Predictors of Nicotine Replacement Therapy Adherence: Mixed-Methods Research With a Convergent Parallel Design.

BACKGROUND: Few studies have examined the effect of baseline attitudes toward nicotine replacement therapy (NRT) on its actual adherence in a smoking cessation intervention. PURPOSE: This study (i) examined the predictability of baseline variables (quantitative data) on NRT adherence and (ii) explored the congruence of participants' statements about NRT products (qualitative data) during counseling sessions with their baseline attitudes. METHODS: This is a mixed-methods research study using a convergent parallel design. Participants included 74 individuals in the treatment group who received behavioral counseling and combination NRT. A Poisson regression analysis was performed to identify baseline variables predicting NRT adherence. Thematic analysis was completed with a subset of participants (n = 38) who varied in NRT attitude scores and adherence. A joint display was created to integrate quantitative and qualitative data and discover convergence. RESULTS: Approximately 59% of the participants (41/74) used NRT continuously for ≥5 weeks. Having negative attitudes toward NRT and depressive symptoms predicted NRT adherence even after controlling for education and anxiety symptoms. Thematic analysis revealed that NRT adherence is a learning process that consists of the following three distinctive but interrelated phases: (i) information needs, (ii) comprehensive readiness, and (iii) experiential learning. Of the 38 participants, 34 (89.5%) showed convergence between baseline attitude scores and statements about NRT made during counseling sessions. CONCLUSIONS: Individuals who have negative attitudes toward NRT are less likely to use the products in a smoking cessation intervention. Counselors should assess attitudes toward NRT at baseline and address them proactively during counseling sessions.

Few research studies have explored how attitudes toward nicotine substitutes (nicotine patches, gum, and lozenges) affect people's adherence to those substitutes (using them consistently as directed). This study examined (i) whether age, gender, education, attitudes toward the substitutes, and depressive and anxiety symptoms would predict peoples' adherence to these nicotine substitutes during a study to help stop smoking and (ii) whether peoples' statements about their experiences with the substitutes would reveal any patterns. The study was conducted with 74 individuals who received behavioral counseling and combination nicotine substitutes. Having negative attitudes toward the substitutes and depressive symptoms predicted adherence. Age, gender, education, positive attitudes, and anxiety symptoms did not. Statements from a subset of participants (n = 38) revealed that adherence to the substitutes is a learning process that consists of the following three phases: (i) needing more information assuring the safety of the substitutes, (ii) being mentally and situationally ready, and (iii) learning while being involved in the process such as "trial and error." Individuals who have negative attitudes toward the substitutes are less likely to use them, and counselors should assess attitudes toward nicotine replacement therapy before suggesting their use and address these attitudes proactively during smoking cessation counseling sessions.

Smoking Cessation Tool Utilization Among Individuals with and Without Cancer Across Smoking Status.

Background: There are many tools to assist with cigarette smoking cessation (e.g., counseling, pharmacotherapy). However, tool use among cancer patients is understudied despite the consequences of continued smoking after a cancer diagnosis.Objectives: Study aims included describing and comparing cessation tool use among individuals with and without cancer who were currently smoking and who quit to determine if there are different preferences among those with cancer.Methods: Participants (N = 203) completed an online survey about demographics, cigarette use, and cessation tool use.Results: Eighty-nine participants reported being diagnosed with cancer (45 quit after diagnosis, 44 currently smoking) and 114 reported not having cancer (57 quit, 57 currently smoking). Individuals with cancer who were smoking used more evidence-based resources than those with cancer who quit (B = 1.86, SE = 0.50, p < 0.0001). Individuals with cancer who were smoking used more total cessation resources than participants without cancer who were smoking (B = 2.00, SE = 0.58, p = 0.001), but there was no difference in use of evidence-based resources between these two groups (p > 0.05). Lastly, individuals with cancer who quit also used more total cessation tools (B = 1.23, SE = 0.41, p = 0.003) and evidence-based tools (B = 1.03, SE = 0.36, p = 0.005) than those without cancer who quit.Conclusions: Individuals with cancer may be using more resources before successfully quitting. Cancer patients may need additional help to quit smoking, and further research is needed to better understand unique barriers that preclude quitting among this vulnerable population.

A National Dental Practice-Based Research Network phase II, cluster-randomized clinical trial assessing nicotine replacement therapy sampling in dental settings: study protocol for the Free Samples for Health (FreSH) study.

BACKGROUND: Cigarette smoking has major detrimental effects on oral health. Tobacco interventions in dental settings are effective, but rarely delivered. The American Dental Hygienists Association recommends that oral health providers: Ask patients about tobacco use, Advise quitting tobacco use, and Refer to state quitlines (Ask-Advise-Refer; AAR). While AAR connects patients to counseling, it does not directly connect patients to medication. Nicotine replacement therapy sampling (NRTS) is an empirically supported intervention to provide starter packs of nicotine replacement therapy (NRT) to people who smoke. NRTS combined with AAR could be an effective tobacco treatment intervention for dental settings. METHODS: This manuscript describes the study protocol for the Free Samples for Health (FreSH) study, a group randomized clinical trial testing the effectiveness of NRTS + AAR vs. AAR alone on long-term smoking abstinence. Fifty dental practices in the Midwest and Northeast nodes of the National Dental Practice-Based Research Network are randomly assigned to provide AAR and either a 2-week supply of 14-mg nicotine patches and 4-mg nicotine lozenges (NRTS condition) or an electric toothbrush (ET condition). Approximately 1,200 patients who currently smoke-regardless of interest in quitting- are recruited during dental visits. Participants complete a baseline survey in-person, then after visit, 1-, 3-, and 6-month follow-up surveys remotely. The primary outcome is carbon monoxide-confirmed 7-day point prevalence abstinence from combustible tobacco measured at 6 months post-enrollment. Secondary outcomes include: 24-h intentional quit attempts, change in cigarettes smoked per day, NRT utilization, attitudes toward NRT, intention to use NRT, and intention to quit smoking. A key informant process evaluation and cost effectiveness analysis will provide information for future implementation of NRTS. DISCUSSION: This is the first clinical trial to assess the effectiveness of NRTS on promoting smoking cessation in dental settings. If effective, this treatment could be implemented to increase the provision of smoking cessation interventions in dental settings to provide an additional treatment access point for people who smoke. TRIAL REGISTRATION: Registered at ClincalTrials.gov (NCT05627596) on 11/25/2022.

Quitline usage does not improve rates of smoking cessation in orthopaedic trauma patients unless combined with nicotine replacement therapy.

PURPOSE: The negative effects of smoking following traumatic orthopaedic injury can lead to serious complications and decreased quality of life. The widely available quitline could be easily implemented in the orthopaedic postoperative period to improve outcome, but the effectiveness of this intervention in this population is unknown. The goal of this study was to determine if active referral to a quitline would improve rates of smoking cessation in this population. METHODS: This is a secondary analysis of a randomized control trial assessing the effectiveness of an inpatient intervention with varying intensities to promote smoking cessation. Participants were actively referred to the quitline as part of their intervention. Participants were surveyed at 6 weeks, 3 months and 6 months following their injury for 7-day abstinence, chemically confirmed with exhaled carbon monoxide monitoring. RESULTS: Smoking quitline use alone does not independently improve 7-day abstinence. Quitline and nicotine use are synergistic (OR, 5.6 vs. 2.3 at 3 months in patients who used nicotine patch and quitline vs. patch; OR, 7.8 vs. 2.1 at 3 months in patients who used any NRT and quitline vs. NRT alone). CONCLUSIONS: NRT use improves smoking cessation rates in orthopaedic trauma patients. Although smoking quitline use might not independently improve cessation rates in orthopaedic trauma patients postoperatively, concomitant use of NRT with quitline improves quit rates over NRT alone. Patients referred to quitline should be encouraged to use NRT.

Have there been sustained impacts of the COVID-19 pandemic on trends in smoking prevalence, uptake, quitting, use of treatment, and relapse? A monthly population study in England, 2017-2022.

BACKGROUND: Studies conducted during the early stages of the pandemic documented mixed changes in smoking behaviour: more smokers quitting successfully but little change in prevalence. This study aimed to examine whether there have been sustained impacts of the COVID-19 pandemic on smoking patterns in England. METHODS: Data were from 101,960 adults (≥ 18 years) participating in the Smoking Toolkit Study, a monthly representative household survey, between June 2017 and August 2022. Interviews were conducted face-to-face until March 2020 and via telephone thereafter. Generalised additive models estimated associations of the pandemic onset (March 2020) with current smoking, uptake, cessation, quit attempts, and use of support. Models adjusted for seasonality, sociodemographic characteristics, and (where relevant) dependence and tobacco control mass-media expenditure. RESULTS: Before the COVID-19 pandemic, smoking prevalence fell by 5.2% per year; this rate of decline slowed to 0.3% per year during the pandemic (RRΔtrend = 1.06, 95% CI = 1.02, 1.09). This slowing was evident in more but not less advantaged social grades (RRΔtrend = 1.15, 1.08, 1.21; RRΔtrend = 1.00, 0.96, 1.05). There were sustained step-level changes in different age groups: a 34.9% (95% CI = 17.7, 54.7%) increase in smoking prevalence among 18-24-year-olds, indicating a potential rise in uptake, in contrast to a 13.6% (95% CI = 4.4, 21.9%) decrease among 45-65-year-olds. In both age groups, these step-level changes were followed by the pre-pandemic declines stopping, and prevalence remaining flat. There were sustained increases in quitting among past-year smokers, with a 120.4% (95% CI = 79.4, 170.9%) step-level increase in cessation and a 41.7% (95% CI = 29.7, 54.7%) increase in quit attempts. The main limitation was the change in modality of data collection when the pandemic started; while this may have contributed to the step-level changes we observed, it is unlikely to explain changes in the slope of trends. CONCLUSIONS: In England, the rate of decline in adult smoking prevalence stagnated during the COVID-19 pandemic through to 2022. At the start of the pandemic, a potential reduction in smoking prevalence among middle-aged adults and increases in quitting among smokers may have been offset by an increase in smoking among young adults. The slowing in the rate of decline was pronounced in more advantaged social grades.

Electronic nicotine delivery systems (ENDS): A convenient means of smoking?

Electronic nicotine delivery systems (ENDS), which are becoming increasingly popular in many parts of the world, have recently become more sophisticated in terms of their more active content and better controlled vaporisation. This review begins by describing how cigarette smoking led to the development of ENDS as a means of combatting nicotine addiction. ENDS are usually categorised as belonging to one of only three main generations, but a fourth has been added in order to differentiate the latest, most powerful, most advanced and innovative that have improved heating efficiency. Descriptions of the principal substances contained in ENDS are followed by considerations concerning the risk of toxicity due to the presence of albeit low concentrations of such a variety of compounds inhaled over a long time, and the increasingly widespread use of ENDS as a means of smoking illicit drugs. We also review the most widely used pharmacotherapeutic approaches to smoking cessation, and recent epidemiological data showing that ENDS can help some people to stop smoking. However, in order to ensure their appropriate regulation, there is a need for higher-quality evidence concerning the health effects and safety of ENDS, and their effectiveness in discouraging tobacco smoking.

Randomized clinical trial examining financial incentives for smoking cessation among mothers of young children and possible impacts on child secondhand smoke exposure.

This randomized clinical trial examined whether financial-incentives increase smoking cessation among mothers of young children and potential impacts on child secondhand-smoke exposure (SHSe). 198 women-child dyads were enrolled and assigned to one of three treatment conditions: best practices (BP, N = 68), best practices plus financial incentives (BP + FI, N = 63), or best practices, financial incentives, and nicotine replacement therapy (BP + FI + NRT, N = 67). The trial was completed in Vermont, USA between June 2015 and October 2020. BP entailed staff referral to the state tobacco quitline; financial incentives entailed mothers earning vouchers exchangeable for retail items for 12 weeks contingent on biochemically-verified smoking abstinence; NRT involved mothers receiving 10 weeks of free transdermal nicotine and nicotine lozenges/gum. Baseline, 6-, 12-, 24-, and 48-week assessments were conducted. Primary outcomes were maternal 7-day point-prevalence abstinence and child SHSe through the 24-week assessment with the 48-week assessment exploratory. Results were analyzed using mixed model repeated measures for categorical data. Odds of maternal abstinence were greater among mothers in BP + FI and BP + FI + NRT compared to BP at the 6- and 12-week assessments (ORs ≥ 7.30; 95% CIs: 2.35-22.71); only abstinence in BP + FI remained greater than BP at the 24-week assessment (OR = 2.95; 95% CIs: 1.06-8.25). Abstinence did not differ significantly between treatment conditions at the 48-week assesssment. There was a significant effect of treatment condition (F[2109] = 3.64, P = .029) on SHSe with levels in BP and BP + FI significantly below BP + FI + NRT (ts[109] ≥ -2.30, Ps ≤ 0.023). Financial incentives for smoking abstinence are efficacious for increasing maternal cessation but that alone was insufficient for reducing child SHSe. ClinicalTrials.gov:NCT05740098.

Outcomes Among People With Schizophrenia Participating in General-Population Smoking Cessation Treatment: An Observational Study.

OBJECTIVE: People with schizophrenia are much more likely than others to smoke tobacco, raising risks of disease and premature mortality. These individuals are also less likely to quit successfully after treatment, but the few existing clinical and observational studies have been limited by small sample sizes, and have generally considered specialized treatment approaches. In this analysis, we examine outcomes, service use, and potential explanatory variables in a large sample of people with schizophrenia treated in a general-population cessation program. METHOD: Our sample comprised 3,011 people with schizophrenia and 77,790 controls receiving free nicotine replacement therapy through 400 clinics and health centres. We analysed self-reported 7-day abstinence or reduction at 6-month follow-up, as well as the number of visits attended and self-reported difficulties in quitting. We adjusted for demographic, socioeconomic, and health variables, and used multiple imputation to address missing data. RESULTS: Abstinence was achieved by 16.2% (95% confidence interval [CI], 14.5% to 17.8%) of people with schizophrenia and 26.4% (95% CI, 26.0% to 26.7%) of others (absolute difference = 10.2%; 95% CI, 8.5% to 11.9%; P < 0.001). After adjustment, this difference was reduced to 7.3% (95% CI, 5.4% to 9.3%; P < 0.001). Reduction in use was reported by 11.8% (95% CI, 10.3% to 13.3%) and 12.5% (95% CI, 12.2% to 12.8%), respectively; this difference was nonsignificant after adjustment. People with schizophrenia attended more clinic visits (incidence rate ratio [IRR] = 1.15, 95% CI = 1.12% to 1.18%, P < 0.001) and reported more difficulties related to "being around other smokers" (odds ratio [OR] = 1.28; 95% CI, 1.11% to 1.47%; P = 0.001). CONCLUSION: There is abundant demand for tobacco cessation treatment in this population. Outcomes were substantially poorer for people with schizophrenia, and this difference was not explained by covariates. Cessation remained much better than for unaided quit attempts, however, and engagement was high, demonstrating that people with schizophrenia benefit from nonspecialized pharmacological treatment programs.

Using the Behaviour Change Wheel and modified Delphi method to identify behavioural change techniques for improving adherence to smoking cessation medications.

BACKGROUND: Medication adherence is a crucial component of the pharmacological treatment of smoking. Previous interventions targeted to improve adherence to smoking cessation medications (SCMs) were designed using pragmatic approaches. This study aims to develop a comprehensive intervention strategy to improve adherence to SCMs using the Behaviour Change Wheel (BCW) and a modified Delphi method. METHODS: Recommendations for the design of intervention strategies were based on the BCW guide and six studies conducted by the research team. Factors related to healthcare providers and consumers (person making a quit attempt) that showed associations with adherence were mapped into the Capability, Opportunity, Motivation, Behaviour (COM-B) model, and corresponding intervention functions and policy categories. Interventions were then represented using the Behaviour Change Technique Taxonomy. Finally, a modified Delphi study using 17 experts was conducted to evaluate the nominated strategies using the Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity (APEASE) criteria. RESULTS: Following a stepped approach, an adherence support wheel was designed to guide implementation strategies and programmes. Thirteen intervention strategies were selected. The selected interventions include providing detailed instructions on how to use SCMs; establishing realistic expectations from SCMs; and providing training for healthcare providers regarding comprehensive smoking cessation care with specifics on the provision of adherence support. CONCLUSION: The BCW guide and a modified Delphi were applied successfully to design interventions tailored to improve adherence to SCMs. Improving adherence to SCMs requires a comprehensive intervention approach involving various stakeholders. Future research is needed to assess the effectiveness of the nominated intervention strategies.

Assessing the Effect of an Inpatient Smoking Cessation Brief Intervention Tool on Long-Term Smoking Cessation Rates and Patient Interest for Nicotine Replacement Therapy: A Retrospective Analysis.

INTRODUCTION: Smoking cessation among hospital inpatients is essential to reduce risk of surgical complications and all-cause mortality. In the Australian state of Queensland, the Smoking Cessation Clinical Pathway (SCCP), a brief intervention tool, has been used by clinical staff in public hospitals to uniformly support patients to quit smoking since 2015. This study aims to assess the effect of the SCCP on long-term smoking cessation rates recorded in subsequent readmissions, and whether the SCCP as an intervention affects inpatients' interest in nicotine replacement therapy (NRT) during admission and after discharge. METHODS: We retrospectively analysed data provided by the Princess Alexandra Hospital (PAH) on patients who self-identified as a current smoker on admission to any ward and were admitted to the PAH between 1st January 2018 and 31st December 2019. Smoking cessation rates and patient interest in NRT by SCCP completion were analysed using χ2 tests and a multinomial logistic regression. RESULTS: Of 1,902 included patients, NRT was offered to 1,397 patients (73.4%) and accepted by 332 patients (17.5%). Patients who had completed a SCCP were more likely to be offered NRT than those who had not (p < 0.0001). Of the 452 patients with multiple readmissions, 100 (22%) ceased smoking at any point in the 2-year study period. At the end of the 2-year study period, 75 (75%) patients remained abstinent and only 25 (25%) relapsed to smoking as per their final smoking status at the end of the 2-year study period. Patients with a completed SCCP were 1.8 times (RRR: 1.825, p = 0.030) more likely to quit smoking at any point in the 2-year study period, and twice as likely to have quit at the end of the 2-year study period (RRR: 2.064, p = 0.044). DISCUSSION: The SCCP may be effective at increasing smoking cessation rates among hospital inpatients. Future policies promoting long-term smoking cessation should consider implementation of post-discharge follow-up appointments.

Maternal nicotine exposure induces congenital heart defects in the offspring of mice.

Maternal cigarette smoking is a risk factor for congenital heart defects (CHDs). Nicotine replacement therapies are often offered to pregnant women following failed attempts of smoking cessation. However, the impact of nicotine on embryonic heart development is not well understood. In the present study, the effects of maternal nicotine exposure (MNE) during pregnancy on foetal heart morphogenesis were studied. Adult female mice were treated with nicotine using subcutaneous osmotic pumps at 0.75 or 1.5 mg/kg/day and subsequently bred with male mice. Our results show that MNE dose-dependently increased CHDs in foetal mice. CHDs included atrial and ventricular septal defects, double outlet right ventricle, unguarded tricuspid orifice, hypoplastic left ventricle, thickened aortic and pulmonary valves, and ventricular hypertrophy. MNE also significantly reduced coronary artery size and vessel abundance in foetal hearts. Moreover, MNE resulted in higher levels of oxidative stress and altered the expression of key cardiogenic regulators in the developing heart. Nicotine exposure reduced epicardial-to-mesenchymal transition in foetal hearts. In conclusion, MNE induces CHDs and coronary artery malformation in mice. These findings provide insight into the adverse outcomes of foetuses by MNE during pregnancy.

Medium- and longer-term cardiovascular effects of e-cigarettes in adults making a stop-smoking attempt: a randomized controlled trial.

BACKGROUND: Smoking is a major risk factor for cardiovascular disease and smoking cessation reduces excess risk. E-cigarettes are popular for smoking cessation but there is little evidence on their cardiovascular health effect. Our objective was to compare the medium- and longer-term cardiovascular effects in smokers attempting to quit smoking using e-cigarettes with or without nicotine or prescription nicotine replacement therapy (NRT). METHODS: This was a single-center, pragmatic three-arm randomized (1:1:1) controlled trial, which recruited adult smokers (≥ 10 cigarettes/day), who were willing to attempt to stop smoking with support (n = 248). Participants were randomized to receive behavioral support with either (a) e-cigarettes with 18 mg/ml nicotine, (b) e-cigarettes without nicotine, and (c) NRT. Flow-mediated dilation (%FMD) and peak cutaneous vascular conductance (CVCmax) responses to acetylcholine (ACh) and sodium nitroprusside (SNP), mean arterial pressure (MAP), and other outcomes were recorded at baseline, 3, and 6 months after stopping smoking. Data were analyzed using generalized estimating equations (GEE). RESULTS: At 3- and 6-month follow-up, %FMD showed an improvement over baseline in all three groups (e.g., p < 0.0001 at 6 months). Similarly, ACh, SNP, and MAP improved significantly over baseline in all groups both at 3 and 6 months (e.g., ACh: p = 0.004, at 6 months). CONCLUSIONS: Smokers attempting to quit experienced positive cardiovascular impact after both a 3- and 6-month period. None of the groups (i.e., nicotine-containing and nicotine-free e-cigarettes or NRT) offered superior cardiovascular benefits to the others. TRIAL REGISTRATION: ClinicalTrials.gov NCT03061253 . Registered on 17 February 2017.

The impact of COVID-19 on smoking cessation in pregnancy.

OBJECTIVES: A greater proportion of non-pregnant smokers attempted to stop smoking during compared to before the COVID-19 pandemic. The objective of this study was to determine if a greater proportion of pregnant women also attempted to stop smoking during the pandemic rather than before. METHODS: The use of antenatal smoking cessation services and nicotine replacement therapies (NRT) in pregnant women was audited before (2019-2020) and during the COVID pandemic (2020-2021). Anonymised data from January 2019 to March 2021 were analysed from the Lambeth and Southwark smoking cessation service. RESULTS: A total of 252 pregnant women who smoked were referred to their local antenatal smoking cessation service, of which 90 (35.7%) (median age: 31 years [19-52 years]) chose to attend smoking cessation clinics. The COVID-19 pandemic was not associated with an increase in the number of women attending smoking cessation clinics, (2020-2021 n=46 [40.8%] of 110); compared to (2019-2020 n=44 [30.9%] of 142 referred pregnant women pre-pandemic) p=0.061. Eighty-two women utilised NRT to help them stop smoking and the frequency of NRT use did not change during the pandemic (2019-2020 n=39, 2020-2021 n=43; p=0.420). No significant difference in smoking cessation rates between the two periods was observed at either the four-week (p=0.285) or twelve-week follow-up (p=0.829). CONCLUSIONS: Smoking cessation rates in pregnant women and the demand for antenatal smoking cessation services was unchanged during compared to before the COVID-19 pandemic.

Optimal use of smoking cessation pharmacotherapy.

The most effective intervention for stopping smoking is a combination of professional counselling and pharmacotherapy. Medicines are recommended for all smokers who are motivated to quit and are nicotine dependent. Combination nicotine replacement therapy with a patch and an oral product is more effective than the patch alone. An adequate dose of nicotine must be used for an adequate duration. Varenicline is the most effective oral drug. It is safe in people with stable mental illness. Vaping nicotine is a second-line treatment which can be considered for smokers who are unable to quit with other methods.

Pathophysiology of nicotine, place of nicotine substitutes and electronic cigarettes in plastic surgery: A review of the literature.

OBJECTIVE: Smokers are more likely to undergo postoperative complications after plastic surgeries. Our main purpose was to update nicotine's effects after plastic surgeries and assess whether nicotine-replacement therapy and vaping are safe enough to be recommended in peri-operatory circumstances. METHODS: We set up a literature review including 40 documents from 1986 to 2020 available on Pubmed. RESULTS: Nicotine has undeniable detrimental effects on patients undergoing plastic surgeries like cutaneous necrosis, skin flap failure and surgical site infection. Nevertheless, this toxicity seems to depend on the plasma concentration of nicotine and thus on the way of administration. While smoking is definitely harmful, nicotine replacement therapies (NRT) like patches and gums do not appear to increase postoperative risks based on available studies. The situation is different with the electronic cigarette since the pharmacokinetic parameters are close to those of the traditional cigarette. Even if powerful studies are lacking because the device is recent, preliminary in vitro studies and case reports suggest non-zero surgical risks for e-cigarette users. CONCLUSION: It seems more appropriate to suggest stopping all nicotine intake before and after plastic surgery. However, if strict cessation is not achievable, it appears preferable to use nicotine replacement therapies rather than e-cigarettes and most of all tobacco.

Comparative efficacy and safety of pharmacological interventions for smoking cessation in healthy adults: A network meta-analysis.

Smoking is the leading cause of morbidity and mortality in different non-communicable diseases, and cessation leads to immense health benefits. The present network meta-analysis has been conducted to evaluate and compare the effects of available pharmacological interventions for smoking cessation in adults. A standard meta-analysis protocol was developed and after performing a comprehensive literature search on MEDLINE/PubMed, Cochrane databases, and International Clinical Trials Registry Platform, reviewers extracted data from 97 randomized controlled trials. PRISMA guidelines were followed in data extraction, analysis and reporting of findings. Random effects Bayesian network meta-analysis was done to pool the effects across the interventions. Network graph was built, and for closed triangles in the network graph, node splitting analysis was performed. The primary outcome measure was self-reported biochemically verified smoking abstinence at six months. The number of participants achieving continuous abstinence was reported. Data for the number of participants reporting at least one adverse event was also extracted, if available. Combination of nicotine receptor agonist and nicotine replacement therapy had a significant odd of 4.4 (95%CrI:2.2-8.7), bupropion and nicotine receptor agonist 4.0 (95%CrI:2.1-7.7), bupropion and nicotine replacement therapy 3.8 (95%CrI:2.3-6.2), combination nicotine replacement therapy has an odd of 2.6 (95%CrI:1.8-3.8), and nicotine receptor agonist had a significant odd of 2.7 (95%CrI:2.3-3.2) when compared to placebo (moderate quality of evidence) for continuous abstinence at 6 months. When compared with behavioural therapy, the odds ratio of interventions was not statistically significant. Combination of nicotine receptor agonist and nicotine replacement therapy has the highest probability of being the best treatment for abstinence from smoking.

Beyond "Safe and Effective": The urgent need for high-impact smoking cessation medications.

Smoking cessation medications (SCMs) are an evidence-based cornerstone of comprehensive tobacco control programs globally. However, the impact of SCMs on population smoking prevalence is controversial, with inconsistencies between randomized controlled trials (RCTs) and population-based observational studies. We estimated SCM impact on permanent cessation and population smoking prevalence by extrapolating efficacy estimates from meta-analyses of RCTs, using the standard population impact formula: efficacy*reach. We calculated the potential SCM impact under a range of assumptions for permanent cessation (20%,14%), behavioral support (yes/no), reach (40%-2%), and underlying smoking prevalence. Assuming behavioral support for all, depending on reach, 8%-0.3% of smokers are expected to quit permanently. Without behavioral support, permanent cessation is estimated to be 6.4%-0.2%. Assuming an underlying population smoking prevalence of 14%, (current U.S. prevalence), the maximum impact on population smoking prevalence is 1.12%. Impact on prevalence increases with increasing underlying country-specific levels of prevalence. With current U.S. levels of reach, behavioral support and smoking prevalence, we estimate that, based on a single course of treatment, 2.3% of smokers would quit permanently, contributing to a 0.3% decrease in population level smoking prevalence. Even under ideal conditions, the potential of current first-line SCMs to increase cessation in a substantial proportion of smokers, and reduce population smoking prevalence, is limited. In order to avert the predicted billion tobacco-caused deaths in this century, "safe and effective" medications are not sufficient: SCMs with high population impact are urgently needed. Policies to ensure the availability and accessibility of highly efficacious SCMs, with behavioral support, are crucial.

Do e-cigarette sales reduce the demand for nicotine replacement therapy (NRT) products in the US? Evidence from the retail sales data.

Despite mixed evidence, many smokers use e-cigarettes to quit smoking. With the substantial growth of e-cigarette sales in recent years, it is important to understand how it may affect FDA-approved nicotine replacement therapy (NRT) products in the US. This study aims to investigate the impact of e-cigarette prices and TV advertising on the demand for NRT products. Quarterly (2010 Q1-2017 Q4) retail sales and price data of e-cigarettes and NRT gum and patch, compiled from Nielsen retail store scanner database, were linked with contemporaneous quarterly television rating data for e-cigarettes and NRT products, compiled from Kantar Media, using state and county identifier. Market, year, and quarter fixed effects models were used to estimate the impact of NRT price and TV advertising, as well as e-cigarette price and TV advertising, on the demand for NRT gum and patch. NRT gum price elasticity was estimated to be -0.91. Higher patch price was found to decrease gum sales (cross-price elasticity -0.96). Higher e-cigarette prices were found to decrease NRT gum sales. Higher cigarette prices were found to increase NRT gum sales. NRT patch price elasticity was estimated to be -2.05. Higher gum price was found to increase patch sales (cross-price elasticity 0.97). E-cigarette TV advertisement was positively associated with NRT gum sales. NRT gum appeared to be complements for e-cigarettes. Recent growth in e-cigarette sales may have increased the demand for NRT gum. More studies are needed to understand the differential behavioral patterns of NRT gum users and NRT path users.

Factors motivating smoking cessation: a cross-sectional study in a lower-middle-income country.

INTRODUCTION: Only one-quarter of smokers in Pakistan attempt to quit smoking, and less than 3% are successful. In the absence of any literature from the country, this study aimed to explore factors motivating and strategies employed in successful smoking cessation attempts in Pakistan, a lower-middle-income country. METHODS: A survey was carried out in Karachi, Pakistan, amongst adult (≥ 18 years) former smokers (individuals who had smoked ≥100 cigarettes in their lifetime but who had successfully quit smoking for > 1 month at the time of survey). Multivariable logistic regression, with number of quit attempts (single vs. multiple) as the dependent variable, was performed while adjusting for age, sex, monthly family income, years smoked, cigarettes/day before quitting, and having suffered from a smoking-related health problem. RESULTS: Out of 330 former smokers, 50.3% quit successfully on their first attempt with 62.1% quitting "cold turkey". Only 10.9% used a cessation aid (most commonly nicotine replacement therapy: 8.2%). Motivations for quitting included self-health (74.5%), promptings by one's family (43%), and family's health (14.8%). Other social pressures included peer-pressure to quit smoking (31.2%) and social avoidance by non-smokers (22.7%). Successful smoking cessation on one's first attempt was associated with being married (OR: 4.47 [95% CI: 2.32-8.61]), employing an abrupt cessation mode of quitting (4.12 [2.48-6.84]), and telling oneself that one has the willpower to quit (1.68 [1.04-2.71]). CONCLUSION: In Pakistan, smoking cessation is motivated by concern for self-health and family's health, family's support, and social pressures. Our results lay a comprehensive foundation for the development of smoking-cessation interventions tailored to the population of the country. IMPLICATIONS: Little is known about the patterns and strategies employed by smokers who are attempting to quit smoking, especially in lower-middle-income countries like Pakistan. Likewise, there are very few smoking cessation programs designed to assist in quitting. Our study will allow for a better understanding of the culture-specific motivating factors and strategies that most contributed to successful quit attempts. Based on these results, evidence based smoking cessation interventions can be developed tailored to the socioeconomic demographic of our country and region, including smoking cessation clinics and public outreach and media campaigns highlighting key elements of successful smoking cessation.

Supporting visitor compliance with a smoke-free policy at hospital using a nicotine replacement therapy vending machine.

ISSUE ADDRESSED: To support visitors to comply with Central Coast Local Health District's (CCLHD) smoke-free hospital grounds policy, a need was identified for round-the-clock availability of nicotine replacement therapy (NRT). Providing NRT through a vending machine was identified as a possible solution. This initiative complemented other strategies that provide staff and patients who smoke with NRT. METHODS: NRT was originally provided through a snack vending machine; however, there were commercial and regulatory concerns with this method. In 2015, dedicated NRT vending machines were installed at Gosford and Wyong Hospitals, and were operated by the Health Promotion Service. The appropriate regulatory permission was gained to supply a specific brand of NRT. Sales and incident data were recorded, and ongoing smoking counts were performed both before and after installation. RESULTS: In all, 247 sales of NRT gum were made through the vending machines from early 2017 to late 2019. Smoking counts show that there are very low rates of visitor smoking (<1%) in the approximately 4.5 years pre- and post-installation of dedicated vending machines. There was no statistically significant change in the smoking rate of visitors since the vending machine was installed at Wyong Hospital. CONCLUSIONS: While NRT is generally provided to patients and staff within health settings to support compliance with smoke-free policies, alternatives to smoking for visitors are typically overlooked. A NRT vending machine achieves this. However, because there are few purchases made, the vending machines as currently operating are unlikely to make any significant impact on smoke-free policy compliance at these hospitals. SO WHAT?: While vending machines have limited effectiveness on overall smoke-free policy compliance, this strategy may have applicability to all sectors with smoke-free policies, especially those operating 24 hours a day, as a means of providing an alternative to smoking for visitors.