Efficacy and safety of cytisine versus nortriptyline for smoking cessation: A multicentre, randomized, double-blinded and placebo-controlled trial.

BACKGROUND AND OBJECTIVE: Cytisine serves as an affordable smoking cessation aid with acceptable safety profile. However, data comparing its efficacy and safety to standard therapies are limited. We aimed to examine efficacy and safety of cytisine compared to nortriptyline, which is the only approved smoking-cessation medication in Thailand. METHODS: A 12-month, multicentre, randomized, double-blinded, placebo-controlled trial was conducted. Participants aged ≥20 years who smoked ≥10 cigarettes/day were randomly assigned to receive a 25-day cytisine or a 12-week nortriptyline treatment course. Brief interventions (BI) for smoking cessation were provided to all participants. The primary outcome was biochemically verified continuous abstinence rate (CAR) at 12 months. Additionally, self-reported abstinence, verified by exhaled carbon monoxide (CO) ≤ 10 ppm, was collected at 2 weeks, 1, 3, 6 and 12 months to assess both CAR and 7-day point prevalence abstinence rate (PAR). RESULTS: A total of 1086 participants were recruited and randomized into cytisine (n = 540) and nortriptyline (n = 546) groups. The 12-month CAR was 12.22% for cytisine and 9.52% for nortriptyline. The relative difference was 0.03 (95% confidence interval [CI]; -0.01 to 0.06) and the relative risk was 1.28 (95% CI; 0.91-1.81). No differences were observed in secondary outcomes between both groups. The incidence of adverse effects from cytisine appeared to be lower than that of nortriptyline. CONCLUSION: At 12 months, cytisine plus BI was as effective as nortriptyline plus BI for smoking cessation. The adverse events for both cytisine and nortriptyline were minimal and well-tolerated.

A cost-effectiveness analysis of national smoking cessation services among chronic obstructive pulmonary disease patients in Thailand.

AIMS: Thailand's national smoking cessation services (FAH-SAI clinics) were founded in 2010. A cost-effectiveness analysis (CEA) is needed to inform policymakers of the allocation and prioritization of the limited budget to maximize the value for money of reimbursing these services. Chronic obstructive pulmonary disease (COPD) patients would benefit from smoking cessation services. Therefore, this study aimed to assess the cost-effectiveness of these multidisciplinary services compared to the usual care among COPD patients in Thailand from a societal perspective. METHODS: We conducted a CEA from a societal perspective using a Markov model to simulate lifetime costs and quality-adjusted life years (QALYs) gained by each smoking cessation intervention over the patient's lifetime. We derived the effectiveness of the smoking cessation services from a multicenter, longitudinal study of smoking cessation services in Thailand and estimated the natural quit rate, transition probabilities, health utility, and cost data from the published literature. Costs and outcomes were discounted at 3%. Sensitivity analyses were performed. RESULTS: Compared to the usual care, FAH-SAI clinics were associated with higher costs (4,207 THB (US$133)) and improved QALYs (0.11), with an incremental cost-effectiveness ratio of 37,675 THB/QALY (US$1,187/QALY). The effectiveness of FAH-SAI clinics was a key driver of the cost-effectiveness results. At the willingness-to-pay (WTP) threshold of 160,000 THB (US$5,042) per QALY gained, the probability of being cost-effective was 96.5%. CONCLUSIONS: FAH-SAI clinics were cost-effective under Thailand's WTP threshold. Our results could inform policymakers in allocating resources to support smoking cessation services for COPD patients in Thailand.

Cost-effectiveness analysis of the SMART quit clinic program in smokers with cardiovascular disease in Thailand.

INTRODUCTION: The SMART Quit Clinic Program (FAHSAI Clinic) has been implemented in Thailand since 2010; however, it remains unclear whether the benefits gained from this program justify its costs. We assessed its cost-effectiveness compared to usual care in a population of Thai smokers with cardiovascular disease (CVD) from a societal perspective. METHODS: We conducted a cost-utility analysis using a Markov model to simulate lifetime costs and quality-adjusted life years (QALYs) of Thai smokers aged ≥35 years receiving smoking cessation services offered from FAHSAI Clinic or usual care over a horizon of 50 years. The model used a 6-month continuous abstinence rate from a multicenter prospective study of 24 FAHSAI Clinics. A series of sensitivity analyses including probabilistic sensitivity analysis were conducted to assess robustness of study findings. Cost data are presented in US$ for 2020. RESULTS: The FAHSAI Clinic was dominant as it was less costly ($9537.92 vs $10964.19) and more effective (6.06 vs 5.96 QALYs) compared with usual care over the 50-year time horizon. Changes in risks of stroke and coronary heart disease among males had the largest impact on the cost-effectiveness findings. The probability that FAHSAI Clinic was cost-effective was 99.8% at a willingness-to-pay threshold of $5120. CONCLUSIONS: The FAHSAI Clinic smoking cessation program was clinically superior and cost-saving compared to usual care for Thai patients with CVD in all scenarios. A budget impact analysis is needed to estimate the financial impact of adopting this program within the Thai healthcare system.

Assessment of the real-world impact of the Thai smoking cessation programme on clinical outcomes: protocol for a multicentre prospective observational study.

BACKGROUND: Tobacco smoking is the most common preventable cause of morbidity and mortality in the world. In an effort to counteract the harmful consequences of smoking, various tobacco control measures have been implemented, including the use of smoking cessation programmes to reduce the number of new smokers as well as helping current smokers to quit smoking. In Thailand, the SMART Quit Clinic Program (FAH-SAI Clinics) was launched in 2010 to provide smoking cessation services by a multidisciplinary team. There are currently 552 FAH-SAI Clinics established across all 77 provinces of Thailand. AIM: This protocol describes a study aiming to evaluate the SMART Quit Clinic Program (FAH-SAI Clinics) in terms of programme performance and clinical outcomes. We hope that the results of the study could be used to improve the current service model and the programme's success. METHOD: A multicentre prospective observational study will be conducted. The study will focus on 24 FAH-SAI Clinics across 21 provinces of Thailand. The primary outcomes are seven-day point prevalence abstinence rate and continuous abstinence rate at three and six months. The outcomes will be measured using a self-reported questionnaire and biochemical validated by exhaled carbon monoxide. DISCUSSION: This study will be the first real-world study that reports the effectiveness of the well-established smoking cessation programme in Thailand. Findings from this study can help improve the quality of smoking cessation services provided by multidisciplinary teams and other smoking cessation services, especially those implemented in low- and middle-income countries.

The impact of Thai multidisciplinary smoking cessation program on clinical outcomes: A multicentre prospective observational study.

Introduction: Tobacco use is the leading preventable cause of morbidity and mortality worldwide. Since 2010, Thailand has implemented a multidisciplinary smoking cessation clinic, which provides smoking cessation services, but the effectiveness of the clinics was not formally evaluated. This study was conducted to assess the real-world effectiveness of this multidisciplinary smoking cessation program. Methods: We conducted a prospective, multicentre, observational study on Thai participants aged 13 years and older in 24 smoking cessation clinics across Thailand's 13 health regions. Each clinic offered smoking cessation interventions according to the well-established 5As model for smoking cessation (Ask, Advise, Assess, Assist, and Arrange). Outcomes of interest were continuous abstinence rates (CAR) at 3 and 6 months. Biochemical confirmation and self-reporting were used to assess the outcomes. Descriptive statistics (mean, SD, median, IQR, and percentage) were used to analyze the smoking cessation outcomes in both intention-to-treat and per-protocol analysis approaches. Results: Smokers receiving services from the Thai multidisciplinary smoking cessation clinics had CAR of 17.49 and 8.33% at 3 and 6 months, respectively. For those with cardiovascular disease (CVD) or cerebrovascular disease, CAR was found to be 26.36% at 3 months and 13.81% at 6 months. While participants with chronic obstructive pulmonary disease (COPD) had CAR ranging from 32.69% at 3 months to 17.31% at 6 months. Conclusion: The multidisciplinary team smoking cessation clinic was effective in assisting smokers in quitting smoking. The effectiveness of the clinic was more pronounced for smokers with CVD, cerebrovascular disease, or COPD. Findings from this study support a decision to include multidisciplinary smoking cessation clinics in the universal health care benefits package.

Fiscal Impact of Smoking Cessation in Thailand: A Government Perspective Cost-Benefit Analysis.

We evaluate the broader public economic consequences of investments in smoking cessation that change lifetime productivity, which can influence future government tax revenue and social transfer costs and health care spending. The analysis applies a government perspective framework for assessing the intergenerational relationships between morbidity and mortality and lifetime tax revenue and social transfers received. Applying smoking prevalence in Thailand, a cohort model was developed for smoker and former smokers to estimate impact on lifetime direct taxes and tobacco taxes paid. Age-specific earnings for males and wage appropriate tax rates were applied to estimate net taxes for smokers and former smokers. Introducing smoking cessation leads to lifetime public economic benefits of THB13 998 to THB43 356 per person depending on the age of introducing smoking cessation. Factoring in the costs of smoking cessation therapy, an average return on investment of 1.35 was obtained indicating fiscal surplus generated for government from the combined effect of increased tax revenues and of averting smoking-attributable health care costs.

Impact of Tobacco Control Campaigns on Smoking Behaviors in Thai Medical Schools.

Objective: To explore the changes in the prevalence of smoking behavior, attitudes, and cessation training among medical students after the establishment of the Thai Health Professional Alliance against Tobacco (ThaiPAT) and its major campaigns by using the nationwide Global Health Professions Student Surveys (GHPSS). Material and Method: Multiple cross-sectional studies were conducted after three major campaigns were launched between 2007 and 2011, the Deans' Summit on Tobacco Control, implemented tobacco control into the medical curriculum, and 100% smoke-free hospitals and medical schools. The results of two rounds of GHPSS among third year medical students across the nation in 2006 and 2011 were compared. Results: Overall prevalence of active cigarette smoking remained unchanged at 2.6%. Passive cigarette smoke exposure in public areas appeared to decrease slightly over time. In the most recent national survey, the prevalence of passive smoke exposure was 53.7%. Moreover, the number of student that agreed with the smoking ban in pubs, bars, and nightclubs increased significantly from 80.8 to 90.5%. There was significant improvement in the cessation training among medical students (p<0.001). A significant increase in the number of student that agreed that healthcare personnel needed specific training in cessation techniques (p = 0.004) and should always advise their patients to quit smoking (p<0.001). Conclusion: Nationwide tobacco control campaigns in Thai medical schools significantly improved the attitudes toward smoking cessation and cessation training among their students, although overall prevalence of active and passive cigarette smoking was unchanged.

Thai-shock survey 2013: survey of shock management in Thailand.

OBJECTIVE: Pragmatic surveys for shock management by Thai physicians are unavailable. The objective of this study is to identify the shock management patterns on both; the incidence of septic shock and hemorrhagic shock here in Thailand. MATERIAL AND METHOD: Two thousand questionnaires were sent to physicians who are called on to care for patients in shock across Thailand. The questionnaire is composed of 58 items regarding all aspects of the management of septic and hemorrhagic shock. A frequency scale has been defined by 5 levels of patient proportion estimates from routine practices. RESULTS: Between April and August, 2013, 533 of the distributed questionnaires (26.7%) were returned. In severe sepsis and septic shock management, 406 physicians (76.2%) have reported the routine use of the quantitative resuscitation protocols. Urine output, mean arterial pressures and central venous pressures have been more frequently used than central venous oxygen saturation and lactate levels for the resuscitation goals. Nearly 80% of these clinicians have shown "often and always" for the achievement of the resuscitation goals within 6 hours. Most of the physicians (65.3%) had never used procalcitonin biomarkers. Antimicrobial empirical treatments were started within 1 hour of admission for 87.7% of these patients and were continued for less than 5 days in 67.3% of the cases prior to de-escalating the treatments. Crystalloids have been the common, initial fluid used for resuscitation (98.9% in sepsis, 99.3% in trauma). The most commonly used vasopressors are norepinephrine (69.6%) for sepsis and dopamine (63.1%) for trauma. The median of the cortisol threshold level for steroid replacement therapy is 15 mg/dL, taken from the interquartile range or IQR of 5-19 mg/dL. Nearly all the physicians currently use hydrocortisone (96.4%). The median daily dose of hydrocortisone is 300 mg (IQR; 200-300). Approximately 50% of the physicians prescribed the hydrocortisone in divided doses to be administered every 8 hours and 31.8% ordered the medications as a continuous infusion. Tapering the dose in reduction varied by 33.6% ofthe physicians over a period of 2 to 3 days. Central venouspressures (CVP) and fluid challenge tests were more frequently used in the evaluation ofpreload rather than some of the newer fluid responsiveness methods. Less than 15% of the physicians continued to use pulmonary artery catheters in their routine practices. Regarding hemorrhagic and traumatic shock, only 162 physicians (39.3%) have been certified in Advance Traumatic Life Support (ATLS), but 311 physicians (75.6%) have reported in following with the ATLSguidelines. In patients requiring massive transfusions, physicians used packed red cells (PRC) and fresh frozen plasma (FFP) in a ratio of 1:1 (34.1%). Focus assessment sonography for trauma (FAST) was the most commonly used diagnostic method in cases of traumatic shock. CONCLUSION: Most physicians manage shock with the current protocols. Hemodynamic goals are preferred over tissue perfusion targets. Early antimicrobial therapy and de-escalation are routinely practiced without the use of infective biomarkers. Crystalloids are preferred over colloids for the initial resuscitation. CVPs and fluid challenges are still preferred over the new fluid responsiveness methods for preload assessment. Hydrocortisone is the most common steroid prescribed for septic shock but the threshold of initiation, frequency of use and methods of discontinuation vary.

Commitment contracts and team incentives: a randomized controlled trial for smoking cessation in Thailand.

BACKGROUND: Treatment for tobacco dependence is not available in many low-resource settings, especially in developing countries. PURPOSE: To test the impact of a novel mix of monetary and social incentives on smoking abstinence in rural communities of Thailand. DESIGN: An RCT of commitment contracts and team incentives for rural smokers to quit smoking. Smokers were not blinded to treatment status, although the assessor of the biochemical urine test was. SETTING/PARTICIPANTS: All adult smokers living in the study area were eligible to participate; 215 adult smokers from 42 villages in Nakhon Nayok province, Thailand, participated. Fourteen smokers who lacked teammates were dropped. INTERVENTION: A total of 201 smokers were assigned to a two-person team, and then randomly assigned by team (in a 2:1 ratio) with computer-generated random numbers to receive smoking-cessation counseling (control group) or counseling plus offer of a commitment contract, team incentives, and text message reminders for smoking cessation at 3 months (intervention group). MAIN OUTCOME MEASURES: The primary outcome was biochemically verified 7-day abstinence at 6 months, assessed on an intention-to-treat basis. Secondary outcomes include study participation, biochemically verified abstinence at 3 months, self-reported abstinence at 14 months, and the incremental cost per quitter of the intervention, nicotine gum, and varenicline in Thailand. Data were collected in 2010-2011 and analyzed in 2012. RESULTS: The trial enrolled 215 (10.5%) of 2055 smokers. The abstinence rate was 46.2% (61/132) in the intervention group and 14.5% (10/69) in the control group (adjusted OR 7.5 [3.0-18.6]) at 3 months; 44.3% (58/131) and 18.8% (13/69) at the primary end point of 6 months (adjusted OR 4.2 [1.8-9.7]); and 42.0% (55/131) and 24.6% (17/69) at 14 months (adjusted OR 2.2 [1.0-4.8]). The purchasing power parity-adjusted incremental cost per quitter from the intervention is $281 (95% CI=$187, $562), less than for nicotine gum ($1780, 95% CI=$1414, $2401) or varenicline ($2073, 95% CI=$1357, $4388) in Thailand. CONCLUSIONS: The intervention enhanced abstinence by 91%-136% at 6 months, relative to the control group, although self-reports at 14 months suggest tapering of the treatment effect. The intervention may offer a viable, cost-effective alternative to current smoking-cessation approaches in low-resource settings. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov NCT01311115.

Acinetobacter baumannii nosocomial pneumonia in tertiary care hospitals in Thailand.

BACKGROUND: Nosocomial pneumonia (NP) is an important cause of morbidity and mortality in hospitalized patients. Acinetobacter baumannii is one of the common causative pathogens in NP. The prevalence of multi-drug resistance in A. baumannii has been increasing. The information on clinical features and clinical courses of A. baumannii NP in Thai patients are limited. OBJECTIVE: To determine the clinical features, risk factors and clinical courses of A. baumannii NP in Thai patients hospitalized in tertiary care hospitals in Thailand. MATERIAL AND METHOD: This was a prospective, hospital-based, active surveillance study on hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) in adults hospitalized in 12 tertiary care hospitals in Thailand between 2008 and 2009. RESULTS: There were 651 NP patients. A. baumannii was the most common cause of NP in 198 patients (30.4%). Most of NP patients were males with median age of 71 years. About 80% had late onset NP with the median duration of 10 days after admission in both A. baumannii and non-A. baumannii NP. Most of NP occurred in patients hospitalized in general medical wards. Most of the features of NP in A. baumannii NP and non-A. baumannii NP were not significantly different. The initial antibiotics prescribed were concordant in about 50% of the patients in both groups. Colistin was usually prescribed to the patients who received antibiotic modifications. The initial clinical responses in A. baumannii NP were less favorable than those in non-A. baumannii NP. The mortality rate in A. baumannii NP seemed to be more than that in non-A. baumannii NP. There was a trend of more persistence of pathogen in A. baumannii NP. Most isolates of A. baumannii were resistant to antibiotics including carbapenems. The patients with extensive drug resistant A. baumannii NP had less favorable responses than NP due to other bacteria, including non-extensive drug resistant A. baumannii. VAP, NP developed in medical ICU and NP with bilateral lung involvements on chest X-ray were associated with A. baumannii as the isolated pathogen. CONCLUSION: A. baumannii is the most common causative pathogen for NP in tertiary care hospitals in Thailand and most of A. baumannii isolates were resistant to many antibiotics including carbapenems. The hospitalized patient in tertiary care hospitals with VAP, or NP that was developed in medical ICU, or NP with bilateral lung involvements on chest x-ray was likely to be due to A. baumannii. Many NP patients received inappropriate initial antibiotic regimens leading to a high mortality.

Efficacy of fresh lime for smoking cessation.

OBJECTIVE: To determine the efficacy of fresh lime as a smoking cessation aid compared with nicotine gum. MATERIAL AND METHOD: A randomized, controlled trial was conducted between March 2009 and September 2009. Only regular smokers aged 18 or older who were willing to quit were randomized to receive either fresh lime (n = 47) or nicotine gum (n = 53). Smokers were excluded if they were using other smoking cessation aids, allergic to citrus, or had dental problems. Exhaled carbon monoxide (CO)-confirmed continuous abstinence rate (CAR) during week 9-12 was measured as the primary outcomes. To grade the severity of craving, a 100-mm visual analogue scale (VAS) was used. RESULTS: There was no significant difference in CO-confirmed CAR between the fresh lime group and the nicotine gum group during weeks 9-12 (61.7% vs. 66.0%; p = 0.65), although 7-day point prevalence abstinence at week 4 of the fresh lime users was statistically significant lower than those using nicotine gum (38.3% vs. 58.5%; p = 0.04). Cravings did not differ significantly between the groups, although fresh lime users tend to report more cravings intensity. CONCLUSION: Fresh lime can be used effectively as a smoking cessation aid, although not as good as nicotine gum in reducing cravings.

Forensic aspect of cause of subendocardial hemorrhage in cardiopulmonary resuscitation cases: chest compression or adrenaline.

Subendocardial hemorrhage (SEH) is a striking feature seen in many forensic autopsy cases. It was believed earlier to represent an agonal phenomenon without any particular reference to the cause of death. However, the latest study showed that even minor SEH might have an influence on cardiac function and might be involved in the mechanism of death. To rule out the possible cause of SEH from defibrillation, autopsies were performed in 240 adults admitted to Department of Forensic Medicine, Faculty of Medicine, Srinakarinwirot University and Department of Forensic Medicine, Faculty of Medicine, Chulalongkorn University between July 2006 and June 2008. All the subjects were subdivided into 2 groups: one group receiving resuscitation and the other group receiving no resuscitation. In the former group, 76 patients had attempted cardiopulmonary resuscitation with adrenaline and 44 patients without adrenaline. While in the latter group, 120 patients received no resuscitation attempt. Approximately, 43.4% of resuscitation with adrenaline cases (33/76) demonstrated SEH in contrast to 4 cases of resuscitation without adrenaline (9.1%, P < 0.05). This demonstrates an increasing trend of SEH in cases with prolonged resuscitation and higher level of adrenaline utilizations.

Effect of nicotine polyestex gum on smoking cessation and quality of life.

OBJECTIVE: To determine the effectiveness and safety of the novel nicotine polyestex gum for smoking cessation, along with its impact on the quality of life (QOL). MATERIAL AND METHOD: A double-blind, placebo-controlled, randomized clinical trial was conducted on 43 smokers. All of them received either nicotine gum or placebo. Only those who could quit completely and continuously by the end of 3 months were considered total abstinence. QOL was also measured using WHO questionnaires. RESULTS: Treatment with nicotine polyestex gum resulted in significantly greater abstinence rate at 3 months compared with placebo (50% vs. 9%; p = 0.003). Adverse events were modest and not encountered more often than those seen in the placebo group. QOL at 3-months improved in both groups, but there was no statistically significant difference between the groups. CONCLUSION: Nicotine polyestex gum is effective and safe for smoking cessation. It is also associated with significant improvement in the QOL.