the risk of infection.

Physicians' very brief (30-sec) intervention for smoking cessation on 13 671 smokers in China: a pragmatic randomized controlled trial.

BACKGROUND AND AIMS: Three to 10 minutes of smoking cessation advice by physicians is effective to increase quit rates, but is not routinely practised. We examined the effectiveness of physicians' very brief (approximately 30 sec) smoking cessation intervention on quit rates among Chinese outpatient smokers. DESIGN: A pragmatic, open-label, individually randomized controlled trial. SETTING: Seventy-two medical outpatient departments of hospitals and/or community health centers in Guangdong, China. PARTICIPANTS: Chinese adults who were daily cigarette smokers (n = 13 671, 99% males) were invited by their physician to participate during outpatient consultation. Smokers who were receiving smoking cessation treatment or were judged to need specialist treatment for cessation were excluded. INTERVENTIONS: The intervention group (n = 7015) received a 30-sec intervention including physician's very brief advice, a leaflet with graphic warnings and a card with contact information of available cessation services. The control group (n = 6656) received a very brief intervention on consuming vegetables and fruit. A total of 3466 participants in the intervention group were further randomized to receive a brief booster advice from trained study personnel via telephone 1 month following their doctor visit. MEASUREMENTS: The primary outcome was self-reported 7-day point prevalence abstinence (PPA) in the intervention and control groups at the 12-month follow-up. Secondary outcomes included self-reported 30-day abstinence and biochemically validated abstinence at 12-month follow-up. FINDINGS: By intention-to-treat, the intervention (versus control) group had greater self-reported 7-day abstinence [9.1 versus 7.8%, odds ratio (OR) = 1.14, 95% confidence interval (CI) = 1.03-1.26, P = 0.008] and 30-day abstinence (8.0 versus 6.9%, OR = 1.14, 95% CI = 1.03-1.27, P = 0.01) at 12-month follow-up. The effect size increased when only participants who received the intervention from compliant physicians were included (7-day PPA, OR = 1.42, 95% CI = 1.11-1.74). The group difference in biochemically validated abstinence was small (0.8 versus 0.8%, OR = 1.00, 95% CI = 0.71-1.42, P = 0.99). CONCLUSION: A 30-sec smoking cessation intervention increased self-reported abstinence among mainly male smokers in China at 12-month follow-up (risk difference = 1.3%), and should be feasible to provide in most settings and delivered by all health-care professionals.

Effects of active referral combined with a small financial incentive on smoking cessation: study protocol for a cluster randomised controlled trial.

INTRODUCTION: Evidence-based smoking cessation treatments are effective but underutilised, accentuating the need for novel approaches to increase use. This trial investigates the effects of active referral combined with a financial incentive to use smoking cessation services on smoking abstinence among community smokers. METHODS AND ANALYSIS: This ongoing study is a two-arm, assessor-blinded, pragmatic, cluster randomised controlled trial with follow-ups at 1, 2, 3 and 6 months after randomisation. We aim to enrol 1134 daily smokers from 70 community sites (clusters) in Hong Kong. All participants receive Ask, Warn, Advise, Refer, Do-it-again (AWARD) guided advice and a self-help booklet at baseline. Additionally, participants in the intervention group receive an offer of referral to smoking cessation services at baseline and a small financial incentive (HK$300≈US$38) contingent on using any of such services within 3 months. The primary outcomes are bioverified abstinence (exhaled carbon monoxide <4 ppm and salivary cotinine <10 ng/mL) at 3 and 6 months. Secondary outcomes include self-reported 7-day point prevalence of abstinence, smoking reduction rate, quit attempts and the use of smoking cessation services at 3 and 6 months. Intention-to-treat approach and regression models will be used in primary analyses. ETHICS AND DISSEMINATION: This protocol has been approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (IRB reference number: UW 18-318). The results of this trial will be submitted for publication in peer-reviewed journals, and the key findings will be presented at national and international conferences. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry NCT03565796.