Rachna Begh

Influence of smoking cessation after diagnosis of early stage lung cancer on prognosis: systematic review of observational studies with meta-analysis

Objective To systematically review the evidence that smoking cessation after diagnosis of a primary lung tumour affects prognosis. Design Systematic review with meta-analysis. Data sources CINAHL (from 1981), Embase (from 1980), Medline (from 1966), Web of Science (from 1966), CENTRAL (from 1977) to December 2008, and reference lists of included studies. Study selection Randomised controlled trials or observational longitudinal studies that measured the effect of quitting smoking after diagnosis of lung cancer on prognostic outcomes, regardless of stage at presentation or tumour histology, were included. Data extraction Two researchers independently identified studies for inclusion and extracted data. Estimates were combined by using a random effects model, and the I2 statistic was used to examine heterogeneity. Life tables were used to model five year survival for early stage non-small cell lung cancer and limited stage small cell lung cancer, using death rates for continuing smokers and quitters obtained from this review. Results In 9/10 included studies, most patients studied were diagnosed as having an early stage lung tumour. Continued smoking was associated with a significantly increased risk of all cause mortality (hazard ratio 2.94, 95% confidence interval 1.15 to 7.54) and recurrence (1.86, 1.01 to 3.41) in early stage non-small cell lung cancer and of all cause mortality (1.86, 1.33 to 2.59), development of a second primary tumour (4.31, 1.09 to 16.98), and recurrence (1.26, 1.06 to 1.50) in limited stage small cell lung cancer. No study contained data on the effect of quitting smoking on cancer specific mortality or on development of a second primary tumour in non-small cell lung cancer. Life table modelling on the basis of these data estimated 33% five year survival in 65 year old patients with early stage non-small cell lung cancer who continued to smoke compared with 70% in those who quit smoking. In limited stage small cell lung cancer, an estimated 29% of continuing smokers would survive for five years compared with 63% of quitters on the basis of the data from this review. Conclusions This review provides preliminary evidence that smoking cessation after diagnosis of early stage lung cancer improves prognostic outcomes. From life table modelling, the estimated number of deaths prevented is larger than would be expected from reduction of cardiorespiratory deaths after smoking cessation, so most of the mortality gain is likely to be due to reduced cancer progression. These findings indicate that offering smoking cessation treatment to patients presenting with early stage lung cancer may be beneficial.

Brief opportunistic smoking cessation interventions: A systematic review and meta-analysis to compare advice to quit and offer of assistance

AIMS This study aimed to assess the effects of opportunistic brief physician advice to stop smoking and offer of assistance on incidence of attempts to stop and quit success in smokers not selected by motivation to quit. METHODS We included relevant trials from the Cochrane Reviews of physician advice for smoking cessation, nicotine replacement therapy (NRT), varenicline and bupropion. We extracted data on quit attempts and quit success. Estimates were combined using the Mantel-Haentszel method and heterogeneity assessed with the I(2) statistic. Study quality was assessed by method of randomization, allocation concealment and follow-up blind to allocation. RESULTS Thirteen studies were included. Compared to no intervention, advice to quit on medical grounds increased the frequency of quit attempts [risk ratio (RR) 1.24, 95% confidence interval (CI): 1.16-1.33], but not as much as behavioural support for cessation (RR 2.17, 95% CI 1.52-3.11) or offering NRT (RR 1.68, 95% CI: 1.48-1.89). In a direct comparison, offering assistance generated more quit attempts than giving advice to quit on medical grounds (RR 1.69, 95% CI: 1.24-2.31 for behavioural support and 1.39, 95% CI: 1.25-1.54 for offering medication). There was evidence that medical advice increased the success of quit attempts and inconclusive evidence that offering assistance increased their success. CONCLUSIONS Physicians may be more effective in promoting attempts to stop smoking by offering assistance to all smokers than by advising smokers to quit and offering assistance only to those who express an interest in doing so.

Screening and brief intervention for obesity in primary care: a parallel, two-arm, randomised trial.

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Does reduced smoking if you can’t stop make any difference?

BackgroundPromoting and supporting smoking reduction in smokers with no immediate intention of stopping smoking is controversial given existing fears that this will deter cessation and that reduction itself may not improve health outcomes.DiscussionEvidence shows that smokers who reduce the number of daily cigarettes smoked are more likely to attempt and actually achieve smoking cessation. Further, clinical trials have shown that nicotine replacement therapy benefits both reduction and cessation. Worldwide data suggests that ‘non-medical’ nicotine is more attractive to people who smoke, with electronic cigarettes now being widely used. Nevertheless, only one small trial has examined the use of electronic cigarettes to promote reduction, with direct evidence remaining inconclusive. It has been suggested that long-term reduced smoking may directly benefit health, although the benefits are small compared with cessation.SummaryThe combined data imply that smoking reduction is a promising intervention, particularly when supported by clean nicotine; however, the benefits are only observed when it leads to permanent cessation.

Promoting smoking cessation in Pakistani and Bangladeshi men in the UK: pilot cluster randomised controlled trial of trained community outreach workers

BackgroundSmoking prevalence is high among Pakistani and Bangladeshi men in the UK, but there are few tailored smoking cessation programmes for Pakistani and Bangladeshi communities. The aim of this study was to pilot a cluster randomised controlled trial comparing the effectiveness of Pakistani and Bangladeshi smoking cessation outreach workers with standard care to improve access to and the success of English smoking cessation services.MethodsA pilot cluster randomised controlled trial was conducted in Birmingham, UK. Geographical lower layer super output areas were used to identify natural communities where more than 10% of the population were of Pakistani and Bangladeshi origin. 16 agglomerations of super output areas were randomised to normal care controls vs. outreach intervention. The number of people setting quit dates using NHS services, validated abstinence from smoking at four weeks, and stated abstinence at three and six months were assessed. The impact of the intervention on choice and adherence to treatments, attendance at clinic appointments and patient satisfaction were also assessed.ResultsWe were able to randomise geographical areas and deliver the outreach worker-based services. More Pakistani and Bangladeshi men made quit attempts with NHS services in intervention areas compared with control areas, rate ratio (RR) 1.32 (95%CI: 1.03-1.69). There was a small increase in the number of 4-week abstinent smokers in intervention areas (RR 1.30, 95%CI: 0.82-2.06). The proportion of service users attending weekly appointments was lower in intervention areas than control areas. No difference was found between intervention and control areas in choice and adherence to treatments or patient satisfaction with the service. The total cost of the intervention was £124,000; an estimated cost per quality-adjusted life year (QALY) gained of £8,500.ConclusionsThe intervention proved feasible and acceptable. Outreach workers expanded reach of smoking cessation services in diverse locations of relevance to Pakistani and Bangladeshi communities. The outreach worker model has the potential to increase community cessation rates and could prove cost-effective, but needs evaluating definitively in a larger, appropriately powered, randomised controlled trial. These future trials of outreach interventions need to be of sufficient duration to allow embedding of new models of service delivery.Trial registrationCurrent Controlled Trials ISRCTN82127540

Promoting smoking cessation through smoking reduction during Ramadan

Ramadan restricts smoking and leads to reduction. Recent research on reduction has focused upon using nicotine replacement therapy (NRT) as a substitute for missed cigarettes and behavioural approaches have been neglected, despite evidence of efficacy. Ramadan reminds us of the need to harness these natural experiments to enhance smoking reduction and hence cessation.

Electronic cigarettes for smoking cessation

### What you need to know A 42 year old electrician has tried to stop smoking several times, including with the aid of pharmacotherapy and behavioural support. He asks you about using electronic cigarettes (e-cigarettes). His work partner stopped smoking a year ago and is still using e-cigarettes now. He has heard that e-cigarettes are as damaging as the real things and worries that if he ends up addicted to e-cigarettes he’ll not have gained anything. About 60% of current adult smokers in Great Britain have tried electronic cigarettes (e-cigarettes), and 18% are current e-cigarette users.1 In England, over 40% of people who try to stop smoking do so with the aid of e-cigarettes.2 About 52% of current e-cigarettes users are former smokers.1 Some people who stop smoking with an e-cigarette are still using e-cigarettes a year later.1 In this article we look at whether e-cigarettes help people who smoke to cut down and stop smoking, what are the health risks from e-cigarette use, and how these compare with smoking. ### Cigarette and nicotine addiction Most people who smoke cigarettes are addicted, and the main vehicle of that addiction is nicotine. When stopping smoking, people experience cravings for cigarettes, which drives return to smoking. These cravings for smoking are less intense when nicotine is substituted; thus replacing nicotine from sources other than cigarettes can facilitate achieving abstinence. Transferring from cigarettes to other nicotine delivery devices, such as nicotine replacement therapy (NRT) or e-cigarettes, can transfer cigarette addiction to nicotine addiction. …

Lack of attentional retraining effects in cigarette smokers attempting cessation: A proof of concept double-blind randomised controlled trial

BACKGROUND Observational studies have shown that attentional bias for smoking-related cues is associated with increased craving and relapse. Laboratory experiments have shown that manipulating attentional bias may change craving. Interventions to reduce attentional bias could reduce relapse in smokers seeking to quit. We report a clinical trial of attentional retraining in treatment-seeking smokers. METHODS This was a double-blind randomised controlled trial that took place in UK smoking cessation clinics. Smokers interested in quitting were randomised to five weekly sessions of attentional retraining (N=60) or placebo training (N = 58) using a modified visual probe task from one week prior to quit day. Both groups received 21 mg nicotine patches (from quit day onwards) and behavioural support. Primary outcomes included change in attentional bias reaction times four weeks after quit day on the visual probe task and craving measured weekly using the Mood and Physical Symptoms Scale. Secondary outcomes were changes in withdrawal symptoms, time to first lapse and prolonged abstinence. RESULTS No attentional bias towards smoking cues was found in the sample at baseline (mean difference = 3 ms, 95% CI = -2, 9). Post-training bias was not significantly lower in the retraining group compared with the placebo group (mean difference = -9 ms, 95% CI = -20, 2). There was no difference between groups in change in craving (p = 0.89) and prolonged abstinence at four weeks (risk ratio = 1.00, 95% CI = 0.70, 1.43). CONCLUSIONS Taken with one other trial, there appears to be no effect from clinic-based attentional retraining using the visual probe task. Attentional retraining conducted out of clinic may prove more effective. CLINICAL TRIAL REGISTRATION UK Clinical Trials ISRCTN 54375405.

Association between smoking-related attentional bias and craving measured in the clinic and in the natural environment

Previous laboratory studies have investigated associations between attentional bias and craving, but ecological momentary assessment (EMA) may provide ecologically-valid data. This study examines whether clinic-measured attentional bias is associated with noticing smoking cues, attention to smoking, and craving assessed by EMA and whether EMA-assessed cues and attention to smoking are associated with craving in a secondary analysis of data from 100 cigarette smokers attempting cessation. Two weeks before quitting, participants completed attentional bias assessments on visual probe (VP) and Stroop tasks and completed random EMA-assessments for seven weeks thereafter. Participants completed 9,271 random assessments, averaging 3.3 prompts/day. Clinic-measured attentional bias was not associated with cues seen (VP: OR = 1.00, 95% CI = [0.99, 1.01]; Stroop: OR = 1.00, 95% CI [0.99, 1.00]), attention toward smoking (VP: OR = 1.00, 95% CI [0.99, 1.02]; Stroop: OR = 1.00, 95% CI [0.99, 1.00]), or craving (VP: OR = 1.00, 95% CI [0.99, 1.02]; Stroop: OR = 1.00, 95% CI [0.99, 1.01]). EMA responses to seeing a smoking cue (OR = 1.94, 95% CI [1.74, 2.16]) and attention toward smoking (OR = 3.69, 95% CI [3.42, 3.98]) were associated with craving. Internal reliability was higher for the Stroop (α = .75) than visual probe task (α = .20). In smokers attempting cessation, clinic measures of attentional bias do not predict noticing smoking cues, focus on smoking, or craving. However, associations exist between noticing smoking cues, attention toward smoking, and craving assessed in the moment, suggesting that attentional bias may not be a stable trait. (PsycINFO Database Record

Screening and brief intervention for obesity in primary care

• Users may freely distribute the URL that is used to identify this publication. • Users may download and/or print one copy of the publication from the University of Birmingham research portal for the purpose of private study or non-commercial research. • User may use extracts from the document in line with the concept of ‘fair dealing’ under the Copyright, Designs and Patents Act 1988 (?) • Users may not further distribute the material nor use it for the purposes of commercial gain.