Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation

Smoking cessation is still a heavily researched and talked about topic.  While quitting smoking may seem simple to a non-smoker, the reality is that trying to stop smoking can be a difficult and expensive choice.  This study looked at how financial incentives may increase sustained abstinence from smoking.

2,538 people enrolled in the study and were then assigned to either one of four incentive programs or the usual care for smoking cessation.  Of the the four incentive programs, two were targeted to individuals and two were targeted to groups of six.  These two groups then differentiated by being either a reward-based program or a deposit-based program (refundable deposit plus a reward).  The results of the study showed that while 90% of participants accepted the assignment when the program was reward-based, only 13.7% of participants accepted the assignment when the program was deposit-based.  After six months, rates of sustained abstinence were higher for every program (9.4% to 16.0%) than the basic care group (6.0%).  Additionally, the reward-based programs had higher abstinence rates than the deposit-based programs.

I found the results of this study surprising.  I understand that stopping smoking can be extremely difficult but I still expected the percentage of abstinence to be higher when the reward was $800 for six months of abstinence.  One of the programs had an extremely high denial rate.  It required people to deposit $150 dollars, which they would get back if they successfully completed the six months.  After seeing the results, I now understand why the amount was so low.  Incentive-programs like these do make a significant difference.  However, with the percentages being so low I find it hard to believe that anyone would fund the program without a financial incentive, which only comes from the deposit-based reward system that most smokers would not attempt.

Halpern SD, French B, Small DS, et al. Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation. N Engl J Med. 2015;372(22):2108-117.

http://www.nejm.org/doi/full/10.1056/NEJMoa1414293#t=articleMethods

Pain Intensity Related to Smoking Dependency

It has been proven through previous studies that there is a positive correlation between smoking dependency and pain. It is hard, however, to determine which comes first.  Is it that pain patients turn to smoking or the smoking creates higher levels of pain?  Previous studies identified the correlation between the two, but left out some important parameters we needed to get a closer look at this correlation.  A problem with previous studies is that they specifically looked at patients that were being seen for pain.   If a patient is seeking treatment for pain then it is probably on the more moderate to severe end of the pain scale.  This particular study that I looked into wanted to see how strong this correlation was when comparing smoking dependency in patients that had little to no pain against patients that had moderate to severe pain.

In this study, they wanted to look at how strong the correlation was between patient’s pain and their smoking habits. The best way to measure these two categories was with surveys.  Participants in this study were given multiple surveys to fill out to determine their pain level and smoking dependency.  These surveys include  the “Smoking History Questionnaire” (SHQ) to understand the patients smoking history, the “Fagerstrom Test for Nicotine Dependence” (FTND) that helps determine how depend a patient is to smoking, “The Short –Form Health Survey” which was used to determine the bodily pain in the patient, and the “Positive and Negative Affect Scale” (PANAS) which assessed a patients emotions.  The DSM-IV was also used during the assessment process.

The results of the study showed that there was an increase in smoking dependency in individuals that have a higher intensity of pain.  That being said, the study did have many limitations including diversity issues and relying heavily on self-reporting.  This study was a good step towards trying to figure out whether smoking dependency was associated with increased levels of pain.   This study is helpful because we can use this information to help patients that are trying to quit.  We can try to treat their pain so that we can reduce their dependency.  Further studies would help better understand this correlation and improve treatment of this disease.

http://Psychiatry Res. 2016 Mar 30;237:67-71. doi: 10.1016/j.psychres.2016.01.073. Epub 2016 Feb 3.

Motivating smokers with mental illness to quit found to be more effective than educational intervention

Significantly more individuals who smoke that have a mental illness made an attempt to quit after receiving a single 45-minute counseling session compared to those who received an interactive educational intervention. The researchers randomized 98 smokers with serious mental illness to receive either the counseling session or the interactive educational intervention. They found that a significantly greater portion of the patients who received motivational interviewing made an attempt to quit by the 1-month follow-up. The findings suggest that motivational interviewing may be the key to having people with mental illnesses quit smoking.

The researchers say that people who have mental illnesses are less likely to quit compared to those who don’t. Therefore, using motivational interviewing might be the most effective way to get these patients to quit smoking.

I think this article is interesting because it shows the effectiveness of motivational interviewing that we learned about in Community Health 2. Since people told us it is useful, it was cool to find a study that actually showed its effectiveness. Moreover, I think it is also interesting that researchers are trying to determine the best ways to motivate people to see which methods are most effective. My question for the class is: How do you think pharmacists can implement motivational interviewing into their practice?

Reference:

Marc L. Steinberg, Jill M. Williams, Naomi F. Stahl, Patricia Dooley Budsock, Nina A. Cooperman. An Adaptation of Motivational Interviewing Increases Quit Attempts in Smokers With Serious Mental IllnessNicotine & Tobacco Research, 2016; 18 (3): 243 DOI:10.1093/ntr/ntv043

Expanding Cessation Pharmacotherapy Via Videoconference Educational Outreach to Prescribers

According to studies that assessed current smoking rates among the population, it was found that people diagnosed with a mental illness are two to three times more likely to smoke than those who are not. For this reason, this study focused at providing these patients underutilized forms of smoking cessation pharmacotherapy to determine if a change could be made in this pattern. Researchers utilized two different forms of smoking cessation education methods in an attempt to determine the best way to deliver this information to patients. While the first method provided traditional group in-person cessation education sessions,  the second method aimed at determining if the use of videoconferencing technology would be an adequate alternative method for education. Members of the study analyzed the results by examining filled Medicaid pharmacotherapy claims along with the prescribers’ attitudes toward the different forms of education services. Although researchers hypothesized that in-person delivery of smoking cessation programs would be more effective than videoconferencing, they found that there were no significant differences between the two groups of patients receiving this service. They did note that patients receiving either form of this service were more likely to follow through with actions to quit smoking than those who did not.

I believe studies like these are important for future pharmacists to be aware of because it is our goal to make sure that patients are utilizing treatment options in an appropriate matter to ensure that they will receive the best health benefit. Since we are often the easiest person within the health care system for patients to approach with their issues, it is crucial that we know how to counsel them on these types of health-related concerns. Knowing that just providing some form of cessation education improves the likelihood that a patient will attempt to follow actions required to quit harmful behaviors is a positive sign that our work as professionals can have a significant impact on the people we are serving. It is for this reason that we should continually provided counseling services to patients at multiple stages in the treatment process, such as initiation of therapy and follow-ups. I believe that these actions will have a beneficial impact on patients and will make doing our job a much more fulfilling experience. I would be very interested to see how this type of study would show improvement in limiting the harmful impact that other health concerns have on the population.

Brunette MF, Dzebisashvili N, Xie H, et al. Expanding cessation pharmacotherapy via videoconference educational outreach to prescribers. Nicotine Tob Res. 2015;17(8):960-7.

Tobacco Control and the Reduction in Smoking-Related Premature Deaths in the United States, 1964-2012

This study was conducted as part of the 50th anniversary of the first time the surgeon general released a report on smoking and its effects on health.  The purpose of the study was to determine the effects that tobacco control has had on smoking-related mortality.

The study was conducted by estimating the smoking histories of people under actual conditions and under conditions that would have occurred if tobacco control had not happened.  Mortality rates were determined using analytical studies that show the effect smoking has on death rates.  The actual mortalities caused by smoking from the year 1964 through 2012 were then compared to the estimated mortalities that would have occurred with no tobacco control.  The main outcomes of the study were to show the number of deaths avoided, the years of life saved and the change in life expectancy at age 40.

The study showed that 8.0 million fewer premature smoking-related deaths occurred because of tobacco control.  Additionally, 157 million years of life were saved, which divides into an average of 19.6 years per person.  During this 48-year period, the life expectancies of men and women increased by 7.8 and 5.4 years, respectively.  From the study it was found that 2.3 years for men and 1.6 years for women can be connected with tobacco control.

I found this study interesting because it shows the effects of tobacco control on a large scale.  A lot of time and money has been spent on this topic and it is still a heavily talked about issue.  While smoking rates are down, there are people who still smoke and who do not fully understand the consequences.  This study shows that the time and money spent had a purpose and shows that continuing to shine a light on the topic will have real effects.

Holford, Theodore R., Rafael Meza, Kenneth E. Warner, Clare Meernik, Jihyoun Jeon, Suresh H. Moolgavkar, and David T. Levy. “Tobacco Control and the Reduction in Smoking-Related Premature Deaths in the United States, 1964-2012.” Jama 311.2 (2014): 164. Web.

http://jama.jamanetwork.com/article.aspx?articleid=1812962

Inhaled Toxicants from Hookah vs. Cigarette Smoking

Although smoking cigarettes may be declining among the US college population, it seems that smoking one of its counterparts, the hookah, is on the rise.  The hookah contains communal pipes that allow users to draw tobacco smoke through water.  This specially made tobacco comes in many unique flavors.  There seems to be the misconception that smoking from a water pipe (hookah) is less harmful, however, many of the health risks are the same as smoking cigarettes.  In fact, since users often believe this misconception, one hookah smoking session can often become more dangerous.

In a recent systematic review and meta-analysis of inhaled toxicants from water pipe and cigarette smoking, it was discovered that, compared with a single cigarette, one hookah session delivers approximately 125 times the smoke, 25 times the tar, 2.5 times the nicotine and 10 times the carbon monoxide.  This study clearly shows that a hookah smoking session exposes users to higher amounts of smoke volume and toxicants.  Led by lead author Dr. Brian A. Primack,M.D., Ph.D., a University of Pittsburgh School of Medicine professor, he states that the results show that smoking hookah tobacco poses real health concerns and should be monitored more closely than it currently is.  The methods to this study include searching through biomedical bibliographic databases for relevant articles and conducting meta-analysis to calculate the parameters of smoke volume, nicotine, tar, and carbon monoxide between a single cigarette and a single hookah smoking session.  Out of 542 potentially relevant studies, only 17 were qualified for meta-analysis.

A caveat is that due to the various ways of usage of cigarette and hookah smoking, it is difficult to accurately analyze the effects of both counterparts and develop a perfect comparison.  Thus, the researchers cannot say which is “worse,” however, it can be noted that hookah users are probably being exposed to a lot more toxicants than they realize.

I feel that this is an important issue that needs to be brought up more often in healthcare, with a focus on the college aged population.  More education and media coverage on the dangers of this activity should also be exposed.  It has been studied that about one-third of U.S. college students have used a hookah, and many of those individuals had not used other forms of tobacco previously.

Public Health Rep. 2016;131(1):76-85.

The Proposal for Smoke Free Public Housing

As pharmacy students in a city, we interact regularly with a wide variety of patient populations. It is not uncommon to speak with patients who live in government provided public housing and whose incomes fall below the poverty line. Unfortunately, most of these patients suffer from poor health outcomes. Home life and income are both social determinants of health; smoking rates are higher in these populations than the general population. In fact, though the US smoking rates have dropped in the general adult population to under 17%, yet it remains above 26% in populations with incomes below the poverty line. The effects of smoking reach even further because of secondhand smoke. Therefore, children and people nearby also suffer the consequences of their parents or neighbors smoking. In housing projects, 37% of children experience smoking related health problems simply by second hand smoke.

These are alarming statistics and the US Department of Housing and Urban Development (HUD) is taking action. By the end of 2016, HUD-provided housing will require non-indoor smoking to be listed in the lease agreement. This type of policy has the ability to impact more than 2 million individuals living in 954,000 government provided homes throughout the country. The Public Housing Authorities will be responsible for implementing this rule, and will not allow any form of lit cigars, cigarettes or pipes indoors. Residents will have to walk more than 25 feet away from the property in order to smoke. If a neighbor sees someone smoking, they are encouraged to report it. Though this seems like an intrusion on individual rights, the majority of current residents in public housing are in support of this new rule, as they are currently subjected to excessive second hand smoke through open windows and air vents from their neighbors.

In addition to the obvious health benefits of decreased smoking and second hand smoke, this plan also has several financial perks. A nation-wide effort would result in annual cost savings of $153 million, including $94 million in health care savings and $59 million in reduced poverty costs.

Implementation of a plan like this would help health professionals in the movement for smoking cessation all together. I believe making residents go outside in the cold to smoke rather than in the comfort of their own home will help push the patient to make the decision him/herself to quit. Pharmacists and other health professionals should jump on this opportunity and be ready to provide cessation resources to patients currently addicted to smoking who live in public housing.

Do you think a plan like this is feasible? Do you think this is violating a patient’s right to make personal lifestyle decisions?

 

Read the original article here.

Geller AC, Rees VW, Brooks DR. The Proposal for Smoke-Free Public Housing: Benefits, Challenges, and Opportunities for 2 Million Residents. JAMA. 2016;1380

Effects of Nicotine Patch vs Varenicline vs Combination Nicotine Replacement Therapy on Smoking Cessation

Smoking tobacco is a widespread problem throughout the world, and there have been many attempts to create pharmacotherapies for smoking cessation. A study in the Journal of the American Medical Association compared traditional nicotine replacement therapy (NRT), varenicline, and a combination nicotine replacement therapy (C-NRT) in 1086 smokers. The difference in abstinence rates between the NRT patch and the other two therapies were not considered to be significant. It was also found that those in the C-NRT and varenicline groups had significantly lower withdrawal ratings than those just using the patch. The authors mention some problems the study could have faced, including low adherence to the therapies, length of the study, and also it being an open-label study where the patients knew what they were taking.

With how common smoking is, studies revolving around smoking cessation is important. While this study may have some flaws, it illustrates that all these three therapies have an effect on motivating smokers to quit smoking. If the non-prescription patch is as effective as the other two prescription therapies, it can greatly influence some smokers’ decisions about trying to quit smoking. The patch will be a lot cheaper and accessible, thus be able to reach a larger population. A big problem the study pointed out that is also common in other smoking cessation studies is the somewhat low adherence, rates being a little below 50%. In the smokers that did adhere, results could be seen from the lower amount of cigarettes they smoked or even completely quitting. Quitting smoking will greatly improve the health of a person, and these pharmacotherapies can help one with the process.

JAMA. 2016;315(4):371-379.

Interventions by Health Care Professionals in Reducing Tobacco Smoke Exposure in Children : A Review and Meta-analysis

A recent review was conducted to determine the effectiveness of interventions delivered by health care professionals who provide routine child health care in reducing tobacco smoke exposure in children. A meta-analysis conducted on 57 trials was performed. The primary outcome was reduction in child tobacco smoke exposure with a secondary outcome of parental smoking cessation. 16 studies met the selection criteria. The only trials that demonstrated a significant overall intervention effect were trials that affected maternal postpartum smoking relapse prevention.

Although this meta-analysis did not provide much in the way of finding interventions that could be effective in reducing child tobacco smoke exposure, it did find one intervention that could affect child TSA. This could be a first step towards finding other interventions that are effective. Much like the other intervention types, this intervention gets to the heart of the problem; parents smoking around their offspring. Even though tobacco use in adults over 18 have decreased since 2004, the percentage of adult smokers are still high. I believe interventions like this will prove useful in the future.

Daly JB., Mackenzie LJ., Freund M., et al Interventions by Health Care Professionals Who Provide Routine Child Health Care to Reduce Tobacco Smoke Exposure in Children. J Am Pharm Assoc Ped 2016; 170