Smoking Relapse Prevention Intervention Research Articles

Presenting and Evaluating a Smartwatch-Based Intervention for Smoking Relapse (StopWatch): Feasibility and Acceptability Study.

Despite the benefits of smoking cessation, maintaining abstinence during a quit attempt is difficult, and most attempts result in relapse. Innovative, evidence-based methods of preventing relapse are needed. We present a smartwatch-based relapse prevention system that uses passive detection of smoking to trigger just-in-time smoking cessation support. This study aims to evaluate the feasibility of hosting just-in-time smoking cessation support on a smartwatch and the acceptability of the "StopWatch" intervention on this platform. The person-based approach for intervention development was used to design the StopWatch smoking relapse prevention intervention. Intervention delivery was triggered by an algorithm identifying hand movements characteristic of smoking from the smartwatch's motion sensors, and the system-generated intervention messages (co-designed by smokers) were delivered on the smartwatch screen. A total of 18 smokers tested the intervention over a 2-week period, and at the end of this period, they provided qualitative feedback on the acceptability of both the intervention and the smartwatch platform. Participants reported that the smartwatch intervention increased their awareness of smoking and motivated them to quit. System-generated intervention messages were generally felt to be relevant and timely. There were some challenges with battery life that had implications for intervention adherence, and the bulkiness of the device and the notification style reduced some participants' acceptability of the smartwatch platform. Our findings indicate our smoking relapse prevention intervention and the use of a smartwatch as a platform to host a just-in-time behavior change intervention are both feasible and acceptable to most (12/18, 66%) participants as a relapse prevention intervention, but we identify some concerns around the physical limitations of the smartwatch device. In particular, the bulkiness of the device and the battery capacity present risks to adherence to the intervention and the potential for missed detections. We recommend that a longer-term efficacy trial be carried out as the next step.

Personal Network Changes among Smoking Relapse Prevention Intervention Participants

Objectives: Tobacco use remains a leading cause of preventable death in the United States, and relapse rates among those who quit smoking are alarmingly high. Personal networks (PNs) substantially influence smoking and quitting behaviors but have not been incorporated into relapse prevention approaches. Thus, we carried out a pilot study employing PNs in relapse prevention and measured changes in participants′ PNs. Methods: This pilot study was a single-group pre-post intervention where participants received Helpers Stay Quit (HSQ), a behavioral relapse prevention intervention we designed to instruct persons who recently quit smoking to deliver a “helping conversation” (HC) to encourage others to quit smoking. Results: The majority of the 64 participants abstained from smoking (86%) and had HCs (89%). Those who abstained from smoking throughout the study significantly increased the number of non-family members and individuals who smoke in their networks at follow-up, which increased their opportunities for carrying out a HC. HC recruits reported cessation-related behavior changes after receiving an HC. Conclusions: This is promising evidence of the potential of HSQ to facilitate cessation in the network of those who recently quit smoking, which may benefit their ability to stay quit.

Women's Perspectives on Smoking During Pregnancy and Factors Influencing Their Willingness to Quit Smoking in Pregnancy: A Study From the United Kingdom.

Objective This was a prospective questionnaire-based survey conducted in the Barnsley District of the United Kingdom amongantenatal women smoking during pregnancy. The aim of the study was to assess the awareness of women regarding the risks with smoking during pregnancy, study their smoking behavior, their willingness to quit smoking during pregnancy, and the factors that could influence their intention to quit smoking. Methods A cohort of antenatal women smoking during pregnancy was surveyedprior to their contact with the maternity Stop Smoking Services. A well-structured, pre-tested, and validated questionnaire was usedto assess their awareness regarding risks with smoking during pregnancy and their willingness to quit smoking during pregnancy. Descriptive statistics were used to analyze the results. Binomial logistic regression (univariate and multivariate) was used to identify the factors influencing the women's willingness to quit smoking during pregnancy. Results Among 66 women surveyed, 52 (79%) were multigravida and 14 (21%) were primigravida, with a mean age of 27.4 ± 5.7 years. Most women (68%) were in the first trimester of their pregnancy. Nearly two-thirds of women (64%) had low educational attainment, 53% were unemployed, 68% lived with family members who smoked, and 35% had mental health problems. One-third (33%) of women had an unsuccessful attempt at quitting smoking in the past. Around 44% of women had a low level of nicotine dependence, while 56% had a moderate level of nicotine dependence. More than three-fourths of women (77%) were aware that smoking during pregnancy is harmful for their baby, though most could not report the specific adverse effects. Nearly half of the women (51.5%) were willing to quit smoking during pregnancy with the rationality of having a healthy baby. On multivariate logistic regression analysis,awarenessof the women that smoking during pregnancy has ill effects on the baby (adjusted odds ratio (aOR): 46.459, confidence interval (CI): 5.356-402.961, p value <0.001) was found to be the strongest predictor of willingness to quit smoking during pregnancy. Other determinants found to be significantly associated with willingness to quit smoking during pregnancy were unsuccessful quit attempts in the past (aOR: 0.048, CI: 0.007-0.309, p value 0.001) and the absence of any mental health concerns (aOR: 6.097, CI: 1.105-33.647, p value 0.038). Conclusion There is considerable room for raising awareness about the risks of smoking during pregnancy and providing effective smoking cessation and relapse prevention interventions in pregnancy. Obstetricians and midwives should actively participate in providing risk-focused information to pregnant women on smoking during pregnancy and support them in smoking cessation. Various factors such as employment status, nicotine dependence, previous failed attempts at quitting smoking, mental health issues, and awareness levels significantly influence the willingness to quit smoking during pregnancy. Hence, there is an imperative need to identify and address the barriers that could affect a woman's intention to quit smoking during pregnancy.

Trajectories of Return to Cigarette Smoking Up to 1 Year Postpartum Among People Who Quit Smoking During Pregnancy.

Previous work has identified predictors of relapse to smoking postpartum among parenting people who quit during pregnancy, but less is known about the time course of postpartum relapse. The study goals were to document patterns and correlates of smoking resumption among people who quit smoking during pregnancy and were motivated to remain abstinent. We conducted a secondary analysis among participants in a randomized controlled trial of postpartum-specific smoking relapse prevention interventions who self-reported no smoking since the quit date to delivery (n = 280). Participants provided expired air samples of carbon monoxide, and completed self-report measures of mood, perceived stress, and demographic and pregnancy-related information. Timeline follow-back interviews were conducted at the end of pregnancy and 12-, 24-, and 52-weeks postpartum. The largest group (49.7% of participants) belonged to a trajectory reflecting abstinence across 1 year postpartum. Another 13% remained abstinent 5-6 months after delivery. However, one in five started to smoke consistently within 100 days after delivery, and 16% relapsed in a pattern that can be described as inconsistent smoking. Participants with more prior quit attempts and those who smoked more cigarettes prior to their quit attempt were more likely to relapse within 100 days of delivery. The first 3 months postpartum represent a critical window for relapse prevention, given that most individuals who relapsed did so in the first 100 days or so after delivery. Assessing prior smoking history can help identify pregnant people who will need additional support in the early postpartum period. Relapse to smoking during the year after childbirth is common, but the time course of relapse after delivery is poorly understood. This study provides evidence for 4 distinct trajectories of relapse, and highlights variables linked to early relapse that may improve efforts to target and time intervention efforts. Specifically, assessing age at initiation, quantity of tobacco use prior to quit attempt, and number of previous quit attempts will identify pregnant people at greatest risk of early relapse. These findings also suggest that additional support early in the postpartum period is crucial for most people in the postpartum who will relapse.

Preventing smoking relapse in patients with cancer: A randomized controlled trial

Abstaining from smoking after a cancer diagnosis is critical to mitigating the risk of multiple adverse health outcomes. Although many patients with cancer attempt to quit smoking, the majority relapse. The current randomized controlled trial evaluated the efficacy of adapting an evidence-based smoking relapse prevention (SRP) intervention for patients with cancer. The trial enrolled 412 patients newly diagnosed with cancer who had recently quit smoking. Participants were randomized to usual care (UC) or SRP. Participants in the UC group received the institution's standard of care for treating tobacco use. Participants in the SRP group in addition received a targeted educational DVD plus a validated self-help intervention for preventing smoking relapse. The primary outcome was smoking abstinence at 2 months, 6 months, and 12 months. Abstinence rates for participants in the SRP and UC groups were 75% versus 71% at 2 months and 69% versus 64% at 6 months (Ps>.20). At 12 months, abstinence rates among survivors were 68% for those in the SRP group and 63% for those in the UC group (P=.38). Post hoc analyses revealed that across 2 months and 6 months, patients who were married/partnered were more likely to be abstinent after SRP than UC (P=.03). A smoking relapse prevention intervention did not reduce relapse rates overall, but did appear to have benefited those participants who had the social support of a partner. Future work is needed to extend this effect to the larger population of patients.

Depressive Symptoms Assessed Near the End of Pregnancy Predict Differential Response to Postpartum Smoking Relapse Prevention Intervention.

Depressive symptoms are prevalent during pregnancy and the postpartum period and affect risk for smoking relapse. Whether and how depression affects response to postpartum interventions designed to sustain smoking abstinence is unknown. We examined end-of-pregnancy depressive symptoms as a moderator of response to two postpartum-adapted smoking relapse prevention interventions. Women (N = 300) who quit smoking during pregnancy were randomized to receive either a postpartum intervention focused on psychosocial factors linked to postpartum smoking (Strategies to Avoid Returning to Smoking [STARTS]) or an attention-controlled comparison intervention (SUPPORT). Women completed the Edinburgh Postnatal Depression Scale at the end of pregnancy. Smoking status was biochemically assessed at the end of pregnancy and at 12, 24, and 52 weeks postpartum. End-of-pregnancy depressive symptoms moderated response to postpartum smoking relapse prevention interventions (χ2 = 10.18, p = .001). After controlling for variables previously linked to postpartum smoking relapse, women with clinically significant end-of-pregnancy depressive symptoms (20%) were more likely to sustain abstinence through 52 weeks postpartum if they received STARTS. In contrast, women with few end-of-pregnancy depressive symptoms were more likely to sustain abstinence through 52 weeks postpartum if they received SUPPORT. Changes in the psychosocial factors addressed in the STARTS intervention did not mediate this moderation effect. Assessment of end-of-pregnancy depressive symptoms may help determine success following postpartum smoking relapse prevention interventions. Women with elevated end-of-pregnancy depressive symptoms benefited from postpartum relapse prevention intervention tailored to their psychosocial needs, while those with few symptoms were more successful in postpartum intervention that used standard behavioral components. NCT00757068.

Do Psychiatric Disorders or Measures of Distress Moderate Response to Postpartum Relapse Prevention Interventions?

Most women who quit smoking during pregnancy will relapse postpartum. Interventions for sustained postpartum abstinence can benefit from understanding prenatal characteristics associated with treatment response. Given that individuals with psychiatric disorders or elevated depressive symptoms have difficulty quitting smoking and that increases in depressive symptoms prenatally are common, we examined the relevance of psychiatric diagnoses, prenatal depressive symptoms, and stress to postpartum relapse prevention intervention response. Pregnant women (N = 300) who quit smoking during pregnancy received intervention (with specialized focus on mood, weight, and stress [STARTS] or a comparison [SUPPORT]) to prevent postpartum relapse. As previously published, nearly one-third and one-quarter of women achieved biochemically-confirmed sustained abstinence at 24- and 52-weeks postpartum, with no difference in abstinence rates between the interventions. Women completed psychiatric interviews and questionnaires during pregnancy. Smoking was assessed in pregnancy, and 24- and 52-weeks postpartum. Psychiatric disorders did not predict sustained abstinence or treatment response. However, treatment response was moderated by end-of-pregnancy depressive symptoms (χ2 = 9.98, p = .002) and stress (χ2 = 6.90, p = .01) at 24- and 52-weeks postpartum and remained significant after including covariates. Women with low distress achieved higher abstinence rates in SUPPORT than in STARTS (37% vs. 19% for depressive symptoms; 36% vs. 19% for stress), with no difference for women with high symptoms. Prenatal depressive symptoms and stress predicted differential treatment efficacy in women with low symptoms, not in women with high symptoms. Diagnostic history did not predict treatment differences. Future research to address prenatal distress may help tailor postpartum relapse prevention interventions. We examined prenatal history of psychiatric disorders and psychiatric distress as moderators of response to postpartum smoking relapse prevention intervention that either included or did not include added content on mood, stress, and weight concerns. For women with lower psychiatric distress, the added focus is not necessary, as these women achieved greater sustained abstinence in the less-intensive treatment. Understanding which women need which level of care to sustain abstinence can help allocate resources for all postpartum former smokers. These findings underscore the importance of perinatal symptom monitoring and promoting behavioral health more broadly in pregnant and postpartum women.

Self-help materials for smoking relapse prevention: a process evaluation of the SHARPISH randomized controlled trial

UK Stop Smoking Services are effective at assisting smokers to quit. However, smoking relapse rates are high, representing a significant public health problem. No effective interventions are currently available. This embedded qualitative process evaluation, within a randomized controlled trial of a self-help smoking relapse prevention intervention, aimed to understand patient perspectives in explaining the null trial finding, and to make recommendations for intervention development. The intervention was a British version of the 'Forever Free' self-help booklets (SHARPISH-ISRCTN 36980856). The qualitative evaluation purposefully sampled 43 interview participants, triangulated with the views of 10 participants and 12 health professionals in focus groups. Data were thematically analysed. Analysis revealed important variation in individual engagement with the self-help booklets. Variation was interpreted by the meta-themes of 'motivation for cessation', and 'positioning on information provision', interacting with the theme of 'mechanisms for information provision'. Targeting self-help information towards those most motivated to engage may be beneficial, considering the social and cultural realities of individual's lives. Individual preferences for the mechanisms of information delivery should be appraised when designing future interventions. Long-term personalized follow-up may be a simple step in improving smoking relapse rates.

Development of a Targeted Smoking Relapse-Prevention Intervention for Cancer Patients.

We describe the series of iterative steps used to develop a smoking relapse-prevention intervention customized to the needs of cancer patients. Informed by relevant literature and a series of preliminary studies, an educational tool (DVD) was developed to target the unique smoking relapse risk factors among cancer patients. Learner verification interviews were conducted with 10 cancer patients who recently quit smoking to elicit feedback and inform the development of the DVD. The DVD was then refined using iterative processes and feedback from the learner verification interviews. Major changes focused on visual appeal, and the inclusion of additional testimonials and graphics to increase comprehension of key points and further emphasize the message that the patient is in control of their ability to maintain their smoking abstinence. Together, these steps resulted in the creation of a DVD titled Surviving Smokefree®, which represents the first smoking relapse-prevention intervention for cancer patients. If found effective, the Surviving Smokefree® DVD is an easily disseminable and low-cost portable intervention which can assist cancer patients in maintaining smoking abstinence.

Smoking relapse-prevention intervention for cancer patients: Study design and baseline data from the surviving SmokeFree randomized controlled trial

Continued smoking after a cancer diagnosis contributes to several negative health outcomes. Although many cancer patients attempt to quit smoking, high smoking relapse rates have been observed. This highlights the need for a targeted, evidence-based smoking-relapse prevention intervention. The design, method, and baseline characteristics of a randomized controlled trial assessing the efficacy of a self-help smoking-relapse prevention intervention are presented. Cancer patients who had recently quit smoking were randomized to one of two conditions. The Usual Care (UC) group received the institution's standard of care. The smoking relapse-prevention intervention (SRP) group received standard of care, plus 8 relapse-prevention booklets mailed over a 3month period, and a targeted educational DVD developed specifically for cancer patients. Four hundred and fourteen participants were enrolled and completed a baseline survey. Primary outcomes will be self-reported smoking status at 6 and 12-months after baseline. Biochemical verification of smoking status was completed for a subsample. If found to be efficacious, this low-cost intervention could be easily disseminated with significant potential for reducing the risk of negative cancer outcomes associated with continued smoking.

Preventing Postpartum Smoking Relapse: A Randomized Clinical Trial.

Most women who quit smoking during pregnancy will relapse postpartum. Previous efforts to prevent postpartum relapse have been unsuccessful at increasing rates of sustained abstinence. To evaluate the relative efficacy of 2 different approaches to prevent postpartum smoking relapse. Pregnant women who recently had quit smoking were recruited before the end of pregnancy. Intervention sessions were conducted through a combination of telephone calls and in-person visits beginning at delivery and continuing through 24 weeks postpartum. Participants completed assessments at the prenatal baseline and at 12, 24, and 52 weeks postpartum. Participants were recruited between March 2008 and December 2012. The dates of the analysis were April 2014 to February 2015. Women received postpartum-adapted, behavioral smoking relapse prevention intervention and were randomly assigned to an enhanced cognitive behavioral intervention that included additional specialized strategies and content focused on women's postpartum concerns about mood, stress, and weight (Strategies to Avoid Returning to Smoking [STARTS]) or a supportive, time and attention-controlled comparison (SUPPORT). Intervention began before delivery and continued through 24 weeks postpartum. The primary outcome was biochemically confirmed sustained tobacco abstinence at 52 weeks postpartum. Secondary outcomes were self-reported mood, levels of perceived stress, and degree of concern about smoking-related weight gain. The study cohort comprised 300 participants (150 randomly assigned to each group). Their mean (SD) age was 24.99 (5.65) years. Overall, 38.0% (114 of 300), 33.7% (101 of 300), and 24.0% (72 of 300) of the sample maintained abstinence at 12, 24, and 52 weeks' postpartum, respectively. There were no differences between the intervention groups in abstinence or time to relapse. Self-reported depressive symptoms and perceived stress significantly improved over time, and improvements were similar for both intervention groups. Women with more depressive symptoms and higher levels of perceived stress were more likely to relapse (hazard ratio, 1.02; 95% CI, 1.00-1.04; P = .04 for depressive symptoms and hazard ratio, 1.04; 95% CI, 1.01-1.07; P = .003 for stress). An intervention designed to address women's concerns about mood, stress, and weight did not differentially improve rates of sustained tobacco abstinence postpartum compared with a time and attention-controlled comparison. Women in STARTS and SUPPORT reported postpartum improvements in mood and stress, and the experience of fewer depressive symptoms and less perceived stress was related to sustained abstinence. Given that most pregnant quitters will relapse within 1 year postpartum and that postpartum smoking has negative health consequences for women and children, effective interventions that target postpartum mood and stress are needed. clinicaltrials.gov Identifier: NCT00757068.

A content analysis of attributions for resuming smoking or maintaining abstinence in the post-partum period.

A significant proportion of women who self-quit smoking during pregnancy subsequently relapse to smoking post-partum. This study examined free-text responses describing attributions of smoking relapse or maintained abstinence at 1, 8, and 12 months post-partum. This study reports secondary analyses from a randomized clinical trial (N = 504) for preventing post-partum smoking relapse. At each follow-up, one survey item asked the participant to describe why she resumed smoking or what helped her maintain abstinence. A thematic content analysis was conducted on responses from the 472 participants (94.0 % of the original sample) who returned at least 1 survey. Content analyses revealed several themes for participants' reasons for relapse and abstinence. Stress was the most frequently cited reason for smoking relapse across all follow-ups. Health concerns for children and family was the most common reason provided for remaining abstinent. Chi square analyses revealed differences in written responses related to income, age, and depressive symptoms. Overall, these findings suggest that during the post-partum period, stress and familial health concerns are perceived contributors to smoking relapse and abstinence, respectively. These results confirmed key risk and protective factors that have been identified through other assessment modalities (e.g., quantitative surveys and focus groups). They also provide support for targeting these variables in the development, content, and delivery of future post-partum smoking relapse-prevention interventions. The high response rate to these open-ended attribution questions suggests that future studies would benefit from including these and similar items to allow for additional insight into participant perspectives.

Prepartum and Postpartum Predictors of Smoking

Reduction of smoking during pregnancy and in the postpartum period remains a public health priority. This study tested whether variables (demographic, pregnancy related, emotional, and smoking related) assessed in abstinent women during their pregnancy predicted resumed smoking at 1 month and 1 year postpartum. Additionally, pregnancy-related and smoking-related variables obtained in the immediate postpartum period were examined as predictors of smoking at 1 year postpartum. Participants were pregnant women in their second and third trimester (N = 504) who enrolled in a randomized controlled trial of a smoking relapse-prevention intervention. Multivariate regression analyses were conducted with baseline data collected during pregnancy and follow-up assessments completed at 1 month and 12 months postpartum. Independent predictors of smoking at 1 month postpartum included not intending to remain abstinent, lower quitting confidence, the presence of other household smokers, and not planning to breast feed. Smoking at 12 months postpartum was predicted by only not intending to remain abstinent and having a partner who maintained his or her smoking rate. In contrast, when assessed at 1 month postpartum, smoking at 12 months was predicted by current smoking status and lower quitting confidence. Baseline variables measured during pregnancy differentially predicted early versus late smoking status. After delivery, the best predictor of later smoking status was current smoking status, reinforcing the need to focus on preventing early postpartum relapse. The importance of quitting confidence, or self-efficacy, was also reinforced. Findings may be useful for screening women at risk of relapse and targeting interventions to key variables.

Strategies to Avoid Returning to Smoking (STARTS): A randomized controlled trial of postpartum smoking relapse prevention interventions

The majority of women who quit smoking during pregnancy relapse postpartum and many experience increased depressive symptoms and concerns about body shape and weight. Given the relationship of weight concerns and negative mood to smoking relapse, interventions designed to address the postpartum experience are indicated. However, there are several challenges to research with postpartum women. We describe the rationale of a randomized controlled trial of postpartum smoking relapse prevention intervention and discuss methods to address the specific challenges to recruiting, retaining and conducting health behavior interventions among postpartum former smokers. Pregnant women who had quit smoking for at least one month prior to the 34week of pregnancy and who were motivated to stay quit postpartum were recruited. Women were randomized either to a postpartum specific intervention designed to address concerns about mood, stress and weight using cognitive-behavioral techniques or to a support-only condition designed to control for time and attention. Intervention continues through six months postpartum and women complete follow-up assessments at 12-, 24- and 52-weeks after delivery. Women (n=300) who had quit smoking as a result of pregnancy were recruited and are being followed. The intervention described in this report is designed to address stress, negative mood and concerns about weight that mediate smoking relapse postpartum to sustain abstinence and improve maternal and infant health.

Predictors of smoking relapse in patients with thoracic cancer or head and neck cancer

Cancer patients who continue smoking are at increased risk for adverse outcomes including reduced treatment efficacy and poorer survival rates. Many patients spontaneously quit smoking after diagnosis; however, relapse is understudied. The goal of this study was to evaluate smoking-related, affective, cognitive, and physical variables as predictors of smoking after surgical treatment among patients with lung cancer and head and neck cancer. A longitudinal study was conducted with 154 patients (57% male) who recently quit smoking. Predictor variables were measured at baseline (ie, time of surgery); smoking behavior was assessed at 2, 4, 6, and 12 months after surgery. Analyses of 7-day point prevalence were performed using a Generalized Estimating Equations approach. Relapse rates varied significantly depending on presurgery smoking status. At 12 months after surgery, 60% of patients who smoked during the week prior to surgery had resumed smoking versus only 13% who were abstinent prior to surgery. Smoking rates among both groups were relatively stable across the 4 follow-ups. For patients smoking before surgery (N = 101), predictors of smoking relapse included lower quitting self-efficacy, higher depression proneness, and greater fears about cancer recurrence. For patients abstinent before surgery (N = 53), higher perceived difficulty quitting and lower cancer-related risk perceptions predicted smoking relapse. Efforts to encourage early cessation at diagnosis, and increased smoking relapse-prevention efforts in the acute period following surgery, may promote long-term abstinence. Several modifiable variables are identified to target in future smoking relapse-prevention interventions for cancer patients.

Pathways linking socioeconomic status and postpartum smoking relapse.

Low socioeconomic status (SES) exacerbates the high rate of smoking relapse in women following childbirth. This study examined multiple models of potential mechanisms linking SES and postpartum smoking relapse among women who quit smoking due to pregnancy. Participants were 251 women enrolled in a randomized clinical trial of a new postpartum smoking relapse prevention intervention. Four models of the prepartum mechanisms linking SES and postpartum smoking relapse were evaluated using a latent variable modeling approach. Each of the hypothesized models were a good fit for the data. As hypothesized, SES indirectly influenced postpartum smoking relapse through increased prepartum negative affect/stress, reduced sense of agency, and increased craving for cigarettes. However, the model that included craving as the sole final pathway between SES and relapse demonstrated superior fit when compared with all other models. Findings have implications for future interventions that aim to reduce postpartum relapse.

Nicotine vaccines for smoking cessation.

By reducing the amount of nicotine that reaches the brain when a person smokes a cigarette, nicotine vaccines may help people to stop smoking or to prevent recent quitters from relapsing. The aims of this review are to assess the efficacy of nicotine vaccines for smoking cessation and for relapse prevention, and to assess the frequency and type of adverse events associated with the use of nicotine vaccines. We searched the Cochrane Tobacco Addiction Review Group specialised register for trials, using the term 'vaccine' in the title or abstract, or in a keyword (date of most recent search April 2012). To identify any other material including reviews and papers potentially relevant to the background or discussion sections, we also searched MEDLINE, EMBASE, and PsycINFO, combining terms for nicotine vaccines with terms for smoking and tobacco use, without design limits or limits for human subjects. We searched the Annual Meeting abstracts of the Society for Research on Nicotine and Tobacco up to 2012, using the search string 'vaccin'. We searched Google Scholar for 'nicotine vaccine'. We also searched company websites and Google for information related to specific vaccines. We searched clinicaltrials.gov in March 2012 for 'nicotine vaccine' and for the trade names of known vaccine candidates. We included randomized controlled trials of nicotine vaccines, at Phase II and Phase III trial stage and beyond, in adult smokers or recent ex-smokers. We included studies of nicotine vaccines used as part of smoking cessation or relapse prevention interventions. We extracted data on the type of participants, the dose and duration of treatment, the outcome measures, the randomization procedure, concealment of allocation, blinding of participants and personnel, reporting of outcomes, and completeness of follow-up.Our primary outcome measure was a minimum of six months abstinence from smoking. We used the most rigorous definition of abstinence, and preferred cessation rates at 12 months and biochemically validated rates where available. We have used the risk ratio (RR) to summarize individual trial outcomes. We have not pooled the current group of included studies as they cover different vaccines and variable regimens. There are no nicotine vaccines currently licensed for public use, but there are a number in development. We found four trials which met our inclusion criteria, three comparing NicVAX to placebo and one comparing NIC002 (formerly NicQbeta) to placebo. All were smoking cessation trials conducted by pharmaceutical companies as part of the drug development process, and all trials were judged to be at high or unclear risk of bias in at least one domain. Overall, 2642 smokers participated in the included studies in this review. None of the four included studies detected a statistically significant difference in long-term cessation between participants receiving vaccine and those receiving placebo. The RR for 12 month cessation in active and placebo groups was 1.35 (95% Confidence Interval (CI) 0.82 to 2.22) inthe trial of NIC002and 1.74 (95% CI 0.73 to 4.18) in one NicVAX trial. Two Phase III NicVAX trials, for which full results were not available, reported similar quit rates of approximately 11% in both groups. In the two studies with full results available, post hoc analyses detected higher cessation rates in participants with higher levels of nicotine antibodies, but these findings are not readily generalisable. The two studies with full resultsshowed nicotine vaccines to be well tolerated, with the majority of adverse events classified as mild or moderate. In the study of NIC002, participants receiving the vaccine were more likely to report mild to moderate adverse events, most commonly flu-like symptoms, whereas in the study of NicVAX there was no significant difference between the two arms. Information on adverse events was not available for the large Phase III trials of NicVAX.Vaccine candidates are likely to undergo significant changes before becoming available to the general public, and those included in this review may not be the first to reach market; this limits the external validity of the results reported in this review in terms of both effectiveness and tolerability. There is currently no evidence that nicotine vaccines enhance long-term smoking cessation. Rates of serious adverse events recorded in the two trials with full data available were low, and the majority of adverse events reported were at mild to moderate levels. The evidence available suggests nicotine vaccines do not induce compensatory smoking or affect withdrawal symptoms. No nicotine vaccines are currently licensed for use in any country but a number are under development.Further trials of nicotine vaccines are needed, comparing vaccines with placebo for smoking cessation. Further trials are also needed to explore the potential of nicotine vaccines to prevent relapse. Results from past, current and future research should be reported in full. Adverse events and serious adverse events should continue to be carefully monitored and thoroughly reported.

Cultural Acceptability of a Smoking Relapse Prevention Intervention for Pregnant Women in Puerto Rico: Providers' Feedback.

Hispanic women are more likely than non-Hispanic women to quit smoking during pregnancy, indicating that relapse-prevention interventions may benefit this population. We conducted qualitative interviews with health care providers in Puerto Rico who serve pregnant women regarding the cultural acceptability of Libres Para Siempre Por Mi Bebé y Por Mi (transcreated from the English version, Forever Free for Baby and Me), a smoking relapse-prevention booklet series. Providers praised the overall quality of the content, interactive activities, vignettes, and partner booklet. Recommendations included condensing the content, and distributing the booklets during one-on-one counseling and via "charlas"(community themed presentations). Overall, these smoking relapse-prevention materials are culturally acceptable among health care providers, yet there is a need to attend to local cultural preferences for delivering the intervention.

Effect of Postpartum Lifestyle Interventions on Weight Loss, Smoking Cessation, and Prevention of Smoking Relapse: A Systematic Review

Postpartum lifestyle interventions are recommended for women after pregnancies complicated by preeclampsia, intrauterine growth restriction, and/or gestational diabetes, since they are at increased cardiovascular risk. To identify potential intervention strategies to reduce this risk, a systematic review of the literature is presented on the effectiveness of postpartum lifestyle interventions aimed at weight loss, smoking cessation, and smoking relapse prevention. The main characteristics of these postpartum lifestyle interventions are briefly described. The PubMed, Embase, Web of Science, PsychInfo, and Cinahl databases were searched for studies on the effects of postpartum lifestyle interventions on weight loss, and smoking cessation or prevention of smoking relapse, initiated for up to 1 year postpartum. No studies on the effectiveness of postpartum lifestyle interventions after the aforementioned specific pregnancy complications were found. However, 21 studies are included that describe existing postpartum lifestyle interventions, which were applied to unselected (on the basis of pregnancy complications) postpartum women. Six of 8 weight loss interventions, 4 of 5 smoking cessation interventions, and 4 of 8 smoking relapse prevention interventions were effective. Individually tailored counseling, group counseling sessions, and use of diaries or other correspondence materials were shown to be effective. Currently, postpartum lifestyle interventions tailored specifically for women who experienced the pregnancy complications are lacking. While awaiting their development, it seems reasonable to utilize existing lifestyle interventions shown to be effective in unselected postpartum women. After completion of this educational activity, the obstetrician/gynecologist should be better able to: counsel patients on how to apply existing postpartum lifestyle intervention strategies aimed at weight loss, smoking cessation, and smoking relapse prevention to lower future cardiovascular risk; and educate postpartum women who have experienced preeclampsia, intra-uterine growth restriction, and/or gestational diabetes about their increased cardiovascular risk later in life. Obstetricians & Gynecologists, Family Physicians.

Preventing Relapse Following Smoking Cessation.

Cigarette smoking is the leading cause of preventable deaths worldwide. Long-term smoking cessation can drastically reduce people's risk for developing smoking-related disease. The research literature points to a need for clearer operationalization and differentiation between smoking cessation and relapse prevention interventions and outcomes. That said, extensive meta-analyses and research studies have indicated that there are various efficacious smoking interventions that can both support smoking cessation and relapse prevention efforts. Specifically, behavioral treatments, relapse prevention psychotherapy, pharmacologic interventions, motivational enhancement, smoking reduction to quit, brief advice, alternative intervention modes (telephone, Internet, computer), self-help, and tailored treatments can help prepare smokers for longer-term abstinence. Although these methods vary on reach, they are relatively efficacious, particularly in combined formats.