Welcome to the seventh issue of Smoking Cessation Research Review. We begin this issue with evidence that shows that men in general are not more likely to quit smoking successfully than women. Population data from the USA, Canada and Britain across all age groups consistently showed relatively little difference in cessation between the sexes. An investigation that monitored compliance of a smokefree environment policy at two Sydney hospitals reports a reduction in staff observed smoking on hospital grounds, whereas inpatients’ smoking remained unchanged. The study authors suggest that multi-strategic cessation interventions are a key priority for hospital inpatients who smoke. 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

No gender differences in smoking cessation

Oral health professionals can increase quit rates

Nicotine gum ‘whitens’ teeth

Newly described tobacco withdrawal symptoms

Weight gain after quitting smoking

Dietary advice limits post-cessation weight gain?

Smoke-free environment policies in hospitals

Encourage young adults to use existing services

Legislation restrictions curb teachers’ smoking

Smoking prevalence among occupational groups

Dispelling myths about gender differences in smoking cessation: population data from the USA, Canada and BritainAuthors: Jarvis MJ et al

Summary: Data were analysed from major national surveys conducted in 2006–2007 in the USA (Tobacco Use Supplement to the Current Population Survey), Canada (Canadian Tobacco Use Monitoring Survey) and the UK (General Household Survey) to estimate rates of smoking cessation by age in men and women. Gender differences in smoking cessation were consistent across countries. Below age 50, women were more likely to have given up smoking completely than men, while among older age groups, men were more likely to have quit than women. Across all age groups, there was relatively little difference in cessation between the sexes.

Comment: It is often cited that women are less likely to succeed in quitting smoking then men. Some of the reasons that have been suggested for this difference are that women may respond differently to nicotine than men, and women are more likely to smoke to cope with negative affect. Most of the data showing a gender difference are from studies of smoking cessation interventions. Given that most people stop smoking without formal help, such data may skew the real picture. The evidence to support a sex difference in quit rates is rather mixed. This study used data from large national population surveys across three countries (USA, Canada and the UK) and calculated quit ratios that were calculated as ex-smokers as a percentage of current daily and less than daily smokers + ex-smokers. Overall, there were minimal differences in the quit ratios between men and women. These were slightly higher in women, compared to men in the USA (51% vs 49%) and Canada (58% vs 57%), and slightly lower in women in the UK (51% vs 52%). However, there were more marked differences by age group, with younger women more likely to have quit than men (e.g. in the 20–29 age group the difference in quit ratio ranged from 4%–2%), and women were less likely to quit than men in the older age groups. Overall these data show that in general men are not more likely to quit smoking than women, but do not imply that we stop individualising smoking cessation treatment plans based on the lived realities of women who smoke.

Reference: Tob Control. 2012 May 30. [Epub ahead of print]http://tobaccocontrol.bmj.com/content/early/2012/05/10/tobaccocontrol-2011-050279

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Smoking CessationResearch Review

Smoking Cessation

Issue 7 – 2012

Abbreviations used in this issue

BMI = body mass indexOR = odds ratioNRT = nicotine replacement therapy

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Interventions for tobacco cessation in the dental settingAuthors: Carr AB, Ebbert J

Summary: Combined findings from 14 clinical trials including over 10,500 participants showed that tobacco interventions delivered by oral health professionals and offered to cigarette smokers and smokeless tobacco users in the dental office or community setting can increase tobacco abstinence rates (OR, 1.71) at 6 months or longer. These findings were similar for smokeless tobacco users and smokers.

Comment: In this issue, we cover two papers that are relevant to our colleagues working in oral health. Both smoked and oral tobacco formulations impact negatively on oral health. In this Cochrane systematic review and meta-analysis, the authors pool the results of 14 trials that examine the efficacy of stop smoking interventions delivered by oral health care professionals (OHCPs). The results of the individual studies were somewhat mixed, however, overall the data suggest that brief smoking cessation interventions combined with an oral examination are effective in helping people to stop smoking. OCHPs should routinely screen for tobacco use and offer help to quit for people who smoke. It is important to remember that most people who smoke want to quit and expect health care professionals to ask about smoking. Don’t be put off offering assistance to quit; your patients expect it and don’t see it as nagging and many will be grateful for your help.

Reference: Cochrane Database Syst Rev. 2012 Jun 13;6:CD005084.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005084.pub3/abstract

Randomized controlled trial to evaluate tooth stain reduction with nicotine replacement gum during a smoking cessation programAuthors: Whelton H et al

Summary: These researchers compared the stain reduction efficacy of a nicotine replacement gum (Nicorette® Freshmint Gum) against the reference product, a nicotine replacement sublingual tablet (Nicorette® Microtab), in 200 healthy smokers motivated to quit smoking and with visible staining of teeth. They were randomised to use either product for 12 weeks. The primary endpoint was the mean change in stain index between baseline and week 6. The level of stain was lower at week 6 than at baseline in the gum group (test) and higher than at baseline in the tablet group (control), with mean changes of –0.14 and +0.12, respectively (p=0.005, ANCOVA). The difference in mean change in stain index scores between baseline and 2, 6 and 12 weeks was statistically significant in favour of gum, with greater lightening in the gum-group at each examination period.

Comment: NRT products (e.g. patch, gum, lozenge) are useful in aiding smoking cessation, where it works primarily to reduce the severity of tobacco withdrawal symptoms, making quitting easier. This study suggests that nicotine gum not only relieves withdrawal symptoms but also can ‘whiten’ your teeth at the same time. This advice may be helpful for people trying to decide on which type of NRT to use. It may also be a way to encourage better use of gum (i.e. using enough of it for long enough). Most people stopping smoking will be able to use combination NRT (e.g. patch and gum or patch and lozenge). Remember to advise people on the best technique for using gum (alternating between chewing and resting between the check and gums). People should use each piece of gum for around 30 minutes and aim, initially, for using a piece every hour (some 12–15 pieces per day).

Reference: BMC Oral Health. 2012;12(1):13.http://www.biomedcentral.com/1472-6831/12/13/abstract

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A test of proposed new tobacco withdrawal symptomsAuthors: Etter JF et al

Summary: Several newly described withdrawal symptoms have recently been added to the Minnesota Withdrawal Scale (MWS-R). To test the validity of the MWS-R, an Internet survey was undertaken with 1126 daily and 3239 former smokers who answered the original MWS (9 items), the 8 additional symptoms in the MWS-R and 23 further questions on tobacco withdrawal symptoms. Daily smokers were then randomly assigned to either continue to smoke for 2 weeks or to stop smoking, and they answered follow-up surveys 1, 3 and 7 days after their target quit date. Among the 31 proposed new symptoms, the only withdrawal-like symptom observed was worsening of mood swings. After adjusting for baseline depression, irritability, impatience, restlessness, stress, or anxious/nervous, post-cessation change in mood swings remained statistically significant. Notably, smoking cessation was also associated with positive, immediate effects, including improved sense of smell, sense of taste, and reduced sore throat.

Comment: People who stop smoking commonly experience tobacco withdrawal symptoms. These symptoms include irritability, depression, poor concentration and urges to smoke. The latter is the most common and the occurrence and severity of urges has been shown to predict relapse. This study examined the occurrence of a new set of possible symptoms in a group of recent quitters and continuing smokers. The only additional withdrawal-like symptom found was mood swings. However, a number of positive symptoms were also identified, including an improved sense of smell and taste. Smokers often report these improvements but until now these have not been systematically documented. When helping people to stop smoking they should be advised of some of the ‘negative’ symptoms that can be experienced (e.g. irritability and mood swings), but emphasise that these subside the longer they go without smoking at all. These recent data also show that we can confidently advise people of the positive symptoms they can expect to experience when they quit.

Reference: Addiction. 2012 Jun 15. doi: 10.1111/j. 1360-0443.2012.03981.x. [Epub ahead of print]http://tinyurl.com/bp4pnpg

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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Zyban (bupropion) can be taken for up to 1 year to help your customers quit smoking1-2

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Changes in body weight and food choice in those attempting smoking cessation: a cluster randomised controlled trialAuthors: Leslie WS et al

Summary: Outcomes are reported from a structured programme of dietary advice on weight change and food choice, in adults attempting smoking cessation. Community-based smoking cessation classes were randomised to commence a 24-week intervention focussed on improving food choice and minimising weight gain, or to control, consisting of “usual care” (7 weeks of group support sessions without formally addressing nutrition/diet). By week 24, similar increases in weight were seen in both groups. Analyses of weight change among those successful at quitting smoking indicated greater mean weight gain in intervention subjects (3.9 kg vs 2.7 kg). Between-group differences were not significant. In those not smoking, weight gain was minimised to ≤3 kg in similar proportions of subjects in each group (34.8% of intervention vs 33.3% of control). In comparison to baseline improved consumption of fruit and vegetables and breakfast cereal were reported in the intervention group. A higher percentage of control participants continued smoking (74% vs 66%).

Comment: As the systematic review by Aubin et al showed, weight gain in people stopping smoking is common. Although the risks of continued smoking largely outweigh the health risks associated with 4–5kg of weight gain, this additional weight remains a concern for many. In this study, the investigators tried to address weight gain by improving healthy eating. Although the intervention improved healthy eating it had no effect on weight. More research is required in this area, but in the meantime we should be encouraging people to adopt and maintain healthy eating patterns (e.g. increasing portions of vegetables and decreasing sugar consumption) and physical activity.

Reference: BMC Public Health. 2012;12(1):389.http://www.biomedcentral.com/1471-2458/12/389/abstract

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Weight gain in smokers after quitting cigarettes: meta-analysisAuthors: Aubin HJ et al

Summary: This meta-analysis included 62 published studies of weight gain amongst smokers who had achieved prolonged abstinence for up to 12 months and who quit without treatment or use of drugs to assist cessation. The analyses revealed that smoking cessation was associated with a mean increase of 4–5 kg in body weight after 12 months of abstinence, with substantial differences among study participants, and most of the post-cessation weight gain occurred during the first 3 months.

Comment: Weight gain following smoking cessation is a common occurrence and for many smokers, especially women, the fear of weight gain can be a barrier to quitting. This new meta-analysis combined the results of 62 studies reporting on weight gain following smoking cessation. In the first month of abstinence, people who did not receive any treatment gained 1.12 kg on average. In those who maintained abstinence for a year the average weight gain was 4.97 kg. Weight gain at 12 months was similar for those using NRT (4.86 kg), bupropion (4.08 kg) and varenicline (4.17 kg). Of course not everyone gains weight, and the findings show that at a year 16%–21% of untreated people lost weight. However, it still stands that most people can expect to gain some weight (35%–38% gained less than 5 kg and 29%–34% gained 5–10 kg) and unfortunately 13%–14% will gain more than 10kg.

Reference: BMJ. 2012;345:e4439.http://tinyurl.com/ccnk8mx

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Do smoke-free environment policies reduce smoking on hospital grounds? Evaluation of a smoke-free health service policy at two Sydney hospitalsAuthors: Poder N et al

Summary: These researchers monitored compliance of hospital staff, inpatients and visitors with Sydney South West Area Health Service’s Smoke-free Environment Policy at two hospitals 2 weeks before implementation of the policy and for 2 years after implementation. At 2 years after the policy was implemented, observed smoking incidents were reduced by 44% (p≤0.05) in staff and by 37% (p≤0.05) in visitors, but remained unchanged among inpatients.

Comment: All District Health Boards have smokefree policies that are largely adhered to. However, from time to time, one hears comments about ‘all the smokers than are now standing outside hospital grounds smoking’. Overall, hospital smokefree policies have an important effect. This study shows that such policies in two Australian hospitals were effective in reducing staff and visitor smoking, but had little impact on patient smoking. Of course there is a difference here in that most staff and visitors, unlike patients, are not confined to the hospital for any lengthy period of time. Smokefree policies should be supported by strategies that help manage tobacco withdrawal whilst people are hospitalised. All DHBs in New Zealand have NRT on their hospital formulary, which should be utilised to manage acute symptoms of tobacco withdrawal.

Reference: Aust Health Rev. 2012;36(2):158-62.http://www.publish.csiro.au/paper/AH11998.htm

Efficacy of smoking-cessation interventions for young adults: a meta-analysisAuthors: Suls JM et al

Summary: The efficacy of smoking-cessation programmes in young adults (aged 18–24 years) was investigated, using data from 14 studies published between 2004 and 2008 that investigated smoking cessation. The evidence demonstrated that any type of intervention was more effective in producing successful smoking cessation than the control. This was the case for intent-to-treat analyses as well as complete cases. Interventions with proven efficacy in the larger adult sample were also effective for the younger adult sample.

Comment: Most young people want to quit smoking and many try. However, their chances of success tend to be lower than what is seen in the older age groups. There are limited data on what interventions are effective in helping young people to quit. A logical option would be to offer general adult smoking cessation interventions to young people. To determine if these ‘adult interventions’ might be effective in young people (aged 18–24) the authors of this study pooled data from 14 studies. The results showed that overall ‘adult interventions’ were effective for young people compared with control, with an odds ratio (95% confidence interval) of 1.48 (95% CI 1.11 to 1.97). This suggests that until we have more specific smoking cessation interventions with demonstrated efficacy for young people we should encourage them to use existing services.

Reference: Am J Prev Med. 2012;42(6):655-62.http://www.ajpmonline.org/article/S0749-3797(12)00135-3/abstract

Impact of national smokefree environments laws on teachers, schools and early childhood centresAuthors: Watson D et al

Summary: Outcomes are reported from a national New Zealand cross-sectional survey conducted in 2008 that investigated teachers’ smoking behaviour and perceived adherence to smokefree legislation implemented on 1 January 2004.

Comment: As in hospitals, smokefree policies applied to other environments can have a positive impact. These data from New Zealand show the positive effect of smokefree legislation on smoking behaviour in teachers. The researchers collected data from around 1,400 teachers. Overall smoking prevalence among teachers was low (7%), but was higher in Māori and Pacific teachers (12%). Of the 148 teachers who reported to be smoking in 2004, the majority made changes to their smoking behaviour following the implementation of the smokefree legislation with 34% changing when they smoked, 37% trying to cut down or quit, and 9% quit smoking. However, although school grounds were smokefree, more than a third of teachers who smoke smoked within visible distance of the school boundaries, and a third of teachers reported seeing staff smoking. The authors make the case that smoking cessation efforts should be targeted at schools where smoking prevalence among teachers is high. The following paper by Edwards and others highlights the need to target other occupational groups, especially those that act as role models for children and young people.

Reference: Health Promot J Austr. 2011;22(3):166-71.http://tinyurl.com/7dlleyk

Setting a good example? Changes in smoking prevalence among key occupational groups in New Zealand: evidence from the 1981 and 2006 censusesAuthors: Edwards R et al

Summary: These researchers explored trends in smoking prevalence among a wide range of potential role model occupations in New Zealand, using census data from 1981 (n=1,321,323) and 2006 (n=1,744,479).

Comment: This study summarises smoking prevalence data from the New Zealand 2006 census across a range of professions and compares smoking rates to the 1981 census data. Overall, there has been a drop in smoking rates from 34.5% in 1981 to 21.7% in 2006. When looking at 2006 smoking prevalence by occupation, the lowest rates of smoking were seen in minsters of religion and religious workers (2.7%), dieticians/nutritionists (3.1%) and doctors (3.6%). 14.2% of nurses and 8.8% of dentists and dental assistants reported smoking. The highest rates of smoking were seen in kōhanga reo teachers (47.4%), prison officers (28.2%), social workers (24.2%), nurse aides (23.5%) and hospital orderlies (23.4%). Further analyses also showed that being Māori was associated with higher rates of smoking and lower relative declines in smoking rates between the two time points, compared to non-Māori. Although New Zealand has made significant progress in tobacco control since the 1980s there is still much work to do, especially in assisting groups of people with highest smoking prevalence.

Reference: Nicotine Tob Res. 2012;14(3):329-37.http://ntr.oxfordjournals.org/content/14/3/329.abstract