Emily K. Burns

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.

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.

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.)

Reaching Spanish-Speaking Smokers: State-Level Evidence of Untapped Potential for QuitLine Utilization

OBJECTIVES We examined the effects of a Spanish-language media campaign on the reach and outcomes of a state-sponsored QuitLine among Latino smokers. METHODS In this quasiexperimental (2-group, pre-post) study, we analyzed data from Colorado QuitLine callers before (April-August 2007) and during (September-November 2007) the media campaign. Call volume, service utilization, and quit rates at 7-month follow-up were compared between Latino (n = 243) and non-Latino (n = 527) callers. RESULTS QuitLine calls increased among Latinos during the campaign by 57.6% (1169 vs 1842 in 3-month periods). Compared with precampaign Latino study respondents, Latino respondents during the campaign were significantly younger (younger than 45 years), more often Spanish speaking, uninsured, and less educated. Among Latino enrollees, program completion and nicotine replacement therapy use were similar before and during the campaign, and quit rates during the campaign improved marginally to significantly (7-day abstinence: 29.6% vs 41.0%, P = .07; 6-month abstinence: 9.6% vs 18.8%, P = .04). CONCLUSIONS A well-designed, statewide Spanish-language media campaign increased QuitLine reach and improved cessation outcomes among a young Latino population of low socioeconomic status. QuitLine-supported cessation can be increased among these smokers.

Factors in Nonadherence to Quitline Services: Smoker Characteristics Explain Little

Background. Quitlines offer evidence-based, multisession coaching support for smoking cessation in the 50 U.S. states, Canada, and several other countries. Smokers who enroll in quitline services have, ipso facto, shown readiness to attempt to quit, but noncompletion of coaching services appears widespread and has not been widely investigated. The current study explored the magnitude and correlates of quitline service abandonment. Method. A state’s quitline intake, coaching, and nicotine patch/gum utilization data were obtained for smokers who enrolled during the period July 2007 to June 2008 (n = 20,882). Analyses examined demographic, socioeconomic status, nicotine dependence-related, and nicotine replacement therapy—utilization factors associated with completion of only one coaching session (of five offered). Results. Almost half of enrollees (47.8%) completed only one session. All significant predictors together explained less than 4% of variance; not being sent nicotine replacement therapy was most strongly correlated with completion of only one session. A framework is proposed for directing research toward reducing quitline service nonadherence. Conclusions. Premature user abandonment of coaching calls is widespread within a quitline. Further research should determine the extent of the problem in national quitline systems, increase knowledge of mediators of nonadherence, and develop strategies for increasing coaching completion.

Reduced NRT supplies through a quitline: Smoking cessation differences

INTRODUCTION Quitlines (QLs) provide effective smoking cessation treatment. The most cost-effective protocol for nicotine replacement therapy (NRT) has not been established. The current study compares self-reported 7-day abstinence rates among light to moderate smokers (< or = 20 cigarettes per day [CPD]) when a state QL reduced NRT supplies from 8 to 4 weeks. METHODS The study (n = 1,710) included Colorado QuitLine enrollees who requested free NRT. Analysis compared light to moderate smokers when 8- versus 4-week NRT supplies were available; the nonequivalent control group was heavy smokers (>20 CPD), who were consistently eligible for 8 weeks of NRT during the same time period. RESULTS Under the reduced NRT protocol, abstinence declined by nearly one fourth among light to moderate smokers (29.9% vs. 39.3%, p < .01). Heavy smokers reported no difference in abstinence rates (28.6% vs. 28.4%, p = nonsignificant). DISCUSSION Reducing NRT supplies from 8 to 4 weeks was associated with a one-fourth reduction in smoking abstinence rates among users of a state telephone QL. Future research should experimentally assess cost-effectiveness of 4- versus 8-week NRT protocols in QLs and should examine potentially mediating or moderating factors, such as history-affected expectancies regarding NRT and smoking cessation.

Randomised trial of two nicotine patch protocols distributed through a state quitline

Background Most telephone quitlines provide free nicotine replacement therapy (NRT). An 8-week course is recommended, but few users complete it. Information is needed to help quitlines distribute NRT cost-effectively. Design Randomised two-group trial. Setting/participants Colorado QuitLine callers who smoked 16–20 cigarettes per day at enrolment and who were eligible for and agreed to receive free NRT. Intervention Provision of 4-week versus 8-week NRT supply; the 8-week supply was shipped in halves and required participants to request the second half (split-shipment protocol). Enrolment occurred during March 2010–February 2011, follow-up concluded in November 2011, and analysis was performed in 2012. Main outcome measures Point abstinence (7 and 30 day) and prolonged abstinence (6 month) from tobacco use. Results Overall, 1495 study participants were enrolled and 57.7% completed follow-up. Abstinence rates did not differ significantly between study conditions: 13.8% versus 12.4% in 4-week versus 8-week arms, respectively, (30-day point abstinence, non-respondents treated as smokers). NRT duration was similar in both groups, due in part to purchase of additional patches in the 4-week group. About one-third of the 8-week group requested the full 8-week supply and had higher abstinence rates. Cost per quit was lower in the 4-week (compared to 8-week) group. Conclusions A randomised trial did not find worse cessation outcomes among quitline users who received half the minimum recommended course of NRT, but offering the full recommended course using a split-shipment protocol may be reasonably cost-effective and supportive of NRT adherers. Trial registration number NCT01889771.