A pilot cluster randomised controlled trial of a peer-delivered outreach community-based smoking cessation intervention for women living in disadvantaged communities in Ireland.

INTRODUCTION: The health of women in rural communities is adversely impacted by increased rates of tobacco use linked to socio-economic disadvantage (SED) and by limited access to services. We Can Quit (WCQ) is a smoking cessation programme delivered by trained lay women (community facilitators) in local communities, which was developed using a Community-based Participatory Research (CBPR) approach and tailored to women living in SED areas of Ireland. METHODS: The We Can Quit2 (WCQ2) pilot cluster randomised controlled trial with an inbuilt process evaluation was conducted in four matched pairs of urban and semi-rural SED districts (8-10,000 women per district) to assess feasibility. Districts were independently randomised to WCQ (group support +/- nicotine replacement therapy), or to individual support delivered by health professionals. RESULTS: Findings showed that that the WCQ outreach programme is acceptable and feasible to implement for smoking women living in disadvantaged neighbourhoods. A secondary outcome of smoking abstinence (self-report + biochemical validation) demonstrated 27% abstinence in the intervention group versus 17% in usual care at end of programme. Low literacy was highlighted as a major barrier to participants' acceptability. DISCUSSION: The design of our project provides an affordable solution for governments in prioritising outreach smoking cessation in vulnerable populations in countries with rising rates of female lung cancer. Our community-based model using a CBPR approach empowers local women to become trained to deliver smoking cessation programmes within their own local communities. This provides a foundation to create a sustainable and equitable way to address tobacco use in rural communities.

A process evaluation of 'We Can Quit': a community-based smoking cessation intervention targeting women from areas of socio-disadvantage in Ireland.

BACKGROUND: Smoking poses a serious risk of early preventable death and disease especially for women living with socio-economic disadvantage (SED). A smoking cessation programme, 'We Can Quit', was developed in Ireland tailored to SED women. This includes group-based support delivered by trained lay local community facilitators (CFs) and free nicotine replacement therapy (NRT). The intervention was pilot tested in a cluster randomised controlled trial, 'We Can Quit 2'. This paper reports on the WCQ2 process evaluation which assessed feasibility and acceptability of the programme and trial processes. METHODS: Embedded qualitative design using the UK Medical Research Council's process evaluation framework. Semi-structured interviews with trial participants (N = 21) and CFs (N = 8). Thematic analysis was utilised. RESULTS: Peer-modelling, a non-judgemental environment, CFs facilitation of group support were viewed as acceptable programme related factors. Some participants expressed concerns about NRT side effects. Provision of free NRT was welcomed and accepted by participants, although structural barriers made access challenging. Pharmacists took on a role that became larger than originally envisaged - and the majority provided additional support to women in their quit attempts between group meetings which augmented and supplemented the intervention sessions provided by the CFs. Participants reported good acceptance of repeated measures for data collection, but mixed acceptability of provision of saliva samples. Low literacy affected the feasibility of some women to fully engage with programme and trial-related materials. This was despite efforts made by intervention developers and the trial team to make materials (e.g., participant intervention booklet; consent forms and participant information leaflets) accessible while also meeting requirements under 2018 European General Data Protection Regulation legislation. Hypothetical scenarios of direct (e.g., researcher present during programme delivery) and indirect (e.g., audio recordings of programme sessions) observational fidelity assessments for a future definitive trial (DT) were acceptable. CONCLUSIONS: Intervention and trial-related processes were generally feasible and acceptable to participants and CFs. Any future DT will need to take further steps to mitigate structural barriers to accessing free NRT; and the established problem of low literacy and low educational attainment in SED areas, while continuing to comply within the contemporary legislative research environment. TRIAL REGISTRATION: WCQ2 pilot trial ( ISRCTN74721694 ).

The We Can Quit2 Smoking Cessation Trial: Knowledge Exchange and Dissemination Following a Community-Based Participatory Research Approach.

BACKGROUND: 'We Can Quit2' pilot randomised controlled trial determined the feasibility [of conducting a community-based trial of We Can Quit, a peer-delivered stop-smoking programme (group support, combination nicotine replacement therapy (NRT), and tailored individual support) for women living in socioeconomically disadvantaged areas in Ireland. Lessons from a knowledge exchange (KE) workshop that reengaged trial stakeholders are presented. METHODS: The trial dissemination plan included invitation of community, regional and national stakeholders (n = 176) to a KE interactive workshop, who received an accessible brief beforehand. Trial findings were presented. Enhancements to community engagement, participants' recruitment and retention, and policy priorities arising from the research were discussed. Field notes and responses to a post-event anonymous questionnaire were analysed using thematic content analysis. RESULTS: Workshop attendees (41/176, 23%) recommended: dedicated additional time to engage community stakeholders; social prescribing pathways to enhance recruitment; more adaptation of trial-related information and assistance in completion of data forms for low literacy individuals; encouraging women to join healthy community programmes to facilitate retention and sustainability; removal of barriers to access NRT; and ongoing provision of cessation services tailored to disadvantaged groups. CONCLUSIONS: The findings are relevant to the implementation of other community-based health interventions for disadvantaged groups, to policy makers and to service providers.

An application of PRECIS-2 to evaluate trial design in a pilot cluster randomised controlled trial of a community-based smoking cessation intervention for women living in disadvantaged areas of Ireland.

BACKGROUND: "We Can Quit2" (WCQ2) was a pilot cluster randomised controlled trial with an embedded process evaluation assessing the feasibility and acceptability of 'We Can Quit' (WCQ, a peer-delivered community-based stop-smoking programme for women in disadvantaged communities. The control group comprised 'enhanced usual care' offered by the Irish Health Service Executive (HSE). The PRagmatic Explanatory Continuum Indicator Summary (PRECIS-2) is a tool to assess whether a trial design is more explanatory (working under ideal conditions) or pragmatic (working under 'real-world' conditions). The aim of this paper was to retrospectively evaluate the WCQ2 pilot trial using PRECIS-2 to inform the decision-making process on progression to a future definitive trial (DT). METHODS: The WCQ2 trial protocol and HSE standard stop-smoking service were described across the nine PRECIS-2 domains: eligibility, recruitment, setting, organisation, flexibility-delivery, flexibility-adherence, follow-up and primary outcome. Team members scored the domains as pragmatic or explanatory for each arm in a half-day workshop. RESULTS: Seven team members (practitioners and researchers) assessed the overall trial design as more explanatory than pragmatic. Important differences emerged between the two arms. WCQ targeted adult women from disadvantaged communities whereas HSE run a limited enhanced service for all quitters. Trial recruitment was challenging, intense efforts were needed as the trial proceeded. WCQ was delivered in a non-clinical community setting, HSE services in a clinical setting. WCQ organisation was co-designed with community partners and comprises peer-to-peer group support delivered by trained lay community facilitators, whereas HSE one-to-one support is delivered by Smoking Cessation Officers with a clinical background. Only WCQ allowed flexibility in delivery and adherence. Follow-up was more intensive in WCQ. Greater efforts to improve participant retention will be required in a future DT. CONCLUSIONS: PRECIS-2 allowed the reflection of practitioners and researchers on similarities and differences between intervention and control arms. Results will inform the decision on progression to an effectiveness DT, which will require more a pragmatic and less explanatory design. This novel use of PRECIS-2 to retrospectively evaluate a complex community-based pilot trial in advance of a full DT will also support learning for those undertaking hybrid trials of implementation and effectiveness. TRIAL REGISTRATION: This trial is registered with the ISRCTN registry ( No. 74721694 ).

Peer-Delivery of a Gender-Specific Smoking Cessation Intervention for Women Living in Disadvantaged Communities in Ireland We Can Quit2 (WCQ2)-A Pilot Cluster Randomized Controlled Trial.

INTRODUCTION: We Can Quit" (WCQ) is community-based stop-smoking program delivered by trained community facilitators, based on the socio-ecological framework and developed using a Community-based Participatory Research approach, targeting women living in socioeconomically disadvantaged (SED) areas of Ireland. AIMS AND METHODS: The We Can Quit2 (WCQ2) pilot trial assessed the feasibility of WCQ. A pragmatic cluster randomized controlled trial with a process evaluation WCQ2, was conducted in four matched pairs of SED districts (8-10 000 women per district). Districts were independently randomized to WCQ (group support + nicotine replacement therapy), or to individual support delivered by health professionals. Participants were adult women smokers interested in quitting, who were living or working in trial districts. Recruitment of districts and 194 women in four waves (49 women per wave); retention at 12 weeks and 6 months; fidelity to intervention delivery and acceptability of trial-related processes were assessed. Validated smoking abstinence at 12-week and 6-month post-intervention was recorded, missing data assumed as continued smoking. RESULTS: Eight districts were recruited. 125/188 (66.5%) eligible women consented. The 49 women target was reached in wave4. Retention at 12 weeks was (Intervention [I]: 55.4%; Control [C]: 51.7%), at 6 months (I: 47.7%; C: 46.7%). Smoking abstinence at 12 weeks was (I: 23.1%, [95% CI: 14.5 to 34.7]; C: 13%, [95% CI: 6.9 to 24.1]). 83.8% of session activities were delivered. Trial-related processes were acceptable to facilitators. Low literacy was highlighted as a barrier for participants' acceptability. CONCLUSIONS: WCQ was feasible to deliver by trained facilitators and indicated a positive direction in abstinence rates. Low literacy will need to be addressed in a future trial design. IMPLICATIONS: This pilot trial showed that a stop-smoking intervention tailored to a group of women smokers living in SED areas which was delivered by trained local women within their local communities was feasible. Furthermore, although not formally compared, more WCQ women were abstinent from smoking at the end of treatment. The results are relevant to enhance the design of a fully powered effectiveness trial, and provide important evidence on the barriers to deliver a tailored smoking cessation service to SED women smokers in Ireland.

Long-term contextual memory in infant rats as evidenced by an ethanol conditioned tolerance procedure.

Conditioned tolerance can be conceptualized as a particular case of Pavlovian conditioning in which contextual cues play the role of the conditioned stimulus. Although the evidence is contradictory, it is frequently assumed that long-term contextual conditioning in pre-weanling rats is weak or even absent. This hypothesis comes from and is sustained mainly by behavioral studies that explored different contextual effects in 16-18day-old rats using a fear-conditioning paradigm, but their conclusions are stated in terms of an immature (hippocampal-dependent) declarative memory system. The main goal of the present manuscript was based on a recent antecedent from our laboratory, to analyze whether context-dependent tolerance induced by ethanol during the pre-weanling period persists over time. Results showed that the context was able to modulate ethanol-induced tolerance in 2- and 3-week-old rats. Interestingly, contextual conditioned tolerance was stronger (in terms of persistence) during the third than during the second postnatal week. When subjects were tested 8days after training, when the context presumably lost its influence over tolerance, the opposite effect emerged (sensitization). These results are important for the ethanol literature, adding new evidence of long-term retention of ethanol effects acquired during infancy, whilst also showing striking ontogenetic differences in the sensitivity to ethanol between the 2nd and 3rd postnatal weeks. Importantly, contextual information modulates the expression of these ethanol effects even eight days after training, a result that is particularly relevant to the discussion of the ontogeny of contextual memory.

Transition from ethanol-induced sensitization to tolerance across early and late infancy in the rat.

Drugs of abuse, as cocaine or amphetamine, induce locomotor sensitization during infancy and adulthood of the rat. This effect during the preweanling period is observed only after a short interval of time between training and testing. We recently reported short-term locomotor sensitization induced by ethanol in pups chronically exposed to the drug during the second postnatal week of life. The present series of experiments was designed to explore the persistence of the sensitization effect across the preweanling period. Pups were chronically exposed to ethanol in five consecutive days during the second or the third postnatal weeks, and their locomotor activity was evaluated in an open field 3, 8 or 15days later. Our results showed that, contrarily to what has been observed with other drugs during infancy, sensitization to ethanol persisted at least 8days in rats exposed to the drug during the second postnatal week. Surprisingly, in older pups, the same procedure induced tolerance instead sensitization. This ontogenetic model offers a potentially interesting tool for studying within the same species, how tolerance and sensitization are interrelated, and how these effects affect ethanol-mediated reinforcement and ethanol intake during ontogeny.

Odor-avoidance or odor-preference induced by amphetamine in the infant rat depending on the dose and testing modality.

By the second postnatal week of life infant rats can acquire taste avoidance induced by amphetamine. Psychostimulant drugs supports appetitive and aversive learning in adult rats. Their appetitive effects are more likely to become associated with contextual cues, while the aversive ones have been consistently found in taste aversion learning. To explain this paradox, it has been proposed that rats would avoid a taste that predicts a change in their homeostasis because this species cannot vomit. In this study we assessed the motivational properties of amphetamine in preweanling rats by means of an odor conditioning preparation, which enables the analysis of the hedonic value of the memory by means of a consumption test or in terms of locomotor approach to the odor. Results indicate that regardless of the amphetamine dose (1 or 5 mg/kg), when animals were evaluated in the intake test, subjects avoided the odor. However, the outcome in the locomotor avoidance test varied as a function of the amphetamine dose. Rats trained with the low dose (1 mg/kg) showed odor preference, while the highest amphetamine dose (5 mg/kg) induced odor avoidance. When LiCl was employed as an unconditioned stimulus (US), rats showed avoidance in the intake and locomotor activity tests. These data indicate that amphetamine, like other drugs of abuse, supports appetitive conditioning in preweanling rats. Interestingly, infant rats expressed conditioned odor avoidance or preference depending on the dose and testing modality. Results were discussed considering current theories of avoidance learning induced by rewarding drugs.

Signaling the unconditioned stimulus during the preexposure phase does not attenuate the unconditioned stimulus preexposure effect in preweanling rats.

The unconditioned stimulus preexposure effect (US-PE) is defined as an attenuation of the conditioned response after preexposure to the US prior to conditioning. Evidence exists that this effect can be weakened or eliminated by the presence of a signal predicting the US during the preexposure phase. This evidence has been found consistently across a variety of procedures in adult rats. The aim of the present study was to evaluate whether, in infant rats, signaling the US (LiCl) during preexposure with a salient cue (almond odor) attenuates the US-PE. During the preexposure phase, preweanling rats received three (Experiment 1) or one (Experiment 2) preexposures to LiCl, preceded by exposure to almond odor. Appropriate control groups were also included in these experiments. After preexposure, two conditioning trials were carried out in which subjects were given LiCl after saccharin consumption. During preexposure, three (Experiment 1a), although not one (Experiment 2a), contingent exposures to almond odor and LiCl resulted in a strong odor aversion. Extinction of the learned taste aversion was facilitated by prior experience with LiCl (Experiments 1b and 2b). This effect was observed regardless of whether or not LiCl was signaled by the almond odor. These results do not coincide with the associative hypotheses proposed to explain the US-PE, nor are they concurrent with alternative explanations based on the learned helplessness phenomenon.