Effective Tobacco Dependence Treatment Research Articles

Learning to assist smokers through encounters with standardized patients: An innovative training for physicians in an Eastern European country.

A lack of physician training is a major obstacle for effective tobacco dependence treatment. This study assessed the feasibility of an active learning training program and its effects on smoking cessation counselling skills of medical residents in Armenia, an Eastern European country with high smoking prevalence. The study used a pre-post assessment of smoking cessation counselling activities and a course evaluation survey to assess the feasibility of the intervention in a different environment. We adapted an active learning training model developed in Switzerland. Residents were trained in Yerevan, Armenia, using video-taped counselling sessions, role plays, standardized patients (actors), group discussions and immediate feedback. The training evaluation was done using a semi-structured anonymous questionnaire. The study assessed the physicians' self-reported smoking cessation counselling activities before and 6 months after the training. A non-parametric Mann-Whitney test was used to assess pre-post differences in physicians' counselling skills measured on ordinal scale. Of the 37 residents trained, 75% were female, 89% aged 20-29 years and 83% were never-smokers. Twenty-eight trainees (76%) returned the course evaluation survey and 32 (86%) answered a questionnaire on skills self-assessment at 6 months follow-up. The majority agreed the course was successful in achieving its learning objectives (64%-96%) and increased their confidence in assisting their patients to quit (74%). After 6 months, the physicians were more likely than at baseline to adhere to evidence-based counselling strategies, including assessing the smoking status and dependence and matching the advice to the patient motivation. The training did not, however, improve the prescription of tobacco dependence medications. Six months after the training, several self-reported smoking cessation counselling activities had significantly improved compared to baseline. This training model is acceptable for medical residents in Yerevan, Armenia and offers a promising approach in addressing the lack of physician counselling skills in similar settings and populations.

Evaluation of a Train-the-Trainer Program to Build Capacity for Training Tobacco Treatment Specialists.

Tobacco-treatment specialists (TTSs) and high-quality TTS training programs are needed to improve access to evidence-based tobacco-dependence treatment. To meet this demand, the University of Massachusetts (UMass) Medical School developed the Train-the-Trainer in Tobacco Treatment (T4) program to build a cadre of trainers to deliver the accredited UMass TTS training programs. This paper reports on the feasibility and quality of TTS trainings led by Certified UMass TTS Trainers (Trainer-led) compared with trainings led by UMass staff (On-site). Data were collected between September 2014 and June 2017. Feasibility included the number of Trainers, Trainer-led programs, and participants. Quality compared participant exam results and evaluations of the two training program types. Fifty-three Trainers were certified during 2014-2017, and conducted 26 TTS trainings with 351 participants. There were no significant differences in participant mean exam scores [On-site = 86.33 (SD = 7.83); Trainer-led = 86.15 (SD = 8.47)], and a similar percentage of participants obtained a passing score on the exam (On-site 94.4%, Trainer-led 94.0%). There were no significant differences in increased self-efficacy in delivering effective tobacco-treatment services [On-site = 2.92, Trainer-led = 2.93; p = .52 (3-point Likert scale, 1 = not at all, 3 = a great deal)] or in overall satisfaction with the training [On-site = 3.84; Trainer-led = 3.81; p = .072 (4-point Likert scale, 1 = very dissatisfied, 4 = very satisfied)]. The Trainer-led model expanded the number of UMass-trained TTSs with equivalent participant knowledge and perceived improvement in ability to deliver effective tobacco-dependence treatment compared with the gold-standard training model. It offers a potentially more accessible option for training TTSs compared with the On-site model. Train-the-Trainer in Tobacco Treatment (T4) has increased the capacity to deliver high-quality training to healthcare providers who might not otherwise have access to an accredited TTS training program. Certified Trainers effectively identified potential participants and delivered training that was equivalent in quality to the standard UMass TTS Core Training program. There were no significant differences between the training models in two critical measures: (1) participant exam scores and (2) participants' rating of improvement in their ability to deliver effective tobacco-dependence treatment. Organizations can now choose from two equally effective models for delivering TTS training based on their unique needs and training populations.

An integrated digital/clinical approach to smoking cessation in lung cancer screening: study protocol for a randomized controlled trial

BackgroundDelivering effective tobacco dependence treatment that is feasible within lung cancer screening (LCS) programs is crucial for realizing the health benefits and cost savings of screening. Large-scale trials and systematic reviews have demonstrated that digital cessation interventions (i.e. web-based and text message) are effective, sustainable over the long-term, scalable, and cost-efficient. Use of digital technologies is commonplace among older adults, making this a feasible approach within LCS programs. Use of cessation treatment has been improved with models that proactively connect smokers to treatment rather than passive referrals. Proactive referral to cessation treatment has been advanced through healthcare systems changes such as modifying the electronic health record to automatically link smokers to treatment.MethodsThis study evaluates the impact of a proactive enrollment strategy that links LCS-eligible smokers with an evidence-based intervention comprised of a web-based (WEB) program and integrated text messaging (TXT) in a three-arm randomized trial with repeated measures at one, three, six, and 12 months post randomization. The primary outcome is biochemically confirmed abstinence at 12 months post randomization. We will randomize 1650 smokers who present for a clinical LCS to: (1) a usual care control condition (UC) which consists of Ask–Advise–Refer; (2) a digital (WEB + TXT) cessation intervention; or (3) a digital cessation intervention combined with tobacco treatment specialist (TTS) counseling (WEB + TXT + TTS).DiscussionThe scalability and sustainability of a digital intervention may represent the most cost-effective and feasible approach for LCS programs to proactively engage large numbers of smokers in effective cessation treatment. We will also evaluate the impact and cost-effectiveness of adding proven clinical intervention provided by a TTS. We expect that a combined digital/clinical intervention will yield higher quit rates than digital alone, but that it may not be as cost-effective or feasible for LCS programs to implement. This study is innovative in its use of interoperable, digital technologies to deliver a sustainable, scalable, high-impact cessation intervention and to facilitate its integration within clinical practice. It will add to the growing knowledge base about the overall effectiveness of digital interventions and their role in the healthcare delivery system.Trial registrationClinicalTrials.gov, NCT03084835. Registered on 9 March 2017.

Reframing tobacco dependency management in acute care: A case study

Effective tobacco dependence treatment within acute care tends to be inadequate. The purpose of the Utilizing best practices to Manage Acute care patients Tobacco Dependency (UMAT) was to implement and evaluate an evidence-based intervention to support healthcare staff to effectively manage nicotine withdrawal symptoms of acute surgical patients. Data collection for this one-year longitudinal case study included: relevant patient experiences and staff reported practice, medication usage, and chart review. Over the year each data source suggested changes in tobacco dependence treatment. Key changes in patient survey responses (N=55) included a decrease in daily smoking and cigarette cravings. Of patients who used nicotine replacement therapy, they reported an increase in symptom relief. Staff (N=45) were surveyed at baseline, mid-point and end of study. Reported rates of assessing smoking status did not change over the year, but assessment of withdrawal symptoms emerged as daily practice and questions about cessation diminished. Also delivery of nicotine replacement therapy products increased over the year. Chart reviews showed a shift in content from documenting smoking behavior to withdrawal symptoms and administration of nicotine replacements; also frequency of comments increased. In summary, the evidence-based intervention influenced unit norms and reframed the culture related to tobacco dependence treatment.

Evaluation of a Comprehensive Tobacco Dependence Treatment Program: Dental Students’ Perceptions of Preparedness and Clinical Practice

The aims of this study were to assess dental students' perceptions of their preparedness for providing treatment for tobacco dependence and to determine if their training resulted in successful practice in the dental school clinic. Since the tobacco dependence treatment program began at the University of Detroit Mercy School of Dentistry, all third- and fourth-year dental students have been required to complete an online survey about their attitudes and experience with tobacco dependence treatment. This descriptive study and retrospective analysis utilized these survey data from the initiation of the program in fall 2002 through 2010 (615 third-year and 590 fourth-year students, for a total of 1,205, all of whom participated in the surveys). The results showed that most of the students believed they were at least adequately prepared to provide treatment. The majority said they ask patients about tobacco use and advise patients about its negative health consequences, yet the average of their perception of patient interest in quitting was below 18%. Although the students reported being at least adequately prepared to assess patient interest in quitting, their assessment was much lower than the nearly 70% of U.S. tobacco users that general studies have found are interested in quitting. These students' perception of such low patient interest reflects a misconception they may have about their own preparedness, and it suggests a barrier exists for them in providing effective tobacco dependence treatment services. This perception signals a need for curriculum and assessment changes to increase the effectiveness of this school's tobacco dependence treatment program.

Tobacco dependence treatment teaching by medical school clerkship preceptors: Survey responses from more than 1000 US medical students

ObjectiveTo determine factors associated with tobacco cessation counseling in medical school clerkships. MethodsThird-year medical students at 10 medical schools across the United States completed a 100-item survey, measuring the frequency with which they experienced their preceptors providing clinical teaching components: clear instruction, feedback, modeling behavior, setting clear objectives, and responding to questions about tobacco dependence counseling as well as frequency of use of tobacco prompts and office systems. Our primary dependent measure was student self-reported skill level for items of tobacco dependence treatment (e.g. “5As”). ResultsSurveys were completed by 1213 students. For both family medicine and internal medicine clerkships, modeling and providing clear instruction on ways to provide tobacco counseling were reported most commonly. In contrast, providing feedback and clear objectives for tobacco dependence treatment lagged behind. Overall, students who reported preceptors' provision of optimal clinical teaching components and office system prompts in both family medicine and internal medicine clerkships had higher self-reported skill (P<0.001) than students with no exposure or exposure during only one of the clerkships. ConclusionsFuture educational interventions intended to help students adopt effective tobacco dependence treatment techniques should be engineered to facilitate these critical precepting components.

Barriers to Effective Tobacco-Dependence Treatment for the Very Poor

People who live in poverty have a high prevalence of smoking, are less likely to engage in evidence-based treatment, and find it harder to quit. Their beliefs about smoking and quitting can serve as barriers to quitting. Little is known about the smoking and quitting beliefs of the very poor (about U.S. $15,000 or less annual family income) because they tend not to be included in research. This study sought to assess beliefs about smoking and quitting by the very poor in relation to past quitting behavior and intention to quit in the future. A survey was administered in person to residents in randomly selected addresses in two very impoverished Milwaukee, WI, ZIP codes during the day to ensure the inclusion of the very poor. Six hundred fifty-four people completed the survey, a response rate of 78.3%. Sixty-eight percent reported annual household incomes of less than $15,000 compared with 30.8% in the community as a whole and 13.0% of households nationally. Self-reported smoking prevalence was 42.1%. Specific beliefs about smoking and quitting were related to past quit attempts and intentions to quit in the future. Both race and income predicted beliefs and quitting-related variables independently and jointly. Continued tobacco-control progress requires addressing specific populations with known high tobacco use. One of these populations is those with low income. Efforts to engage them in treatment will have to address specific beliefs about smoking and quitting.

Pharmacologic Agents for Tobacco Dependence Treatment: 2011 Update

Tobacco use remains the most important worldwide cause of preventable death due mainly to cancer, cardiovascular disease, and chronic lung disease. If the current tobacco pandemic continues for another 20years, the annual global tobacco-attributable mortality will exceed 8 million. In the US and many European countries, public health and tobacco control efforts combined with effective tobacco dependence treatment using combined behavioral treatment and pharmacotherapy have contributed significantly to steadily declining rates of tobacco use. Subsequent declines in cardiovascular disease and lung cancer death rates are directly attributable to these lower rates of tobacco use. Despite smoking bans, health warnings and effective pharmacotherapy, one in five Americans continue to smoke. Continued research in tobacco dependence treatment has resulted in newer and more effective pharmacotherapy. In this review, we provide a current update of pharmacologic agents for tobacco dependence treatment and a discussion of recent controversy regarding adverse effects of some these medications.

Smoking Following Renal Transplantation in Hungary and Its Possible Deleterious Effect on Renal Graft Function

Smoking is a known risk factor for kidney damage and also influences graft function following renal transplantation. Because smoking habits following kidney transplantation are not systematically evaluated, we analyzed them in a single center in Hungary. The survey was conducted among 402 randomly selected kidney graft recipients. We assessed smoking-related questions as well as clinical kidney disease and transplantation data. Posttransplantation renal function was analyzed based on serum creatinine values at 1 month and at 3 years after transplantation. In our study 25% (n = 102) of patients continued to smoke after transplantation. Smokers who received grafts displayed a significantly younger age compared with nonsmokers (40.1 ± 13.4 vs 47.1 ± 12.7 years; P < .001) independent of underlying kidney disease. Posttransplantation kidney function in smokers did not differ at 1 month after engraftment, but was significantly impaired at 3 years as assessed based on serum creatinine levels: 138.9 ± 42.4 versus 128.4 ± 48.5 μmol/L ( P < .05). Decrease of renal function correlated with smoking intensity defined in pack-years ( r 2 = 0.102; P < .05). Smoking is common following kidney transplantation in Hungary and might represent a risk factor for kidney damage following renal transplantation. Therefore, effective tobacco-dependence treatment is necessary in this patient population.

DO THE 10 UK SUICIDES AMONG THOSE TAKING THE SMOKING CESSATION DRUG VARENICLINE SUGGEST A CAUSAL LINK?

DO THE 10 UK SUICIDES AMONG THOSE TAKING THE SMOKING CESSATION DRUG VARENICLINE SUGGEST A CAUSAL LINK?

Advances in pharmacotherapy for tobacco dependence.

The discovery that bupropion is an effective treatment for tobacco dependence has triggered a rapid increase in development of potential new non-nicotine pharmacotherapies, including bromocriptine, glucose, GTS-21, reboxetine, rimonabant, selegeline and varenicline. Successful new products will need to have excellent side-effect profiles in addition to proven efficacy. New faster delivery nicotine replacement products have the promise of addressing a broader list of indications, including treatment of nicotine withdrawal during temporary abstinence and long-term nicotine maintenance. Nicotine vaccines will need to demonstrate efficacy and also improve certain consumer acceptability characteristics (e.g., frequency of injections required) before they can become widely used and successful therapies. The best hope of improved treatment comes from combining existing and new pharmacotherapies with effective behavioural therapy.

Effective Tobacco Dependence Treatment

MORE THAN AT ANY TIME IN the past, clinicians, public health professionals, and policy makers now possess sufficient evidence to implement effective tobacco dependence treatment programs and policies. We review key findings of great relevance to treating tobacco dependence: clinical, health system, and community interventions can each independently foster tobacco cessation. A transdisciplinary approach that incorporates all of these components holds the greatest promise for reducing population-based rates of tobacco use. If these interventions are implemented broadly, a larger proportion of the 46 million US adult smokers will try to quit. Among those who do try, the likelihood of successful cessation will increase substantially.

Combination nicotine replacement therapy for smoking cessation: rationale, efficacy and tolerability.

Currently available nicotine replacement therapy (NRT) medications provide effective treatment for tobacco dependence, typically doubling success rates compared with placebo. A strategy for further improving the efficacy of NRT is to combine one medication that allows for passive nicotine delivery (e.g. transdermal patch) with another medication that permits ad libitum nicotine delivery (e.g. gum, nasal spray, inhaler). The rationale for combining NRT medications is that smokers may need both a slow delivery system to achieve a constant concentration of nicotine to relieve cravings and tobacco withdrawal symptoms, as well as a faster acting preparation that can be administered on demand for immediate relief of breakthrough cravings and withdrawal symptoms. This article reviews 5 published studies that have examined the effectiveness of combination NRT compared with monotherapy in providing withdrawal relief and smoking cessation, and examines other factors relevant to the promotion of combination NRT for treating tobacco dependence. The data show that there are conditions under which combinations of NRT products provide greater efficacy in relieving withdrawal and enabling cessation than monotherapy, but the findings are not robust and additional research is warranted to better understand the magnitude and generality of the benefits of combination therapy. There are also regulatory and commercial obstacles that must be considered. Nonetheless, combination NRT has the potential to provide effective treatment of tobacco dependence in persons whose dependence is refractory to currently available treatments.

Nornicotine pretreatment decreases intravenous nicotine self-administration in rats.

Nicotine has been shown to be effective as a treatment for reducing tobacco dependence. However, few studies have examined the effect of other nicotinic agonists to determine if they can also decrease nicotine self-administration. The present study determined if nornicotine, a tobacco alkaloid and major nicotine metabolite in brain, could reduce nicotine self-administration in rats. Each rat was prepared with an indwelling jugular catheter and trained to self-administer intravenous nicotine (0.03 mg/kg per infusion). After nicotine self-administration stabilized, rats were pretreated with either (-)-nicotine (0, 0.1, 0.3, and 1.0 mg/kg free base) or (+/-)-nornicotine (0, 1, 3, 5.6, and 10.0 mg/kg free base) and assessed for nicotine self-administration. A separate group of rats was maintained on sucrose reinforced responding and pretreated with nornicotine to determine the specificity of the pretreatment effect. In another group of rats, the time course of the pretreatment effect of either (-)-nicotine (0.56 and 1.0 mg/kg) or (+/-)-nornicotine (5.6 and 10.0 mg/kg) was examined. Nicotine and nornicotine each produced a dose-dependent decrease in nicotine self-administration. Furthermore, the decrease in nicotine self-administration in response to the 5.6 mg/kg nornicotine pretreatment was specific to nicotine self-administration, as this dose did not decrease sucrose reinforced responding in tolerant animals. In addition, within the dose range tested, the suppressant effect of nornicotine had a two-fold longer duration than that of nicotine (120 versus 60 min). These results suggest that nornicotine may be an effective treatment for tobacco dependence.