Cessation of Smoking Trial in the Emergency Department: Long-Term Follow-up of a Randomized Controlled Trial

The emergency department represents a potentially valuable opportunity to support smoking cessation. Evidence is lacking around the use of e-cigarettes in opportunistic settings like the emergency department. To undertake a randomised controlled trial in people who smoke attending United Kingdom emergency departments, testing a brief intervention which included provision of an e-cigarette versus signposting to smoking cessation services, assessing smoking abstinence. A two-arm pragmatic, multicentre, parallel-group, individually randomised, controlled superiority trial with an internal pilot, economic evaluation and mixed-methods process evaluation. Six emergency departments across England and Scotland. Adults who smoked daily, who were attending the emergency department for medical treatment or accompanying someone attending for medical treatment, were invited to participate. People were excluded if they had an expired carbon monoxide of < 8 parts per million, required immediate medical treatment, were in police custody, had a known allergy to nicotine, were daily e-cigarette users, were considered not to have capacity to consent or had already taken part in the trial. Brief stop smoking advice, e-cigarette starter kit and referral to stop smoking services. The primary outcome was biochemically validated sustained abstinence at 6 months. Those lost to follow-up, or not providing biochemical verification, were considered not to be abstinent. Secondary outcomes were: self-reported 7-day smoking abstinence, number of quit attempts, number of cigarettes per day, nicotine dependence and incidence of self-reported dry cough or mouth or throat irritation. At 6 months, of 972 participants randomised, biochemically verified smoking abstinence was 7.2% in the intervention group and 4.1% in the control group (percentage difference = 3.3%) (95% confidence interval 0.3 to 6.3; p = 0.032) [relative risk 1.76 (95% confidence interval 1.03 to 3.01)]. Self-reported 7-day abstinence at 6 months was 23.3% in the intervention group and 12.9% in the control group (percentage difference = 10.6%) (95% confidence interval 5.86 to 15.41; p < 0.001) [relative risk 1.80 (95% confidence interval 1.36 to 2.38)]. Daily e-cigarette use was 39.4% in the intervention group and 17.5% in the control group at 6 months. No serious adverse events related to taking part in the trial were reported. The economic evaluation found the intervention was likely to be cost-effective, judged by the National Institute for Health and Care Excellence threshold. The process evaluation found the intervention to be acceptable to both staff delivering it and participants receiving it. The brief nature of the intervention was highly adaptable to context, and interviews demonstrated how the intervention supported different pathways towards cessation. The inability to blind participants or researchers, the relatively low level of biochemical verification due to the nature of the population recruited and the fact that those in the control group did not receive usual care. An opportunistic smoking cessation intervention comprising brief advice, an e-cigarette starter kit and referral to stop smoking services is effective for sustained smoking abstinence with few reported adverse events. Future work will include testing other behaviour change interventions in the emergency department and adapting the Cessation of Smoking Trial in the emergency department intervention for other settings. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR129438.

BackgroundSupporting people to quit smoking is one of the most powerful interventions to improve health. The Emergency Department (ED) represents a potentially valuable opportunity to deliver a smoking cessation intervention...

Smoking is the leading preventable cause of premature death in China, yet less than 10% of smokers seeking to quit receive treatment. This study aimed to test the efficacy of a cognitive behavioral therapy (CBT)-based smoking cessation intervention ('Smokefree Life') via a smartphone app in China. A digital, parallel, single-blind, two-arm (1:1) randomized controlled trial. This trial was conducted via 'Smokefree Life' app in the whole of mainland of China between 13 December 2021 and 15 April 2023. Chinese-speaking adult smokers (925 males, 102 females, mean age 35.0 ± 6.7) willing to quit within one month were recruited via WeChat, survey sampling and referral from doctors, friends and family and randomized in a 1:1 ratio. The intervention group (n = 523) received a 13-14 week CBT-based smoking cessation intervention via smartphone app and the control group (n = 504) received only control messages. All participants were followed for 26 weeks post-quit date. The primary outcome was biochemically validated continuous abstinence at 26 weeks. Secondary outcomes were self-reported 7-day abstinence and continuous abstinence at 26 weeks. By intention-to-treat analysis, the biochemically verified 26-week continuous abstinence rate was statistically significantly higher in the intervention group (6.50%) compared with the control group (2.58%) (odds ratio = 2.63, 95% confidence interval = 1.40-5.22, P = 0.0037). Self-reported 7-day and continuous abstinence rates were also consistently higher in the intervention group across follow-ups (all P < 0.05). The 'Smokefree Life' app-based smoking cessation intervention statistically significantly improved 6-month biochemically confirmed quit rates among adult smokers in China.

Efficacy of WeChat-based online smoking cessation intervention (‘WeChat WeQuit’) in China: a randomised controlled trial

Evidence for motivational interviewing for smoking cessation is weak, with limited data on long-term abstinence rates. This trial aimed to evaluate the effect of in-hospital motivational interviewing-based smoking cessation counselling combined with proactive referral to community-based follow-up on 6- and 12-month continuous smoking abstinence in patients with atherosclerotic vascular disease. Multicentre, randomised, open-label, blinded-end-point trial with 1:1 randomisation. Three secondary care hospitals in Norway, with recruitment from November 2021 to October 2023. Hospitalised patients with established atherosclerotic vascular disease who smoked ≥1 cigarette daily prior to unplanned or elective hospitalisation. A total of 221 were randomised (40% women, mean age 65.2years), of whom 213 were included in the primary analysis due to 7 deaths and 1 withdrawal. In the intervention group (n = 109), a trained nurse conducted a single 30-minute motivational interviewing-based counselling session, provided a leaflet explaining the local community-based cessation programme, sent discharge information to the general practitioner and arranged for a personal telephone invitation from the centre staff to the follow-up programme. In the control group (n = 111), a physician gave brief cessation advice and the nurse provided a leaflet about the cessation programme and sent discharge information to the general practitioner. The primary outcome was self-reported continuous smoking abstinence at 6 months. Secondary outcomes included biochemically validated abstinence (measurement of exhaled carbon monoxide) at 6 months and self-reported abstinence at 12 months. Exploratory outcomes included recurrent vascular events over a median 18-month follow-up. Smoking abstinence at 6 months was 49.5% (53/107) and 24.5% (26/106) in the intervention and control groups, respectively [odds ratio (OR) = 3.08, 95% confidence interval (CI) = 1.70-5.55, P < 0.001]. The number needed to treat to achieve one additional abstinence was 4 (95% CI = 3-9). Biochemically validated abstinence was 44.9% (48/107) and 20.8% (22/106) in the intervention and control groups, respectively (OR = 3.28, 95% CI = 1.76-6.12). At 12 months, smoking abstinence was 45.7% (48/105) and 27.5% (28/102) in the intervention and control groups, respectively (OR = 2.31, 95% CI = 1.27-4.20). After a median of 18-month follow-up, a prespecified vascular event occurred in 24.8% (27/109) and 34.2% (38/111) of intervention and control participants, respectively. In-hospital motivational counselling combined with proactive referral to follow-up in a community-based cessation programme approximately doubled long-term smoking abstinence rates in patients with atherosclerotic vascular disease and reduced occurrence of a new vascular event.

To examine the effectiveness of a stage-matched smoking cessation counselling intervention for smokers who had cardiac diseases. A total of 1860 Chinese cardiac patients who smoked at least one cigarette in the past 7 days and aged 18 years or above recruited from cardiac out-patient clinics in Hong Kong hospitals were allocated randomly to an intervention group or control group. The intervention group (n = 938) received counselling matched with their stage of readiness to quit by trained counsellors at baseline, 1 week and 1 month. The control group (n = 922) received brief counselling on healthy diet at baseline. The primary outcomes were self-reported 7-day and 30-day point prevalence (PP) of tobacco abstinence at 12 months after baseline. The secondary outcome measures included biochemically validated abstinence at 12-month follow-up, self-reported 7-day and 30-day PP abstinence and reduction of cigarette consumption by 50% at 3 and 6 months. By intention-to-treat analysis, the intervention and control groups showed no significant difference in self-reported 7-day PP abstinence (intervention: 26.5% versus control: 25.5%; P = 0.60) and 30-day PP (intervention: 25.4% versus control: 24.2%; P = 0.55), biochemically validated abstinence (intervention: 6.6% versus control: 4.9%; P = 0.14) and overall quit attempts of least 24 hours (intervention: 40.3% versus control: 34.3%; P = 0.007) at the 12-month follow-up, adjusted for the baseline stage of readiness to quit smoking. An intervention, based on the Stages of Change model, to promote smoking cessation in cardiac patients in China failed to find any long-term benefit.

Peri-operative cessation of smoking: time for anaesthetists to act.

To examine the effectiveness of guided imagery for immediate smoking cessation and long-term abstinence in adult smokers. A repeated measures design was used with 71 smokers recruited from a hospital outpatient clinic, 38 in the intervention group, and 33 in the control group. Both study groups received educational and counseling sessions in their homes. The intervention group was provided with additional instruction in the use of guided imagery and was encouraged to practice this imagery at least once per day with a 20-minute audio-taped exercise for reinforcement. The repeated measures included smoking rates (cigarettes per day) that were measured and confirmed through corroborating friends and family. At 24-months after the intervention, smoking abstinence rates were significantly higher for the guided health imagery intervention group (26% abstinence rate versus 12% abstinence rate for the placebo-control group). Guided imagery was an effective intervention for long-term smoking cessation and abstinence in adult smokers.

To test the hypothesis that a screening and treatment intervention for early cryptococcal infection would improve survival among HIV-infected individuals with low CD4 cell counts. Newly enrolled patients at Family AIDS Care and Education Services (FACES) in Kenya with CD4≤100 cells/μl were tested for serum cryptococcal antigen (sCrAg). Individuals with sCrAg titre≥1:2 were treated with high-dose fluconazole. Cox proportional hazard models of Kaplan-Meier curves were used to compare survival among individuals with CD4≤100 cells/μl in the intervention and historical control groups. The median age was 34years [IQR: 29,41], 54% were female, and median CD4 was 43 cells/μl [IQR: 18,71]. Follow-up time was 1224 person-years. In the intervention group, 66% (514/782) were tested for sCrAg; of whom, 11% (59/514) were sCrAg positive. Mortality was 25% (196/782) in the intervention group and 25% (191/771) in the control group. There was no significant difference between the intervention and control group in overall survival [hazard ratio (HR): 1.1 (95%CI:0.9,1.3)] or three-month survival [HR: 1.0 (95%CI:0.8,1.3)]. Within the intervention group, sCrAg-positive individuals had significantly lower survival rates than sCrAg-negative individuals [HR:1.8 (95%CI: 1.0, 3.0)]. A screening and treatment intervention to identify sCrAg-positive individuals and treat them with high-dose fluconazole did not significantly improve overall survival among HIV-infected individuals with CD4 counts≤100 cells/μl compared to a historical control, perhaps due to intervention uptake rates or poor efficacy of high-dose oral fluconazole.

Evidence-based pharmacotherapy and behavioral therapy could increase tobacco abstinence but are underused and require further investigation. To evaluate the effectiveness of a novel mobile health (mHealth) profiling via ecological momentary assessment (EMA) in personalizing smoking cessation intervention for individuals who use tobacco with no intention to use smoking cessation services and medications. A 2-arm, assessor-blind, individual-randomized clinical trial was conducted. With online recruitment through social media or email advertisement, 459 adults with daily tobacco use in Hong Kong were recruited from March 23, 2022, to January 4, 2023, with follow-up completed by July 4, 2023. Individuals who had not used smoking cessation services or medications in the preceding 7 days and had no intention to use these aids in the next month were included. Participants were randomized 1:1 to intervention (n = 231) or control (n = 228) groups. Both groups completed 5 EMAs daily for 7 days to report smoking behaviors and triggers. The intervention group additionally received nurse-led telephone counseling and 10-week instant messaging support guided by mHealth profiling from EMA. Primary outcomes were biochemically validated tobacco abstinence and Incremental Behavior Change Toward Smoking Cessation (IBC-S) score at 3 months after EMA initiation. Secondary outcomes were biochemically validated tobacco abstinence and IBC-S status at 6 months, self-reported 7-day point prevalence, abstinence, and use of smoking cessation medications and services at 3 and 6 months after EMA initiation. Intention-to-treat analysis was used. The study included 459 participants (304 males [66.2%]) with a mean (SD) age of 36.7 (10.7) years. Biochemically validated tobacco abstinence rates were 8.2% in the intervention group and 3.5% in the control group (odds ratio [OR], 2.46; 95% CI, 1.06 to 5.75; P = .04) at 3-month follow-up. The corresponding rates at 6-month follow-up were 9.5% and 4.0% (OR, 2.56; 95% CI, 1.15-5.70; P = .02). The intervention group showed a greater increase in IBC-S scores from baseline to both 3-month (β = 1.03; 95% CI, 0.46-1.59; P < .001) and 6-month (β = 0.95; 95% CI, 0.37-1.53; P = .001) follow-ups. The findings of this randomized clinical trial suggest that telephone counseling and instant messaging support, guided by mHealth profiling, increased tobacco abstinence vs EMA alone. This intervention may be used to supplement conventional smoking cessation for individuals who use tobacco and are unwilling to use smoking cessation aids. ClinicalTrials.gov Identifier: NCT05212220.

This randomized controlled trial aimed to examine the effectiveness of a smoking cessation intervention using a risk communication approach. A total of 528 smoking cancer patients were randomly allocated either into an intervention group (n = 268) to receive brief advice based on risk communication by a nurse counselor or a control group (n = 260) to receive standard care. Subjects in both groups received a smoking cessation booklet. Patient follow-ups were at 1 week and at 1, 3, 6, 9 and 12 months. No significant differences were found in self-reported point-prevalence 7-day abstinence between the intervention and control groups at 6 months (15.7% vs 16.5%; OR 0.94, 95% CI 0.59–1.50). The rate of at least 50% self-reported reduction of smoking at 6 months, was higher in the intervention group than in the control group (16.8% vs 12.3%; OR 1.43, 95% CI 0.88–2.35). The biochemically validated quit rate at the 6-month follow-up was higher in the intervention group than in the control group (5.2% vs 3.8%; OR 1.38, 95% CI 0.60–3.16). These data suggest that advice based on risk communication was not effective for quitting but improved the rate of smoking reduction among smoking cancer patients.

Supplementing the Subinternship: Effect of E-Learning Modules on Subintern Knowledge and Confidence

Introduction People with mental health conditions (MHCs) are less likely to achieve long-term abstinence than people without MHCs. The Quit and Stay Quit Monday (QSQM) model offers a long-term approach to treating tobacco use by encouraging people to quit, requit, or recommit to quit smoking every Monday. Aim To evaluate the efficacy, patient satisfaction, and patient engagement with an intervention that integrated the QSQM model into multicomponent smoking cessation services among people with an MHC. Methods This was a randomized controlled pilot trial. Eligibility criteria were as follows: (1) ≥18 years old, (2) smoked a cigarette in the past 30 days, (3) diagnosis of an ICD-10 MHC, (4) interest in quitting smoking, (5) able to receive services in English, and (5) had an active email and a cell phone. The intervention group (n = 33) received QSQM-focused telephone coaching, a weekly QSQM email newsletter, a SmokefreeTXT anchored around a Monday quit date, and 4 weeks of nicotine replacement therapy (NRT). The control group (n = 36) received information about contacting their state Quitline for usual services. Primary outcomes were self-reported quit attempts, 7-day abstinence, and intervention satisfaction at 3 months. Results Twenty-four participants (73%) in the intervention group began telephone coaching, 26 (79%) enrolled in the QSQM email newsletter, 19 (58%) enrolled in SmokefreeTXT, and 15 (46%) used NRT. Using a penalized intent-to-treat approach, quit attempts in the intervention and control groups were 63.6% and 38.9% (OR 2.75, 95% CI 1.03-7.30), respectively. Seven-day abstinence in the two groups was 12.1% and 5.6% (OR 2.35, 95% CI 0.40-13.74), respectively. Of the 15 intervention group participants who set a quit date during the intervention, 13 (86.7%) selected a Monday quit day. Qualitative interviews revealed positive participant experiences with picking a Monday quit day. On follow-up surveys, 89.5%, 69.3%, and 64.3% of intervention participants reported that the counseling, QSQM email, and text messaging, respectively, were very or somewhat helpful. Conclusions The QSQM model was acceptable and potentially efficacious among people with MHCs, but intervention engagement and satisfaction were modest. Future research should adapt or develop new QSQM delivery approaches to improve patient engagement and potential efficacy of the model. This trial is registered with clinicaltrials.gov (NCT04512248).

BackgroundIntensive interventions on smoking cessation increase abstinence rates. However, few electronic mail (E-mail) based intensive interventions have been tested in smokers and none in primary care (PC) setting. The aim of the present study is to evaluate the effectiveness of an intensive E-mail based intervention in smokers attending PC services.Methods/designRandomized Controlled Multicentric Trial. Study population: 1060 smokers aged between 18–70 years from Catalonia, Salamanca and Aragón (Spain) who have and check regularly an E-mail account. Patients will be randomly assigned to control or intervention group. Intervention: Six phase intensive intervention with two face to face interviews and four automatically created and personal E-mail patients tracking, if needed other E-mail contacts will be made. Control group will receive a brief advice on smoking cessation. Outcome measures: Will be measured at 6 and 12 months after intervention: self reported continuous abstinence (confirmed by cooximetry), point prevalence abstinence, tobacco consumption, evolution of stage according to Prochaska and DiClemente's Stages of Change Model, length of visit, costs for the patient to access Primary Care Center. Statistical analysis: Descriptive and logistic and Poisson regression analysis under the intention to treat basis using SPSS v.17.DiscussionThe proposed intervention is an E-mail based intensive intervention in smokers attending primary care. Positive results could be useful to demonstrate a higher percentage of short and long-term abstinence among smokers attended in PC in Spain who regularly use E-mail. Furthermore, this intervention could be helpful in all health services to help smokers to quit.Trial RegistrationClinical Trials.gov Identifier: NCT01494246.

IntroductionTobacco smoking rates in high-income countries are greater in rural, regional, and remote (RRR) areas compared to cities. Yet, there is limited knowledge about interventions targeted to RRR smokers. This review describes the effectiveness of smoking cessation interventions for RRR smokers in supporting smoking abstinence.Aims and MethodsSeven academic databases were searched (inception-June 2022) for smoking cessation intervention studies to include if they reported on RRR residents of Australia, Canada, or the United States, and short- (<6 months) or long-term (≥6 months) smoking abstinence outcomes. Two researchers assessed study quality, and narratively summarized findings.ResultsIncluded studies (n = 26) were primarily randomized control (12) or pre-post (7) designs, from the United States (16) or Australia (8). Five systems change interventions were included. Interventions included cessation education or brief advice, and few included nicotine monotherapies, cessation counseling, motivational interviewing, or cognitive behavioral therapy. Interventions had limited short-term effects on RRR smoking abstinence, decreasing markedly beyond 6 months. Short-term abstinence was best supported by contingency, incentive, and online cessation interventions, and long-term abstinence by pharmacotherapy.ConclusionsCessation interventions for RRR smokers should include pharmacotherapy and psychological cessation counseling to establish short-term abstinence, and identify effective means of maintaining abstinence beyond 6 months. Contingency designs are a suitable vehicle for psychological and pharmacotherapy support for RRR people who smoke, and intervention tailoring should be explicitly considered.ImplicationsSmoking disproportionately harms RRR residents, who can encounter access barriers to smoking cessation support. High-quality intervention evidence and outcome standardization are still required to support long-term RRR smoking abstinence.