Arnold H. Levinson

Discontinuation of Nicotine Replacement Therapy Among Smoking-Cessation Attempters

BACKGROUND Nicotine replacement therapy (NRT) doubles successful quitting, but more than half of NRT users do not comply with optimal treatment regimens. METHODS From the 2005 Colorado state tobacco survey, quit attempters who utilized NRT (N=366) were analyzed in spring 2007. Descriptive and regression analyses were used to examine reasons for discontinuing NRT, length of time on NRT, and quit intentions. RESULTS The reasons for discontinuing NRT were resuming smoking (34%), side effects (17%), NRT not helping with quitting (14%), quitting smoking (10%), and cost (5%). Poverty, age, and non-Latino minority status were associated with reasons for discontinuation other than quitting smoking. Having side effects was associated with a short duration of NRT use and 95% lower odds of intending to quit in the next month. CONCLUSIONS In the first population-level study examining reasons for discontinuing NRT, general-population smokers who initiate NRT use when attempting to quit are highly likely to discontinue NRT prematurely. Age and culturally-appropriate medication management interventions may increase NRT compliance and improve cessation outcomes.

Clinical Faxed Referrals to a Tobacco Quitline: Reach, Enrollment, and Participant Characteristics

BACKGROUND Faxed referrals from healthcare providers may provide a sustainable, low-cost mechanism for enrolling tobacco users in statewide quitlines, but few studies have evaluated implementation in real-world settings. This study evaluated the reach rates, enrollment rates, and participant characteristics of faxed referrals to the Ohio Tobacco Quit Line. METHODS This observational study analyzed reach and enrollment rates from June 2006 to October 2007. Demographics and tobacco-use characteristics of 1616 Quit Line enrollees recruited through faxed referrals were compared to those of enrollees who were not fax-referred. RESULTS A total of 6951 faxed referrals were received during the study period, increasing from an average of 68 per month before promotional initiatives to 412 per month during the study period. However, almost 60% of fax-referred individuals could not be reached for enrollment. Compared to other enrollees (n=36,273), fax-referred enrollees (n=1616) were more likely to be women, aged >/=35 years, have less than a high school education, have at least one comorbid condition, and be uninsured or publicly insured. CONCLUSIONS Faxed referrals from healthcare providers are widely promoted to increase quitline participation and to assist providers in implementing cessation treatment. This study found low enrollment rates from faxed referrals; substantial efforts led to relatively few patients receiving quitline services. However, faxed referrals may reach populations who traditionally have less access to cessation aids. More research is needed to determine how to efficiently and effectively solicit faxed referrals from healthcare providers and to increase quitline enrollment rates among fax-referred smokers as well as to determine the extent to which faxed referrals influence quit outcomes.

Long-term results of a smoking reduction program.

Introduction:There have been few comprehensive evaluations of smoking reduction, especially in health care delivery systems, and little is known about its cost, maintenance of reduced smoking, or robustness across patient subgroups. Methods:A generally representative sample of 320 adult smokers from an HMO scheduled for outpatient surgery or a diagnostic procedure was randomized to enhanced usual care or a theory-based smoking reduction intervention that combined telephone counseling and tailored newsletters. Outcomes included cigarettes smoked, carbon monoxide levels, and costs. Results:Both intervention and control conditions continued to improve from 3- to 12-month assessments. Between-condition differences using intent-to-treat analyses on both self-report and carbon monoxide measures were nonsignificant by the 12-month follow-up (25% vs. 19% achieved 50% or greater reductions in cigarettes smoked). The intervention was implemented consistently despite logistical constraints and was generally robust across patient characteristics (eg, education, ethnicity, health literacy, dependence). Conclusions:In the absence of nicotine replacement therapy, the long-term effects of this smoking reduction intervention seem modest and nonsignificant. Future research is indicated to enhance intervention effects and conduct more comprehensive economic analyses of program variations.

The ID effect on youth access to cigarettes

Objective: To estimate the effect on cigarette sales rates when minors present identification (ID). Design: Controlled experiment in which minors attempting to purchase cigarettes either carried a valid photo ID (documenting they were minors) or carried no ID, and were instructed to show the ID or admit having no ID if the clerk requested proof of age. Setting: Census of retail stores in six urban and suburban Colorado counties. Subjects: Retail cigarette clerks, uninformed of the study. Main outcome measures: Relative risk (RR) of cigarette sale to a minor when ID was requested and presented versus requested but not presented. Results: When clerks requested ID, sales were more than six times as frequent if minors presented ID than if they did not (12.2% v 2.0%, RR 6.2, p < 0.0001). The relative risk remained substantially unchanged under adjustment for demographic and circumstantial covariates. Conclusions: Presentation of photo ID in compliance checks increases illegal cigarette sales to minors. The impact may vary among states or locales and depends strongly on how often clerks request proof of age. Clerk training and responsible cigarette sales practices should include age calculations from photo ID. Programmes relying on investigative purchase attempts to estimate actual rates of cigarette sales to minors should ascertain and replicate local ID presenting behaviours that minors typically use during genuine attempts to buy cigarettes.

Smoking cessation behaviors among persons with psychiatric diagnoses: Results from a population-level state survey

BACKGROUND Persons with psychiatric illnesses are disproportionally affected by tobacco use, smoking at rates at least twice that of other adults. Intentions to quit are known to be high in this population, but population-level cessation behaviors and attitudes by mental health (MH) diagnosis are not well known. METHODS A population-level survey was conducted in 2008 to examine state-level tobacco attitudes and behaviors in Colorado. Respondents were eligible for the study if they had non-missing values for smoking status (n=14,118). Weighted descriptive and multivariate analyses were conducted of smoking prevalence, cessation behaviors, and attitudes toward cessation by MH status and specific diagnosis. RESULTS Among respondents with MH diagnoses, smoking was twice as prevalent as among respondents without an MH diagnosis, adjusted for demographic characteristics (adjusted odds ratio 2.2, 95% confidence interval 1.6-3.1). Compared to smokers without an MH diagnosis, those with MH diagnoses were more likely to attempt quitting (58.7% vs. 44.4%, p<0.05), use nicotine replacement therapy more often, and succeed in quitting at similar rates. Smokers with anxiety/PTSD were less likely to quit successfully compared those with other MH diagnoses (0.7% vs. 11.9%, p=0.03). CONCLUSIONS This population-level analysis found that smokers with mental illness are more likely than those without mental illness to attempt quitting and to use cessation treatment at similar rates, but those with anxiety are less likely to achieve short-term abstinence. Additional approaches are needed for smokers with mental illness in order to reach and sustain long-term abstinence from smoking.

Reduction in acute myocardial infarction hospitalization after implementation of a smoking ordinance.

BACKGROUND Smoking ordinances have been associated with reduced acute myocardial infarction rates, but nearly all studies lack patient-level data. OBJECTIVE We determined whether a smoking ordinance was associated with a reduction in hospitalizations for acute myocardial infarction, irrespective of smoking status and infarct presentation (ST elevation vs. non-ST elevation). METHODS Detailed chart abstraction of biomarkers to confirm first acute myocardial infarction events was performed from the single community hospital serving Greeley, Colorado and adjacent zip codes, 17 months before and 31 months after implementing a public smoking ordinance. Poisson regression analysis, adjusted for population growth, was used to assess changes in mean incidence rates. RESULTS A total of 706 hospitalizations were identified from July 2002 through June 2006: 482 among Greeley city residents and 224 within adjacent zip code areas. A postordinance reduction in hospitalizations was observed in Greeley (relative risk [RR] 0.73; 95% confidence interval [CI], 0.59-0.90). A smaller, nonsignificant decrease was noted in the area immediately surrounding Greeley (RR 0.83; 95% CI, 0.61-1.14). However, the comparison of relative risk reductions between Greeley and the surrounding area was not significant (P=.48). The reduction in Greeley was more pronounced among smokers (RR 0.44; 95% CI, 0.29-0.65) than nonsmokers (RR 0.86; 95% CI, 0.67-1.09) and did not differ by acute myocardial infarction presentation (P=.38). CONCLUSIONS A smoking ordinance was associated with a decrease in acute myocardial infarction hospitalizations of a magnitude similar to previous reports, but could not be distinguished from the adjacent geographic area. Reductions were greatest among smokers, despite previous studies suggesting that benefits accrue primarily among nonsmokers. Smoke-free policy may therefore exert a beneficial effect among smokers, who are disproportionately exposed to direct and sidestream smoke.

Evaluating initial reach and robustness of a practical randomized trial of smoking reduction.

OBJECTIVE This study evaluated the reach, initial effectiveness, and potential moderators and mediators of results of a smoking reduction program. DESIGN A generally representative sample of 320 adult smokers from an HMO, scheduled for outpatient surgery or a diagnostic procedure, were randomized to enhanced usual care or a theory-based smoking reduction intervention that combined telephone counseling and tailored newsletters. MAIN OUTCOME MEASURES Self-reported number of cigarettes smoked and carbon monoxide levels. RESULTS The intervention enrolled 30% of known eligible smokers and produced reductions of 3 cigarettes per day greater than enhanced usual care. Intervention participants were significantly more likely than control participants to achieve at least a 50% reduction in self-reported number of cigarettes using complete cases, imputation analyses, and intent-to-treat procedures. Similar patterns were seen for carbon monoxide results but were significant only in complete case analyses. The intervention was generally robust across patient characteristics (e.g., education, ethnicity, health literacy, and dependence) and phone counselors. CONCLUSION Initial results suggest that this program has potential to reach and assist smokers who may not participate in cessation programs. Additional research is indicated to enhance intervention effects, assess maintenance, and evaluate public health impact.

Smoking Cessation Treatment Preferences, Intentions, and Behaviors Among a Large Sample of Colorado Gay, Lesbian, Bisexual, and Transgendered Smokers

INTRODUCTION Little is known about preferences, intentions, and behaviors regarding evidence-based cessation treatment for smoking cessation among gay, lesbian, bisexual, and transgendered (GLBT) adults. METHODS We obtained and analyzed questionnaire responses from GLBT smokers (n= 1,633) surveyed in 129 GLBT-identified Colorado venues and online during 2007. RESULTS Most respondents (80.4%) smoked daily. Nearly one-third smoked 20 or more cigarettes/day. Fewer than half (47.2%) had attempted quitting in the previous year, and only 8.5% were preparing to quit in the next month. More than one-fourth (28.2%) of quit attempters had used nicotine replacement therapy (NRT), and a similar proportion said they intended to use NRT in their next quit attempt. Lesbians were significantly less likely than gay men to have used or intend to use NRT. One-fourth of respondents said they were uncomfortable talking to their doctor about quitting smoking. Four factors (daily smoking, ever having used NRT, a smoke-free home rule, and comfort asking ones doctor for cessation advice) were associated with preparation to quit smoking. CONCLUSIONS GLBT self-identification was not associated with lower than average acceptance of evidence-based smoking cessation strategies, especially NRT, but a large minority of GLBT smokers were unlikely to seek cessation assistance through clinical encounters. Public health campaigns should focus on supporting motivation to quit and providing nonclinical access to evidence-based treatments.

Differences in smoking duration between Latinos and Anglos

A smokers risk of disease and death from cigarettes is related directly to the duration of smoking. The present study compared duration of smoking between a state-level population of Anglo versus highly acculturated Latino ever-smokers (N = 6,100). Kapla-Meier analysis was used to obtain weighted median smoking duration. Weighted Cox proportional hazard models were used to evaluate the relative likelihood of continued smoking, adjusted for demographics, smoking history, home and workplace smoking restrictions, and socioeconomic covariates (education, health insurance status, and poverty level). On average, Latinos continued smoking longer than Anglos (M = 30 years vs. 27 years; weighted Cox HR = 0.73; 95% CI = 0.60-0.89). The disparity remained significant when adjusted for demographic, smoking history, and smoking-rule covariates but was not significant when adjusted for socioeconomic status (HR = 0.89, 95% CI = 0.73-1.09). Education alone accounted for the majority of the disparity, more so than poverty or health insurance status. We conclude that highly acculturated Latino smokers may be at greater risk of cigarette disease and death related to longer duration of smoking associated with lower socioeconomic status.

Rates and Reasons: Disparities in Low Intentions to Use a State Smoking Cessation Quitline

Purpose. Little is known about population-level rates and reasons for low intentions to call the quitline, a widely available evidence-based smoking cessation treatment. Design. This study is a secondary analysis of the 2008 Colorado Adult Tobacco Attitudes and Behavior Survey. Setting. This is a population-based telephone survey of adults in Colorado. Subjects. Study respondents (N = 1662) included current adult smokers who had heard of the Colorado QuitLine (QL) and did not report that they never intend to quit. Measures. Outcome measures included intent to call the QL, self-reported reasons for not intending to call the QL, and knowledge of QL services. Analysis. Descriptive and multivariate logistic regression analyses were used for each outcome variable. All analyses were weighted for complex survey design to represent the population of Colorado. Results. Overall 45.6% of smokers intend never to call the QL. In multivariate analysis, Latinos (odds ratio [OR] = 2.5; 95% confidence intervals [CI], 1.4, 4.7), gay/lesbian/bisexuals (OR = 5.2; 95% CI, 2.4, 11.4), and those with no insurance compared with Medicaid (OR = 3.8; 95% CI, 1.1, 13.0) were most likely to intend never to call the QL. Perceiving no need for assistance (34.8%) was the most common reason for not calling. Conclusions. A majority of smokers have no or weak intentions of ever calling the QL, with variation by subgroup. Reasons for not intending to call can inform targeted media campaigns to increase QL reach. (Am J Health Promot 2011;25[5 Supplement]:S59-S65.)