[Tobacco cessation - the underused potential in clinical routine]. / Tabakentwöhnung ­ die bisher wenig genutzte Chance im ärztlichen Alltag.

Tobacco control, psychosocial and medical assistance regarding tobacco cessation is still a hidden potential within the German health care system. So far doctors rarely talk to their patients about their smoking status and physical and psychological benefits of quitting.This paper focusses on recommended current diagnostic and treatment standards, as well as evidence-based methods to address the topic on how to stop smoking and its association with certain diseases such as COPD, lung cancer and COVID-19 infection. The role of e-cigarettes as a cessation tool and its health related risks are critically examined. Consequences and advice how to implement smoking cessation procedures into daily practice are presented.

Hypnotherapy compared to cognitive-behavioral therapy for smoking cessation in a randomized controlled trial.

Worldwide, more than eight million people die each year as a result of tobacco use. A large proportion of smokers who want to quit are interested in alternative smoking cessation methods, of which hypnotherapy is the most popular. However, the efficacy of hypnotherapy as a tobacco cessation intervention cannot be considered sufficiently proven due to significant methodological limitations in the studies available to date. The aim of the present study was to compare the efficacy of a hypnotherapeutic group program for smoking cessation with that of an established cognitive-behavioral group program in a randomized controlled trial. A total of 360 smokers who were willing to quit were randomly assigned to either hypnotherapy (HT) or cognitive-behavioral therapy (CBT) at two study sites, without regard to treatment preference. They each underwent a 6 weeks smoking cessation course (one 90 min group session per week) and were followed up at regular intervals over a 12 months period. The primary outcome variable was defined as continuous abstinence from smoking according to the Russell standard, verified by a carbon monoxide measurement at three measurement time points. Secondary outcome variables were 7 days point prevalence abstinence during the 12 months follow up and the number of cigarettes the non-quitters smoked per smoking day (smoking intensity). Generalized estimating equations were used to test treatment condition, hypnotic suggestibility, and treatment expectancy as predictors of abstinence. The two interventions did not differ significantly in the proportion of participants who remained continuously abstinent throughout the follow-up period (CBT: 15.6%, HT: 15.0%) and also regarding the 7 days abstinence rates during the 12 months follow-up (CBT: 21.2%, HT: 16.7%). However, when controlling for hypnotic suggestibility, CBT showed significantly higher 7 days abstinence rates. In terms of the continuous abstinence rates, it can be concluded that the efficacy of hypnotherapeutic methods for smoking cessation seem to be comparable to established programs such as CBT. Clinical trial registration: ClinicalTrials.gov, identifier NCT01129999.

Cigarette craving in virtual reality cue exposure in abstainers and relapsed smokers.

Cue exposure therapy (CET) in substance-use disorders aims to reduce craving and ultimately relapse rates. Applying CET in virtual reality (VR) was proposed to increase its efficacy, as VR enables the presentation of social and environmental cues along with substance-related stimuli. However, limited success has been reported so far when applying VR-CET for smoking cessation. Understanding if effects of VR-CET differ between future abstainers and relapsing smokers may help to improve VR-CET. Data from 102 participants allocated to the intervention arm (VR-CET) of a recent RCT comparing VR-CET to relaxation in the context of smoking cessation was analyzed with respect to tolerability, presence, and craving during VR-CET. Cue exposure was conducted in four VR contexts (Loneliness/Rumination, Party, Stress, Café), each presented twice. Relapsed smokers compared to abstainers experienced higher craving during VR-CET and stronger craving responses especially during the Stress scenario. Furthermore, lower mean craving during VR-CET positively predicted abstinence at 6-month follow-up. Attempts to improve smoking cessation outcomes of VR-CET should aim to identify smokers who are more at risk of relapse based on high craving levels during VR-CET. Specifically measuring craving responses during social stress seems to be well suited to mark relapse. We propose to investigate individualized treatment approaches accordingly.

[Medical societies in Germany call for a ban on flavors in e-cigarettes - A Position Paper of the German Respiratory Society (DGP) in cooperation with other professional associations and organizations]. / Medizinische Fachgesellschaften fordern ein Verbot von Aromen in E-Zigaretten.

E-cigarettes are primarily used by teenagers and young adults. Flavors in e-cigarettes increase their attractiveness and encourage young people and adults to start using them. This exposes young people in particular to the risk of nicotine addiction and various toxic substances from the aerosol of e-cigarettes. There are indications that various flavors in e-cigarettes are harmful to health, although toxicological studies are still lacking for the majority of flavors. There is a need for independent scientific investigations in this area. The scientific societies involved are calling for a ban on flavors in e-cigarettes, a ban on disposable e-cigarettes, effective regulation of the sale of e-cigarettes and effective control and implementation of the provisions for the protection of minors.

[Smoking Cessation in Patients with COPD]. / Tabakentwöhnung bei COPD.

Tobacco dependence is a common comorbidity in patients with COPD (Chronic Obstructive Pulmonary Disease) that negatively affects the course of the disease. However, clinically relevant improvement in COPD can only be achieved by complete and permanent abstinence. Therefore, abstinence from tobacco use is a central therapeutic concept in smoking patients with COPD and requires specific and targeted treatment.After detailed documentation of smoking behaviour and motivational counseling outlining the risks of smoking, all such patients shall be offered a structured therapy for tobacco cessation. There is high-quality evidence for the effectiveness of a combination therapy of behavioral therapy and medication (to treat the withdrawal syndrome). Due to insufficient data, there is currently no recommendation for the use of e-cigarettes as a primary option for a cessation attempt.Smoking is the most important cause of COPD. Smoking cessation is the most effective and cost-efficient single intervention to reduce the risk of developing and progressing COPD.

S3 Guideline "Smoking and Tobacco Dependence: Screening, Diagnosis, and Treatment" - Short Version.

INTRODUCTION: In addition to the prevention of tobacco consumption, the establishment and assurance of high-quality treatment for harmful use and dependence on tobacco products remains an important health-related task in Germany. Regular updating of the Association of the Scientific Medical Societies (AWMF) S3 guideline "Smoking and Tobacco Dependence: Screening, Diagnosis, and Treatment" (Tobacco Guideline) offers a sustainable and reputable source of knowledge on smoking cessation. METHODS: Under the auspices of the German Society for Psychiatry, Psychotherapy, Psychosomatics, and Neurology (DGPPN) and the German Society for Addiction Research and Addiction Therapy (DG-Sucht), the Tobacco Guideline was revised in 2019-2020 by 63 experts, who were involved in the development process of the text, in 11 working groups. Undue influence of conflicts of interest on the guideline could be minimized through careful conflict of interest management. Delegates from 50 professional societies discussed the 80 guideline recommendations and voted online. RESULTS: In addition to recommendations for screening and diagnostics, the Tobacco Guideline takes a positive stance towards the use of low-threshold counseling and support services. If, due to the severity of the tobacco-related disorder, brief counseling, telephone counseling, or internet- or smartphone-based methods are not sufficiently effective, individual or group behavioral therapy, possibly in combination with medication, is indicated. If nicotine replacement therapy is not effective, varenicline or bupropion should be offered. Alternative strategies with a lower level of recommendation are hypnotherapy, mindfulness-based treatments, or medication with cytisine. In adolescents and pregnant women, the use of medication should be limited to well-specified exceptions and nicotine replacement. The mean agreement with the recommendations reached a value of 98%. A general overview of the treatment recommendations of the Tobacco Guideline is provided by three clinical algorithms.

German Guidelines on Screening, Diagnosis, and Treatment of Alcohol Use Disorders: Update 2021.

INTRODUCTION: Alcohol consumption in Germany is associated with considerable health and economic consequences. In addition to prevention, the early detection and differential treatment of those affected play an important role. The guideline "Screening, Diagnosis, and Treatment of Alcohol Use Disorders" forms the basis of this care for people suffering from alcohol use disorders. Regular updates integrate the current state of research evidence and clinical expertise. METHODS: Under the auspices of the German Society for Psychiatry, Psychotherapy, Psychosomatics, and Neurology and the German Society for Addiction Research and Addiction Therapy e.V. (DG-Sucht), the 2019-2020 S3 guideline on alcohol was revised by eight working groups. Thirty-five professional societies participated in a structured consensus process to deliberate the recommendations. Potential conflicts of interest were examined in advance, documented, and taken into account during the voting on the recommendations. RESULTS: The guideline provides recommendations on screening and brief interventions for different groups of people, as well as on treatment of individuals in the acute and post-acute phases of withdrawal. Special emphasis was placed on the treatment of comorbid somatic and psychological disorders. In addition, recommendations for specific groups of people (e.g., children and adolescents, pregnant women) have been made and adapted to the German care landscape.

[Tobacco Cessation - The Underused Potential in Clinical Routine]. / Tabakentwöhnung ­ die bisher wenig genutzte Chance im ärztlichen Alltag.

Tobacco control, psychosocial and medical assistance regarding tobacco cessation is still a hidden potential within the German health care system. So far doctors rarely talk to their patients about their smoking status and physical and psychological benefits of quitting.This paper focusses on recommended current diagnostic and treatment standards, as well as evidence-based methods to address the topic on how to stop smoking and its association with certain diseases such as COPD, lung cancer and COVID-19 infection. The role of e-cigarettes as a cessation tool and its health related risks are critically examined. Consequences and advice how to implement smoking cessation procedures into daily practice are presented.

Subcutaneous fat necrosis in an infant with hypoxic ischaemic encephalopathy stage 3: an uncommon association.

Subcutaneous fat necrosis (SCFN) is inflammation and necrosis of adipose tissue associated with hypoxia and hypothermia. It leads to various metabolic abnormalities, of which the most dreaded is hypercalcaemia. We report a case of a 7-week-old boy with history of birth asphyxia (hypoxic ischaemic encephalopathy stage 3) who presented to us with features suggestive of hypercalcaemia with bilateral nephrocalcinosis. On examination, there were multiple subcutaneous nodules on both arms. Evaluation revealed suppressed parathyroid activity along with low levels of 25(OH)vitamin D3 and elevated 1,25-dihydroxyvitamin D3 Skin biopsy confirmed the diagnosis of SCFN. He was managed with intravenous fluids, single dose of intravenous furosemide and oral prednisolone. Hypercalcaemia responded within 14 days of admission, prednisolone was tapered and stopped in a month. SCFN, in our case, can be attributed to the underlying perinatal asphyxia along with use of therapeutic hypothermia. Through this case, we wish to sensitise practicing neonatologists for the need of screening and early identification of these abnormalities, which if missed can be fatal.

[Potential Savings in Treatment Costs of COPD through Smoking Cessation: Modeling for DMP COPD in Germany - Scientific Action Group on Tobacco Cessation (WAT) e. V.] / Das Einsparpotenzial der Behandlungskosten bei COPD durch Rauchstopp ­ Modellierung für DMP COPD in Deutschland.

Based on real-life data for the stage distribution of COPD patients (GOLD) and the actual stage-related treatment costs in a large nationwide cohort study (COSYCONET) 1, the influence of the reduced smoking rate on treatment costs was determined for the scenario of a reduction in the smoking rate of 26 % in this patient group by 10 percentage points to 16 %. The assumption was made that with a reduced smoking rate, lower stages (I/II) will be more strongly represented, while higher and more cost-intensive stages (III/IV) will be proportionally reduced. The intervention to achieve tobacco abstinence was calculated for the rough model calculations with the typical costs of a guideline-compliant treatment by a behavioral therapy group cessation program and the parallel use of medication support 2 3. The result showed a potential reduction of case costs by 10.5 %, not including reduction in costs associated with treatment of comorbidities.

Novel homozygous missense mutation in ABCA3 protein leading to severe respiratory distress in term infant.

The term baby presented with respiratory distress with X-ray pictures consistent as hyaline membrane disease (HMD). Baby was ventilated and treated with surfactant. Because of the persistence of high ventilation needs with X-ray pictures consistent with HMD with a transient response to surfactant every time, the possibility of an inherited disorder of surfactant metabolism was kept. Whole-exome sequencing revealed a novel homozygous missense mutation in the gene for ATP binding cassette transporter protein A3. The baby died after 100 days of ventilation.

Use of Real-Time Functional Magnetic Resonance Imaging-Based Neurofeedback to Downregulate Insular Cortex in Nicotine-Addicted Smokers.

It has been more than a decade since the first functional magnetic resonance imaging (fMRI)-based neurofeedback approach was successfully implemented. Since then, various studies have demonstrated that participants can learn to voluntarily control a circumscribed brain region. Consequently, real-time fMRI (rtfMRI) provided a novel opportunity to study modifications of behavior due to manipulation of brain activity. Hence, reports of rtfMRI applications to train self-regulation of brain activity and the concomitant modifications in behavioral and clinical conditions such as neurological and psychiatric disorders [e.g., schizophrenia, obsessive compulsive Disorder (OCD), stroke] have rapidly increased. Neuroimaging studies in addiction research have shown that the anterior cingulate cortex, orbitofrontal cortex, and insular cortex are activated during the presentation of drug-associated cues. Also, activity in both left and right insular cortices have been shown to be highly correlated with drug urges when participants are exposed to craving-eliciting cues. Hence, the bilateral insula is of particular importance in researching drug urges and addiction due to its role in the representation of bodily (interoceptive) states. This study explores the use of rtfMRI neurofeedback for the reduction in blood oxygen-level dependent (BOLD) activity in bilateral insular cortices of nicotine-addicted participants. The study also tests if there are neurofeedback training-associated modifications in the implicit attitudes of participants towards nicotine-craving cues and explicit-craving behavior.

[Reimbursement for tobacco cessation: legislator must give up blockade]. / Erstattung der Tabakentwöhnung: Gesetzgeber muss Blockade aufheben.

A constitutional expert opinion, which reviews the social and constitutional foundations of tobacco cessation within the framework of statutory health insurance in Germany, comes to the conclusion that the legislator must release the reimbursement of professional tobacco cessation as a curative service by the statutory health insurance - and not only as a subsidy for a psychotherapeutically oriented measure within the framework of prevention.

Smoking Cessation Attempts and Common Strategies Employed.

BACKGROUND: Clinical guidelines on smoking cessation contain recommendations for various evidence-based methods. The goal of this study was to provide a represen- tative analysis for Germany of the percentage of smokers who try to quit smoking at least once per year, the use of evidence-based methods and other methods of smoking cessation, and potential associations of the use of such methods with the degree of tobacco dependence and with socioeconomic features. METHODS: Data from 19 waves of the German Smoking Behavior Questionnaire (Deutsche Befragung zum Rauchverhalten, DEBRA), from the time period June/July 2016 to June/July 2019, were analyzed. Current smokers and recent ex-smokers (<12 months without smoking) were asked about their smoking cessation attempts in the past year and the methods they used during the last attempt (naming more than one method was permitted). The degree of tobacco dependence in current smokers was assessed with the Heaviness of Smoking Index. RESULTS: Out of 11 109 current smokers and 407 recent ex-smokers, 19.9% (95% confidence interval: [19.1; 20.6]) had tried to quit smoking at least once in the preceding year. 13.0% of them [11.6; 14.5] had used at least one evidence-based method during their last attempt. The stronger the tobacco dependence, the more likely the use of an evidence-based method (odds ratio [OR] = 1.27 [1.16; 1.40]). Pharmacotherapy (nicotine replacement therapy, medication) was used more com- monly by persons with higher incomes (OR = 1.44 per 1000 euro/month [1.28; 1.62]). Electronic cigarettes were the most commonly used single type of smoking cessation support (10.2 % [9.0; 11.6]). CONCLUSION: In Germany, only one in five smokers tries to quit smoking at least once per year. Such attempts are only rarely supported by evidence-based methods and are thus likely to fail. The high cost of treatment must be borne by the individual and thus fall disproportionately on poorer smokers. It follows that there is an urgent need for vered by health insurance pro- viders, in order to give all smokers fair and equal access to the medical care they need.

Process Evaluation of a Medical Student-Delivered Smoking Prevention Program for Secondary Schools: Protocol for the Education Against Tobacco Cluster Randomized Trial.

BACKGROUND: Most smokers start smoking during their early adolescence under the impression that smoking entails positive attributes. Given the addictive nature of cigarettes, however, many of them might end up as long-term smokers and suffering from tobacco-related diseases. To prevent tobacco use among adolescents, the large international medical students' network Education Against Tobacco (EAT) educates more than 40,000 secondary school students per year in the classroom setting, using evidence-based self-developed apps and strategies. OBJECTIVE: This study aimed to evaluate the long-term effectiveness of the school-based EAT intervention in reducing smoking prevalence among seventh-grade students in Germany. Additionally, we aimed to improve the intervention by drawing conclusions from our process evaluation. METHODS: We conduct a cluster-randomized controlled trial with measurements at baseline and 9, 16, and 24 months postintervention via paper-and-pencil questionnaires administered by teachers. The study groups consist of randomized schools receiving the 2016 EAT curriculum and control schools with comparable baseline data (no intervention). The primary outcome is the difference of change in smoking prevalence between the intervention and control groups at the 24-month follow-up. Secondary outcomes are between-group differences of changes in smoking-related attitudes and the number of new smokers, quitters, and never-smokers. RESULTS: A total of 11,268 students of both sexes, with an average age of 12.32 years, in seventh grade of 144 secondary schools in Germany were included at baseline. The prevalence of cigarette smoking in our sample was 2.6%. The process evaluation surveys were filled out by 324 medical student volunteers, 63 medical student supervisors, 4896 students, and 141 teachers. CONCLUSIONS: The EAT cluster randomized trial is the largest school-based tobacco-prevention study in Germany conducted to date. Its results will provide important insights with regards to the effectiveness of medical student-delivered smoking prevention programs at school. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13508.

Proactive multipurpose health risk screening in health care settings: Methods, design, and reach.

OBJECTIVES: Real world implementation of proactive screening and brief intervention in health care is threatened by high cost. Using e-health interventions and screening for multiple health risk factors may provide more efficiency. We describe methodological details of a proactive multipurpose health risk screening in health care settings and report on participation rates, participants' characteristics, and participation factors. METHODS: Patients between 18 and 64 years from ambulatory practices and hospitals were proactively approached by study assistants at three sites for a computerized screening on harmful alcohol and tobacco consumption, depressive symptoms, insufficient fruit/vegetable consumption, physical inactivity and overweight. On the basis of their health risk pattern, a computerized algorithm allocated patients to one of five studies each of them addressing a psychiatric research question. RESULTS: Among all eligible patients, 13,763 (86.5%) were screened. Younger age and being female predicted screening participation. Of those with complete data (n = 12,828), 82.9% reported at least two health risks and 34.0% were eligible for a study. Study participation ranged between 35.2% and 50.8%, and was associated with socio-demographics and problem severity. CONCLUSIONS: This study supports the use of systematic proactive screening for multiple health risks in health care settings as it is more resource-saving than single focused screening.

[Smoking Cessation as an Instrument of Medical Treatment - Attitudes, Barriers, Challenges - Results of an Online Survey and Conclusions]. / Tabakentwöhnung als Instrument der ärztlichen Behandlung.

Smoking is the biggest cause of premature mortality. Almost half of smokers meet the criteria for addiction. Treatment fails primarily because of the lack of reimbursement. Doctors could treat tobacco addiction and with it the secondary diseases with high efficacy if the conditions with behavioral therapy and medication were made available to them.

A Face-Aging App for Smoking Cessation in a Waiting Room Setting: Pilot Study in an HIV Outpatient Clinic.

BACKGROUND: There is strong evidence for the effectiveness of addressing tobacco use in health care settings. However, few smokers receive cessation advice when visiting a hospital. Implementing smoking cessation technology in outpatient waiting rooms could be an effective strategy for change, with the potential to expose almost all patients visiting a health care provider without preluding physician action needed. OBJECTIVE: The objective of this study was to develop an intervention for smoking cessation that would make use of the time patients spend in a waiting room by passively exposing them to a face-aging, public morphing, tablet-based app, to pilot the intervention in a waiting room of an HIV outpatient clinic, and to measure the perceptions of this intervention among smoking and nonsmoking HIV patients. METHODS: We developed a kiosk version of our 3-dimensional face-aging app Smokerface, which shows the user how their face would look with or without cigarette smoking 1 to 15 years in the future. We placed a tablet with the app running on a table in the middle of the waiting room of our HIV outpatient clinic, connected to a large monitor attached to the opposite wall. A researcher noted all the patients who were using the waiting room. If a patient did not initiate app use within 30 seconds of waiting time, the researcher encouraged him or her to do so. Those using the app were asked to complete a questionnaire. RESULTS: During a 19-day period, 464 patients visited the waiting room, of whom 187 (40.3%) tried the app and 179 (38.6%) completed the questionnaire. Of those who completed the questionnaire, 139 of 176 (79.0%) were men and 84 of 179 (46.9%) were smokers. Of the smokers, 55 of 81 (68%) said the intervention motivated them to quit (men: 45, 68%; women: 10, 67%); 41 (51%) said that it motivated them to discuss quitting with their doctor (men: 32, 49%; women: 9, 60%); and 72 (91%) perceived the intervention as fun (men: 57, 90%; women: 15, 94%). Of the nonsmokers, 92 (98%) said that it motivated them never to take up smoking (men: 72, 99%; women: 20, 95%). Among all patients, 102 (22.0%) watched another patient try the app without trying it themselves; thus, a total of 289 (62.3%) of the 464 patients were exposed to the intervention (average waiting time 21 minutes). CONCLUSIONS: A face-aging app implemented in a waiting room provides a novel opportunity to motivate patients visiting a health care provider to quit smoking, to address quitting at their subsequent appointment and thereby encourage physician-delivered smoking cessation, or not to take up smoking.

German Guidelines on Screening, Diagnosis and Treatment of Alcohol Use Disorders.

Evidence-based strategies for screening, diagnosing and treating alcohol use disorders (AUD) are instrumental in the early and better management of individuals at risk for or suffering from AUD. However, existing guidelines vary and may be biased by conflicts of interests. Unbiased recommendations can be achieved only if sufficient detail is provided on the composition and representativeness of author groups, methodological rigor, handling of potential conflicts of interest and financing. This paper presents the first evidence-based guidelines for AUD from German-speaking countries. These guidelines are based on the work of delegates from a representative sample of 46 scientific societies (mostly medical) from Austria, Germany and Switzerland dealing with AUD. It also included patients and relatives. Recommendations were derived from a standardised hierarchical process involving quality controls drawn from existing guidelines, de novo literature searches and/or expert experience. Potential conflicts of interest were assessed yearly and led to exclusion from voting in specific areas. An overall cost of more than 400,000€ (for alcohol and tobacco guidelines) were exclusively covered by the participating societies and academic institutions. More than 100 recommendations on screening, diagnostics and treatment of AUD are outlined in this paper, and their scientific background is given in the online supplementary material. Tables of aggregated study synopses (in English) and the full version of guidelines (in German) are available (see "Links").