Welcome to the eighth issue of Smoking Cessation Research Review. Findings from the first study presented in this issue suggest that varenicline may be helpful with cessation of long-term nicotine replacement therapy use. More research is needed to evaluate long-term efficacy.

A New Zealand study reveals rapid and substantial improvements in indoor air quality following the ban of tobacco in prisons. It concludes that a significant health hazard has been reduced for staff and prisoners alike.

We hope you find this edition stimulating reading, and we welcome any comments or feedback.

Kind Regards,Dr Hayden McRobbiehaydenmcrobbie@researchreview.co.nz

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In this issue:

a RESEARCH REVIEW publication

Varenicline stops long-term NRT use?

Effects of automated smoking cessation help programs

Yogic breathing exercises reduce craving?

Quitting approaches compared

Nicotine vaccines for smoking cessation

Assigning dose of nicotine gum

How smokers perceive ‘endgame’ scenarios

Public perceptions of a Tobacco-Free Commission

Smoking ban in prisons improved indoor air pollution

Smoking and fine particulate levels in city streets

Varenicline to stop long-term nicotine replacement useAuthors: Tønnesen P & Mikkelsen K

Summary: This trial randomised 139 ex-smokers and long-term nicotine replacement therapy (NRT) users to varenicline or placebo, combined with nurse-led counselling, to assist with quitting NRT.

Comment: Long-term use of NRT is not uncommon, particularly in highly dependent smokers. Although there are no known harms of long-term NRT use there are cost implications and some smokers resent being ‘still hooked’ on nicotine. There have been anecdotal reports of people successfully using varenicline to help them cease NRT use. Varenicline is effective in helping people stop smoking and works via its agonist and antagonistic effects on nicotinic acetylcholine receptors. Its antagonistic effects may be helpful in weaning people off NRT.

This study recruited long-term ex-smokers who were still using NRT. They were provided with brief counselling and randomised to receive a 12-week course of varenicline or placebo tablets. Participants were asked to stop using NRT between the first and second weeks of treatment, much like smokers are asked to set a quit date within this time. The study concluded that varenicline was more effective than placebo in helping people cease NRT use and reduce nicotine withdrawal symptoms. Although varenicline may show some promise in helping people cease long-term NRT use more research is required before it can be recommended for this purpose.

Overall, 10% of ex-smokers reported relapsing following the cessation of NRT. I think that this is relatively high and highlights to me the importance of individualising treatment. Some people are likely to benefit from long-term NRT use and although there are disadvantages to this approach, these need to be balanced with the risk of relapsing and the disadvantages associated with returning to smoking.

Reference: Nicotine Tob Res 2012 Sep 27 [Epub ahead of print]

http://ntr.oxfordjournals.org/content/early/2012/09/12/ntr.nts146.abstract

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Population-level effects of automated smoking cessation help programsAuthors: Borland R et al

Summary: These Australian researchers tested the population impact of offering automated smoking cessation interventions via the Internet and/or by mobile phone. The study population consisted of 3530 smokers or recent quitters recruited from those interested in quitting, and seeking self-help resources (n=1335) or cold-contacted from Internet panels (n=2195).

Comment: There is a lot of interest in automated treatment approaches for smoking cessation. They are relatively cheap to deliver and becoming more and more accessible.This randomised controlled trial examined the efficacy of an automated online QuitCoach or support delivered via text message (onQ) used alone or in combination and compared to an online resource that provided information about smoking cessation only. Smokers were randomly allocated to receive support from (1) QuitCoach alone, (2) onQ alone, (3) QuitCoach and onQ, (4) a choice of QuitCoach or onQ or both, or (5) online information only (control). All interventions encouraged the use of smoking cessation medicines and did not restrict people from using other smoking cessation methods.One-month 7-day point prevalence quit rates in the four intervention groups were all significantly greater than quit rates in the control group (QuitCoach=16%, onQ=21%, integrated=21%, choice=20%, control=15%). However, there was no significant difference in sustained 6-month quit rates between groups (QuitCoach=9%, onQ=9%, integrated=9%, choice=9%, control=6%). Overall, there was low use of these automated tools, which may have contributed to low quit rates. There was no evidence that combining these tools resulted in a higher quit rate than achieved when using them on their own. However, nor was there any evidence that combined use undermined quit rates. Choice increased the likelihood that one of the interventions would be used, but had no effect on smoking cessation.Despite the relatively low quit rates, these are still higher than what would be expected with unassisted quitting (around 5% at 6 months). The New Zealand Quitline provides both online QuitCoach support and text messaging, in addition to the more traditional telephone-based support. People who smoke can be directed to the website to find out more www.quit.org.nz.

Reference: Addiction 2012 Sep 20 [Epub ahead of print]http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.04091.x/abstract

The acute effects of yogic breathing exercises on craving and withdrawal symptoms in abstaining smokersAuthors: Shahab L et al

Summary: The findings from this study suggest that while simple yogic-style breathing exercises can reduce cigarette craving in the short-term in abstaining smokers, the benefits appear to have disappeared by 24 hours’ follow-up.

Comment: Breathing exercises may reduce urges to smoke. Slow breathing can decrease sympathetic tone and this may reduce the severity of tobacco withdrawal symptoms. Yoga has been suggested as a complementary treatment for smoking cessation. This study examined the effects of yogic-style breathing exercise on craving in 96 smokers after 12 hours of abstinence. Participants were randomly allocated to either (1) practise yogic breathing exercises for 10 minutes with a yoga instructor, and then encouraged to practise further over the next day, or (2) watching a video on yogic breathing exercises, but not encouraged to practise.The yogic breathing exercises reduced craving acutely (in the group that practised with the instructor), but did not show any effect over the next day. This may have been because compliance with the technique was low. Nevertheless, most participants agreed that it was helpful. Breathing exercises may help people cope with urges to smoke when quitting. However, like many areas of behaviour change, people are likely to benefit from some structured support in adopting new strategies. Simply making the suggestion ‘take deep breaths when you have an urge to smoke’ is unlikely to help most people.

Reference: Psychopharmacology (Berl) 2012 Sep 20 [Epub ahead of print]http://link.springer.com/article/10.1007%2Fs00213-012-2876-9?LI=true

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The most “successful” method for failing to quit smoking is unassisted cessationAuthors: Raupach T et al

Summary: These researchers used data collected for the Smoking Toolkit Study, a monthly series of cross-sectional household surveys of nationally representative samples of adults aged ≥16 years in England, including current, former, and never smokers. This analysis included only those 9,274 smokers reporting to have made a quit attempt in the past 12 months but who had gone back to smoking by the time of the interview (i.e., the quit attempt had failed).

Comment: Over the last year or so there have been a number of reports claiming that smokers are more likely to be successful if they quit unaided, compared to quitting with behavioural and/or pharmacological support. In this letter to the editor, Raupach and colleagues examine data from a national UK database to determine the outcomes of assisted and unassisted quit attempts. The researchers looked at data from 9274 smokers who reported making a quit attempt in the last 12 months, but had relapsed at the time of the follow-up interview. Most (48%) of these people tried to quit unaided, 30% used NRT purchased over the counter, 16% had used prescription smoking cessation medicines and 6% used help from the NHS Stop Smoking services.So can we conclude that going unaided was the best way to fail? Of course not! These data, like the data presented in previous cohort studies showing unassisted quitting is the best way to quit, tell us nothing of the best way to quit smoking. Instead, they only tell us that of a sample of smokers who tried to quit but did not succeed, most went about their quit attempt without support. Similarly, when you take a sample of people that made a quit attempt and did succeed, you usually see that the majority of people made unassisted quit attempts. The only way to determine the true efficacy of different quitting approaches is via controlled trials.

Reference: Nicotine Tob Res 2012 Sep 18 [Epub ahead of print]http://ntr.oxfordjournals.org/content/early/2012/09/12/ntr.nts164.extract

Nicotine vaccines for smoking cessationAuthors: Hartmann-Boyce J et al

Summary: Data were reviewed from 4 randomised controlled trials of nicotine vaccines used as part of smoking cessation or relapse prevention interventions in 2642 adult smokers or recent ex-smokers. Three trials compared NicVAX to placebo and one compared NIC002 (formerly NicQbeta) to placebo. The evidence failed to show that nicotine vaccines enhance long-term smoking cessation.

Comment: Nicotine vaccines have gained a lot of interest in the past few years. Vaccines are often perceived to be a panacea for tobacco dependence. Unfortunately, this is not the case.Nicotine vaccines all work by stimulating the production of nicotine antibodies. These antibodies bind to nicotine and prevent it from passing through the blood brain barrier so that it cannot exert its effect on the reward system in the brain. However, this ‘protective’ action of the vaccine relies on good levels of antibodies being produced. So far, it appears that only a relatively small proportion of people show a good antibody response.This Cochrane review summarises the results from 4 trials of nicotine vaccines for smoking cessation. Pooling the results shows that the vaccines so far have a small, but non-significant, effect on long-term quit rates. There is a suggestion that those with higher antibody levels had a better smoking cessation response.Work on vaccine development is on-going and if these can be improved then we still might have an alternative treatment option for smoking cessation in the future, but for now we will need to stick with encouraging people to get the best use out of the available treatment options.

Reference: Cochrane Database Syst Rev 2012 Aug 15;8:CD007072http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007072.pub2/abstract

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Original investigation assigning dose of nicotine gum by time to first cigaretteAuthors: Shiffman S et al

Summary: This secondary analysis of data from a trial in which 608 smokers were randomised to placebo, 2mg, or 4mg gum (Garvey AJ et al. Nicotine Tob Res 2000;2(1):53-63) evaluated efficacy of the gum when the 4mg dose is assigned based on time to first cigarette (TTFC) being ≤30 minutes. Abstinence rates were doubled or tripled with active treatment compared to placebo. This was also seen in smokers with a history of treatment failure. The effect of 4mg gum was significant among light smokers (<25 CPD) with TTFC ≤30; 2mg gum was not.

Comment: The authors of this study were the first to show that TTFC in the morning was a useful guide to determine which dose of nicotine lozenges should be used when aiding a quit attempt. They now report data showing that the same approach can be used for determining the dose of nicotine gum.TTFC is a relatively good indicator of the degree of tobacco dependence. The sooner someone needs to smoke the greater their degree of dependence. Those who smoke within the first 30 minutes after waking fall into a ‘high dependence’ category. Some are now using ‘smoking within 60 minutes’ as an indicator of higher tobacco dependence. This current study analysed data from an older study that randomly allocated smokers to 4mg, 2mg or placebo gum. Smokers were deemed to be heavy smokers if they smoked >25 cigarettes per day. However, cigarette consumption is a weak indicator of tobacco dependence. Part of the reason for this is that smokers can compensate for lower cigarette consumption by smoking their few cigarettes more intensively. In this study, smokers were re-categorised by TTFC. The more highly-dependent smokers (TTFC <30 minutes) were more likely to be abstinent when given the 4mg gum compared to placebo or 2mg gum, although the comparison with the 2mg gum was not statistically significant. This effect was seen irrespective of cigarette consumption.TTFC is an appropriate mechanism for determining the dose of nicotine gum or lozenges. The current New Zealand NRT dosing recommendations suggest that people who have their first cigarette within 60 minutes of waking should use the higher dose gum or lozenge. Those who smoke after 60 minutes can start on the lower dose products.

Reference: Nicotine Tob Res 2012 Sep 18 [Epub ahead of print]

http://ntr.oxfordjournals.org/content/early/2012/09/12/ntr.nts141.abstract

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‘The times are changing’: New Zealand smokers’ perceptions of the tobacco endgameAuthors: Maubach N et al

Summary: In an attempt to define how New Zealand smokers perceive ‘endgame’ solutions to tobacco smoking, these researchers conducted 47 in-depth interviews with 4 priority groups: Māori, Pacific, young adults and pregnant women; all were smokers or very recent quitters.

Comment: This study aimed to investigate public perception of the 2025 smokefree vision. In-depth interviews were conducted with high-needs groups. It is reassuring to see that a large majority of interviewees supported the smokefree goal. However, there were some feelings of uncertainty as to whether the goal could be achieved. Some participants commented that they could not see whānau ever being smokefree, and thought that they would really struggle to quit.Two of the young people interviewed resented the goal, commenting that it was about ‘telling me what to do’, although interestingly, both saw themselves as smokefree in the future. This reflects what is known about most young smokers in that they never intend to be smoking in later life, but they underestimate how difficult it can be to stop smoking. We also know that most smokers regret ever starting.Participants highlighted some ideas to help people quit. These included the use of incentives and utilising opportunities to share the quitting journey via online communities. Researchers are now starting to think of novel ways to engage and support smokers to quit. Facebook strikes me as an ideal example to be able to support and share ‘smokefree journeys’. Perhaps we will have a smoking cessation equivalent of FarmVille (a Facebook game) in the future where friends and whānau are able to provide help for people to quit.

Reference: Tob Control 2012 Jun 16 [Epub ahead of print]http://tobaccocontrol.bmj.com/content/early/2012/06/15/tobaccocontrol-2011-050398.short

Independent commentary by Dr Hayden McRobbie, Senior Lecturer in the School of Public Health and Psychosocial Studies, Auckland University of Technology and Honorary Senior Lecturer in the School of Population Health at the University of Auckland. He is also a Reader in Public Health Interventions within the UK Centre for Tobacco Control Studies, Queen Mary University of London.

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Qualitative exploration of public and smoker understanding of, and reactions to, an endgame solution to the tobacco epidemicAuthors: Edwards R et al

Summary: Participants in 4 focus groups – Māori smokers; non-Māori smokers; Māori non-smokers; and non-Māori non-smokers – were introduced to the vision of a tobacco-free New Zealand and the concept of a semi-autonomous agency (Tobacco-Free Commission) that would control the tobacco market as part of an endgame approach.

Comment: This New Zealand study explored public understanding and reactions to an endgame strategy. The endgame for tobacco is gaining traction in a number of countries. Endgame strategies can include sales bans on tobacco productions and changes in the ways the nicotine products are regulated. This study tested the understanding and reactions to an endgame strategy that would see the establishment of a non-governmental organisation responsible for limiting the supplies of tobacco, licence tobacco retailers, restrict the number of locations where tobacco could be sold, and require the retailers to also provide access to smoking cessation support.Most participants understood the concept of this endgame strategy and were supportive, especially as they saw this as a way to protect children. These results add to the accumulating evidence that there is wide public support for a smokefree Aotearoa. We now need to get on with implementing strategies that will help towards achieving the 2025 goal. Good and on-going communication with the public is likely to enhance our progress.

Reference: BMC Public Health 2012;12(1):782

http://www.biomedcentral.com/1471-2458/12/782/abstract

Indoor air pollution levels were halved as a result of a national tobacco ban in a New Zealand prisonAuthors: Thornley S et al

Summary: The sale of tobacco has been banned in New Zealand prisons from June 1, 2011. This study measured indoor air quality in a staff base of a New Zealand maximum-security prison before and after the enforcement of tobacco bans. At 14 days before the policy was implemented, the mean indoor fine particulate (PM

2.5) level was

6.58 μg/m3, which declined to 5.17 μg/m3 during the sales ban, and fell to 2.44 μg/m3 after the smoking ban. In a comparison of before and after periods, regression analyses revealed that PM

2.5 levels fell by an average of 57%.

Comment: In this issue, I have included a couple of New Zealand studies that look at the issue of secondhand smoke exposure by measuring the levels of fine particulate matter in air samples. While they are more related to tobacco control policy, as opposed to smoking cessation, they demonstrate objective measures of secondhand smoke and the role policy can play in improving population health.This first study by Thornley and colleagues looks at the effect of the smoking ban in prisons. There are about 7,000 prisoners inhabiting 19 prisons across New Zealand. You may recall the fear that smokefree prisons would not work and prisoners would simply not tolerate enforced abstinence. Anecdotally, I have heard of people that have stopped smoking in prisons and have been able to maintain their smokefree life after release. In the past, it would have been more common to go into prison smokefree and come out smoking.This study demonstrates the positive effects of the smoking ban in prisons on indoor air pollution, showing that there were significant reductions in levels of particulate matter and that breaches of the ban were low.

Reference: Nicotine Tob Res 2012 May 15 [Epub ahead of print]http://ntr.oxfordjournals.org/content/early/2012/05/15/ntr.nts127.abstract

Smoking increases air pollution levels in city streetsAuthors: Patel V et al

Summary: This investigation reports that fine particulate levels significantly increase when smoking is observed on shopping streets.

Comment: In another study measuring fine particulate matter, Patel and colleagues collected air samples on a route of shopping streets in Lower Hutt City. Whilst taking air samples they also made observations of the number of people smoking and the street and measured wind speed. On their journeys around the streets, the researchers observed around 1.5 smokers every 10 minutes. Particulate matter readings were significantly higher in the vicinity of smokers – about 2 times higher than locations without smokers present.These findings have policy implications for smokefree outdoor environments such as smokefree shopping streets and outdoor restaurants. I am personally becoming less tolerant of smoking in outdoor spaces such as restaurants and seating areas. However, as much as I might want to ask these people not to smoke, I often feel that I might come across as nagging. I think that we need to be careful not to ostracise people who smoke, but there are perhaps other ways that we might get our ‘smokefree message’ across. An Auckland University of Technology colleague of mine, Patsi Davies, uses a nice approach to raising the issue of smoking. She starts up a conversation with individuals or groups of smokers that are huddled on the street or in bus shelters, saying something along the lines of “You must think about quitting a lot...” Most people who smoke want to quit, so why not provide some friendly advice. She calls it the ‘simple chat’. Easier said than done for a lot of us I know, but perhaps if we could all get involved a little more in pointing people in the right direction this would contribute to what we all desire – a smokefree society.

Reference: Health Place 2012;18(5):1202-5http://www.sciencedirect.com/science/article/pii/S1353829212001025

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