Smoking Cessation Interventions

Herberts & Sykes, 2012; Price, Jordan, & Dake, 2006; Thyrian et al., 2006). There might be scope for digital interventions to address some of the barriers associated with smoking cessation during pregnancy, since these programmes do not require face-to- face contact, are available any time, and appear to be acceptable for pregnant smokers (Naughton, Jamison, & Sutton, 2013; Naughton et al., 2012; Pollak et al., 2013). However, there are currently no evidence-based smoking cessation websites or smartphone applications specifically designed for pregnant smokers. Equally, there is no published information on what would constitute an effective digital smoking cessation intervention for this population in terms of content, features and mode of delivery. This study solicited HCPs’ views regarding the use of digital smoking cessation interventions with pregnant women to inform the design and delivery of such interventions.

smokers. 11 This, however, is less likely to have a “differential” impact by level of smoking. Other than the presentations associated with the LDCT-LCS guideline recommendations in 2013, there were no efforts in the healthcare system specifically targeting tobacco treatment during 2010–2017. Thus, the implementation of the screening guideline is a plausible explanation for the observed differential trend in smoking cessation intervention based on level of smoking. Furthermore, the supplemental study results indicate that there are positive relationships between LDCT-LCS referral and smoking cessation interventions.

The aim of this systematic review and narrative sum- mary is to identify, describe, and synthesise the evidence about family-based interventions for smoking cessation. In doing so, we aim to develop understandings of family as the ‘active ingredient’ of smoking cessation interven- tions. In contrast to previous reviews, the focus was on family (kin) as opposed to, for instance, social support [18]. The objectives were to describe study design and methods, report intervention effects as well as to de- scribe theories, procedures, functions and content of family-based interventions for smoking cessation. The findings will contribute towards understanding why pre- vious family-based interventions may have limited effect and also point to ways in which future family-based smoking cessation interventions may be improved.

Sundblad et al 20 compared a high intensity in-patient intervention with usual care provided in primary care health centers. A smoking cessation nurse delivered the experi- mental arm for 1 hour per day in groups of 4 – 8 people over 11 days, as part of a wider lifestyle intervention with additional input from a doctor, a physiotherapist, a dieti- tian, a laboratory technician, a psychologist, an occupa- tional therapist, and a nurse. NRT was recommended, and was used by 28% in the experimental group and 14% in the control group. There were also regular follow-up tele- phone calls for 2–3 months after discharge, and the subject and his or her spouse then returned for 2– 4 days as in- patients, followed by additional telephone support fol- low-up until 12 months post-intervention. No information was given on the usual care offered for the control group, although just 20% (46) accessed this. At 1 year, point prevalence abstinence (in the previous 6 months) was sig- nificant (chi-square ⫽ 105.2, P ⬍ .001), with 52% in the intervention group and 7% in the control stopping (odds ratio 14.71, 95% CI 8.14 –26.59). At 3 years these figures had reduced to 38% and 10%, respectively, but the treat- ment difference was still significant (chi-square ⫽ 44.0, P ⬍ .001). There was no difference in outcome based on the severity of the disease. There were no differences re- ported in nicotine dependence between the groups at base- line, although the authors acknowledged that which part of the intervention was effective is difficult to deduce, given the mixed use of pharmacotherapy and the extensive for- mat of the wider intervention.

personality characteristics may be effect the success of smoking intervention. There were problems in contacting the patients for their follow-ups. Patients were not easily contactable or had to be contacted more than twice for the follow-ups to be done. Some patients requested to be contacted at odd hours away from the time allocated for the investigators to conduct the follow-ups via telephone calls. Some patients tend to provide their telephone numbers, answered the first follow-up call, but were reluctant to answer the next time. Again, if an appointment were given to them for their 6-month follow-up, some failed to attend. Thus, our inability to recruit patients as expected and to deliver the full intervention to patients who did enrol raises important issues and a cautionary note for future research and intervention.

The three trials conducted in managed-care settings all found significant intervention effects on sustained quitting, i.e. quitting at both 3 and 12 month follow-up. The pediatric intervention found significant effects on 6 month quitting but was only marginally effective when examining sustained quitting both at 6 and 12 months. Results from the dental trial in fee-for-service practices are still under analysis, but preliminary examination indicates a sizeable and significant effect on sus- tained quitting for smokeless tobacco users—essen- tially replicating the results found in the HMO trial—but no significant effect on cigarette smoking (Severson et al., 1995). Thus there is considerable, convergent validity for the generic low-intensity model employed in these trials. The tailor-made videos were an important component of these interventions, but the trials cannot validate the impact of the video per se. Nevertheless, the consistency of these findings and our experience of patient response to them encourages further use of tailored videos in primary care settings.

There are several limitations in the present study, which should be considered in any interpretation of the fi ndings. There was a high degree of variability in regards to the population, intervention and outcome. For example, an array of stroke diagnoses was found ranging from incident stroke and TIA. A meta-analysis was not conducted due to the varied interventions from the reported studies. Wolfe et al 8 employed pharmacotherapy and advised patients on how to use them. Ellis et al 9 / McManus et al 10 used standard outpatient advice with postdischarge care from a nurse specialist. Papadakis et al 11 used CF pharmacotherapy with counselling support and follow-up. Finally, Frandsend et al 12 used intensive counselling support with CF pharmacotherapy.

Finding from Research Question 2 The second research question was whether desire to quit at baseline was predictive of engagement with and use of tailored print materials. The data showed that that the objective to achieve high exposure was met - that is, most family members recalled getting the family support album (FSA), regardless of desire to quit at baseline. However, desire to quit was not related to engagement with the materials. Nearly half of family members read less than some of the booklet and the amount of the booklet read did not differ by baseline desire to quit. These results, albeit discouraging, are similar to other studies that show it is difficult to get participants to engage with tailored print materials (Brug, Steenhuis et al. 1996; Orleans, Boyd et al. 1998; Campbell, Tessaro et al. 2002; McBride 2004), especially when face-to- face contact is not part of the study design. Men, non-whites, and spouses were less likely to read the booklet than were women, whites, and other family members respectively. Based on a review of the literature, formative research, and expertise with similar interventions, the materials we used were designed to be attractive and interesting to family members. It seems that the desired effect was achieved with some family members but not others. The results indicate that there is some room for improvement. Thus, future studies could benefit from additional formative research as a means of testing message and design concepts.

There are some limitations to these findings. First, health care provider visits and interventions are self- reported by the survey participant; therefore the potential for retrospective recall errors exists. In addition, the MATS instrument only provides an overall description of the health care provider intervention that occurred at any time in the past year and did not examine whether a health care provider assessed their willingness to make a quit attempt or arranged to address smoking at the next visit. Further, we did not determine the reason for the visit or the type of health care provider involved in the visit, both of which may factor into whether smoking was addressed.

A U T H O R S ’ C O N C L U S I O N S Implications for practice The results of this review indicate the potential benefits of inter- ventions given by nurses to their patients. The challenge will be to incorporate smoking cessation interventions as part of standard practice so that all patients are given an opportunity to be asked about their tobacco use and to be given advice to quit along with reinforcement and follow up. Nicotine replacement therapy has been shown to improve quit rates when used in conjunction with counselling for behavioural change and should be considered an important adjunct, but not a replacement for nursing interven- tions (Stead 2008). The evidence suggests that brief interventions from nurses who combine smoking cessation work with other du- ties are less effective than longer interventions with multiple con- tacts, delivered by nurses with a role in health promotion or car- diac rehabilitation.

Incomplete outcome data This was judged to be satisfactory across all studies; for smoking data an intention-to-treat analysis was followed in all studies, so that those participants who could not be contacted at follow-up were assumed to have returned to smoking. This approach assumes that where data on smoking status are missing, participants are smoking; it should be noted that this assumption is conservative and is the standard approach taken when assessing the efficacy of smoking cessation interventions. Follow-up for birth outcomes was generally high with one exception. The treatment group allo- cation for seven women who experienced miscarriage after being randomised within one study (Wisborg 2000), could not be as- certained, so this trial was rated as being unclear with respect to this criterion.

A U T H O R S ’ C O N C L U S I O N S Implications for practice There is as yet no conclusive evidence of long-term benefit for pro- grammes delivered solely by mobile phone. Mobile phone-based smoking cessation interventions have been shown to assist people to stop smoking in the short term. There is no reason to believe that mobile phone interventions would result in greater rates of relapse after the end of the programme than other interventions, and they are already being introduced in conjunction with other programmes such as quitlines and nicotine replacement. The in- terventions in this review include: a purely text message-based pro- gramme with automated proactive text messages and some reac- tive (for help with cravings) and interactive (polls/quizzes) com- ponents; and an automated email/daily Internet page and mobile phone text/audio message programme with proactive and reactive components. The latter programme has also been shown to have benefit to 12 months.

Implications for policy and practice: The evidence shows a range of types of smoking cessation interventions that are feasible and effective within community pharmacies, and supports the commissioning of smoking cessation services in a community pharmacy setting. Smoking ces- sation services, contracted as a core part of the national contract, or part of a national ‘ advanced ’ service, may well be a reasonable option. In addition, the evidence shows that weight management services are no less effective compared with those delivered in other primary care settings. Therefore, given the potential reach, effectiveness and associated costs of these inter- ventions, commissioners may consider using community pharmacies to help deliver some of their smoking cessa- tion and weight management services.

Implications for policy and practice: The evidence shows a range of types of smoking cessation interventions that are feasible and effective within community pharmacies, and supports the commissioning of smoking cessation services in a community pharmacy setting. Smoking ces- sation services, contracted as a core part of the national contract, or part of a national ‘ advanced ’ service, may well be a reasonable option. In addition, the evidence shows that weight management services are no less effective compared with those delivered in other primary care settings. Therefore, given the potential reach, effectiveness and associated costs of these inter- ventions, commissioners may consider using community pharmacies to help deliver some of their smoking cessa- tion and weight management services.

Implications for policy and practice: The evidence shows a range of types of smoking cessation interventions that are feasible and effective within community pharmacies, and supports the commissioning of smoking cessation services in a community pharmacy setting. Smoking ces- sation services, contracted as a core part of the national contract, or part of a national ‘advanced’ service, may well be a reasonable option. In addition, the evidence shows that weight management services are no less effective compared with those delivered in other primary care settings. Therefore, given the potential reach, effectiveness and associated costs of these inter- ventions, commissioners may consider using community pharmacies to help deliver some of their smoking cessa- tion and weight management services.

as patients with HIV, COPD, and cancer and those undergo- ing treatment for substance use disorders. When compared to active control groups or other eHealth modes, we could not find evidence of the effectiveness of internet-based tobacco cessation programs. This is consis- tent with an earlier Cochrane review, which concluded that eHealth smoking cessation interventions (eg, websites or text messages) may produce little or no increase in quitting compared to an active control group. 20,21 Among 12 eHealth smoking cessation interventions conducted with vulnerable patient groups, including five web-based, 80,81,118,119,123 three text-messaging systems, 84,98 and two computer-assisted programs, 139,140 the subgroup analysis suggested that the web-based and tailored text messaging supports may increase cessation while computer-assisted interventions alone have little impact on smoking abstinence. This suggests that tobacco cessation interventions via mobile phone and other wireless devices probably offer the best uptake.

these findings may have been influenced by the sample including a large number of individuals with a history of major depression. Prapavessis 2007 showed that reports of self efficacy for stopping smoking were higher in a cognitive-behavioural support condition compared with an exercise-only condition. Marcus 1999 did not find a significant change in reports of tobacco withdrawal symp- toms and cigarette cravings for exercise versus controls across the treatment period. Kinnunen 2008 did not find any difference in reports of withdrawal symptoms for the exercise group versus the controls at one week post-cessation. Bize 2010 found no signifi- cant differences in reports of withdrawal symptoms, depression, urges to smoke, or perceived stress for the exercise group versus the control group. Marcus 2005 observed that, among 40 women who were abstinent at the end of treatment, those who increased their fitness were more likely to report decreases in depressive symptoms (see Williams 2008). Ussher 2003 observed a reduc- tion in some withdrawal symptoms for exercise versus controls up to three weeks post-cessation. Bock 2012 observed no effects of a yoga intervention on anxiety, depression, or temptations to smoke. Maddison 2014 found no group differences in tobacco withdrawal symptoms. Abrantes 2014 reported significantly lower

Abstract: Tobacco dependence is a chronic condition that usually requires repeated intervention. Effective interventions can produce long-term cessation of up to double the rate achieved by smokers without treatment. Because of the potential health benefits and availability of effective interventions, every smoker should be offered these effective interventions. The identification of smoking status and the provision of brief advice independently increase cessation rate compared to no intervention and should be routine as part of each contact with health services. Interventions involving individual, group or proactive telephone counseling are more effective than no intervention .There is a strong dose response between the intensity (number and length of sessions) of tobacco cessation counseling and its effectiveness. This review article provides recommendations for practitioners to assist them in management of patients engaged in smoking cessation.

P L A I N L A N G U A G E S U M M A R Y Are there any effective interventions to help individuals with schizophrenia to quit or to reduce smoking? People with schizophrenia are, very often, heavy smokers. It is uncertain whether treatments that have been shown to help other groups of people to quit smoking are also effective for people with schizophrenia. In this review, we found that bupropion (an antidepressant medication previously shown to be effective for smoking cessation) helps patients with schizophrenia to quit or to reduce smoking. The effect was clear at the end of the treatment and it may also be maintained after six months. Patients who used bupropion in the trials did not experience any major adverse effect and their mental state was stable during the treatment. Smokers with schizophrenia who receive money as a reward for quitting may have a higher rate of stopping smoking whilst they get payments. However, there is no evidence that they will remain abstinent after the reward stops. There was too little evidence to show whether other treatments like nicotine replacement therapy and psychosocial interventions are helpful.

these issues. Enhancing self-help programmes One of the main criticisms of traditional self-help materials is that they do not take account of individual characteristics and prob- lems in dealing with smoking cessation. This could account for the failure of self-help materials to match the effect of counselling delivered individually or in groups. Tailoring materials to individ- uals’ habits and motivations is an attractive theoretical approach to enhancing the efficacy of such materials. In this review, indi- vidually tailored materials appeared to be effective compared to no self-help intervention. One limitation of the conclusions on the benefit of tailoring compared to standard materials is that in a number of studies the tailoring is confounded with additional con- tact. The small number of studies where contacts were matched had heterogeneous outcomes. One of these studies tested differ- ent number of contacts without detecting a dose response effect, but the tailored materials tended to outperform the standard ones whatever the number of contacts. We are inclined to the view that contact or assessment alone is unlikely to contribute much to the impact of tailoring, and has to form part of the tailoring process.