Mobile Phone Text Messages to Support People to Stop Smoking by Switching to Vaping: Codevelopment, Coproduction, and Initial Testing Study.

BACKGROUND: SMS text messages are affordable, scalable, and effective smoking cessation interventions. However, there is little research on SMS text message interventions specifically designed to support people who smoke to quit by switching to vaping. OBJECTIVE: Over 3 phases, with vapers and smokers, we codeveloped and coproduced a mobile phone SMS text message program. The coproduction paradigm allowed us to collaborate with researchers and the community to develop a more relevant, acceptable, and equitable SMS text message program. METHODS: In phase 1, we engaged people who vape via Twitter and received 167 responses to our request to write SMS text messages for people who wish to quit smoking by switching to vaping. We screened, adjusted, refined, and themed the messages, resulting in a set of 95 that were mapped against the Capability, Opportunity, and Motivation-Behavior constructs. In phase 2, we evaluated the 95 messages from phase 1 via a web survey where participants (66/202, 32.7% woman) rated up to 20 messages on 7-point Likert scales on 9 constructs: being understandable, clear, believable, helpful, interesting, inoffensive, positive, and enthusiastic and how happy they would be to receive the messages. In phase 3, we implemented the final set of SMS text messages as part of a larger randomized optimization trial, in which 603 participants (mean age 38.33, SD 12.88 years; n=369, 61.2% woman) received SMS text message support and then rated their usefulness and frequency and provided free-text comments at the 12-week follow-up. RESULTS: For phase 2, means and SDs were calculated for each message across the 9 constructs. Those with means below the neutral anchor of 4 or with unfavorable comments were discussed with vapers and further refined or removed. This resulted in a final set of 78 that were mapped against early, mid-, or late stages of quitting to create an order for the messages. For phase 3, a total of 38.5% (232/603) of the participants provided ratings at the 12-week follow-up. In total, 69.8% (162/232) reported that the SMS text messages had been useful, and a significant association between quit rates and usefulness ratings was found (χ21=9.6; P=.002). A content analysis of free-text comments revealed that the 2 most common positive themes were helpful (13/47, 28%) and encouraging (6/47, 13%) and the 2 most common negative themes were too frequent (9/47, 19%) and annoying (4/47, 9%). CONCLUSIONS: In this paper, we describe the initial coproduction and codevelopment of a set of SMS text messages to help smokers stop smoking by transitioning to vaping. We encourage researchers to use, further develop, and evaluate the set of SMS text messages and adapt it to target populations and relevant contexts.

Evaluation of Mental Health First Aid from the Perspective Of Workplace End UseRs-EMPOWER: protocol of cluster randomised trial phase.

BACKGROUND: Mental Health First Aid (MHFA) is a mental health intervention that teaches people how to identify, understand and help someone who may be experiencing a mental health issue. Reviews of the implementation of MHFA found between 68 and 88% of trained Mental Health First Aiders had used their skills when in contact with someone experiencing mental health difficulties. Reviews evaluating the impact of MHFA suggest positive outcomes. However, to date, there has been no systematic, rigorous evaluation of the impact of MHFA on recipients of the intervention, the organisations providing it and the cost-effectiveness of MHFA overall. This trial will evaluate the effectiveness and cost-effectiveness of MHFA. METHODS: The study is a multi-centred, two-arm clustered randomised controlled trial. Organisations will be randomly allocated to the control or intervention (estimated sample size 800 recipients). The intervention is the standard MHFA intervention provided by Mental Health First Aid England (MHFAE). The control condition will be organisations having a brief consultation from MHFAE on promoting mental health and well-being in the workplace. The primary outcome is health seeking behaviour, measured using the Actual Help Seeking Questionnaire, at 6 months' follow-up. Data collection will be undertaken at baseline (T0), post-intervention-up to 3 months (T1), at 6 months (T2), 12 months (T3) and 24 months (T4). The primary analysis will be conducted on those participants who receive MHFA, a per protocol analysis. DISCUSSION: The study is the first to evaluate the effect of MHFA in the workplace on employees with direct and indirect experience of the intervention, when compared with usual practice. Being also the first to assess, systematically, the social impact of MHFA and investigate its cost-effectiveness adds to the originality of the study. The study promises to yield important data, as yet unknown, regarding the effectiveness, cost-effectiveness, implementation issues, and the sustainability of MHFA in the workplace. TRIAL REGISTRATION: Clinicaltrials.gov NCT04311203 . Registered on 17 March 2020.

Identity processes in smokers who want to quit smoking: A longitudinal interpretative phenomenological analysis.

The importance of identity in smoking cessation is increasingly becoming recognized by researchers. This study is the first in-depth longitudinal qualitative investigation of identity change processes among smokers who intend to quit. Participants' accounts of smoking, attempts to quit and sense of identity were explored over time to examine identity continuity and change. Ten smokers with a quit intention were interviewed three times, approximately 1 month apart, and approached for follow-up 2 years later. Data from 30 in-depth interviews were analyzed using the interpretative phenomenological analysis approach. Two themes of identity change processes are presented: "Identity transition makes it easier to quit" and "Identity conflict resolution is needed when quitting is unsuccessful or not attempted." Identity transition toward the identity of nonsmoker appeared to be facilitated by permeable identity boundaries, a continuous sense of identity, and a sense of mastery of quitting. Conflicted smoker identities were observed among participants who continued to smoke, along with barriers that appeared to prevent them from identifying with nonsmoking. Among these participants psychological (e.g. using downward comparisons with worse-off smokers) and behavioral strategies (e.g. hiding smoking from others) were seen that may serve to resolve identity conflict and protect a positive sense of identity. Our findings suggest that transition toward a nonsmoker identity may be necessary for successful quitting. Future research investigating ways to help smokers to perceive themselves increasingly as nonsmokers appears indicated.

Progression towards smoking cessation: Qualitative analysis of successful, unsuccessful, and never quitters.

BACKGROUND: Understanding how people transition between phases of not making a quit attempt to stopping smoking successfully is important in order to optimize interventions. This study aimed to explore differences in attitudes towards smoking and quitting among smokers and ex-smokers. METHODS: Adult (age 18 and over) successful (n = 8), unsuccessful (n = 8) and never quitters (n = 7) were recruited through stop-smoking services in England. Semi-structured interviews were conducted and data were analysed using framework analysis. RESULTS: Seven themes (starting to smoke, positive appraisal of smoking, responsibility for past/current smoking, negative effects of smoking, reasons to quit, process of quitting, and identity) were identified in all groups. Sub-group differences were explored and used to derive six typologies with descriptive characteristics: committed smokers, aware smokers, forced attempters, struggling attempters, pragmatic ex-smokers, and committed non-smokers. Using these typologies and the smallest number of differentiating factors between them (awareness of negative effects, motivation to stop and acceptance of responsibility), a parsimonious model of progression towards smoking cessation was developed. CONCLUSIONS: Awareness of negative effects, motivation and, crucially, a sense of commitment for taking responsibility to take actions towards behavior change may be important for whether smokers attempt to quit and progress to a successful quit attempt.

A Systematic Review of Factors Associated with Non-Adherence to Treatment for Immune-Mediated Inflammatory Diseases.

BACKGROUND: Non-adherence impacts negatively on patient health outcomes and has associated economic costs. Understanding drivers of treatment adherence in immune-mediated inflammatory diseases is key for the development of effective strategies to tackle non-adherence. OBJECTIVE: To identify factors associated with treatment non-adherence across diseases in three clinical areas: rheumatology, gastroenterology, and dermatology. DESIGN: Systematic review. DATA SOURCES: Articles published in PubMed, Science Direct, PsychINFO and the Cochrane Library from January 1, 1980 to February 14, 2014. STUDY SELECTION: Studies were eligible if they included patients with a diagnosis of rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, or psoriasis and included statistics to examine associations of factors with non-adherence. DATA EXTRACTION: Data were extracted by the first reviewer using a standardized 23-item form and verified by a second/third reviewer. Quality assessment was carried out for each study using a 16-item quality checklist. RESULTS: 73 studies were identified for inclusion in the review. Demographic or clinical factors were not consistently associated with non-adherence. Limited evidence was found for an association between non-adherence and treatment factors such as dosing frequency. Consistent associations with adherence were found for psychosocial factors, with the strongest evidence for the impact of the healthcare professional-patient relationship, perceptions of treatment concerns and depression, lower treatment self-efficacy and necessity beliefs, and practical barriers to treatment. CONCLUSIONS: While examined in only a minority of studies, the strongest evidence found for non-adherence were psychosocial factors. Interventions designed to address these factors may be most effective in tackling treatment non-adherence.

Structured smoking cessation training for health professionals on cardiology wards: a prospective study.

BACKGROUND: Smoking is a major cardiovascular risk factor, and smoking cessation is imperative for patients hospitalized with a cardiovascular event. This study aimed to evaluate a systems-based approach to helping hospitalized smokers quit and to identify implementation barriers. DESIGN: Prospective intervention study followed by qualitative analysis of staff interviews. METHODS: The prospective intervention study assessed the effects of implementing standard operating procedures (SOPs) for the provision of counselling and pharmacotherapy to smokers admitted to cardiology wards on counselling frequency. In addition, a qualitative analysis of staff interviews was undertaken to examine determinants of physician and nurse behaviour; this sought to understand barriers in terms of motivation, capability, and/or opportunity. RESULTS: A total of 150 smoking patients were included in the study (75 before and 75 after SOP implementation). Before the implementation of SOPs, the proportion of patients reporting to have received cessation counselling from physicians and nurses was 6.7% and 1.3%, respectively. Following SOP implementation, these proportions increased to 38.7% (p < 0.001) and 2.7% (p = 0.56), respectively. Qualitative analysis revealed that lack of motivation, e.g. role incongruence, appeared to be a major barrier. CONCLUSIONS: Introduction of a set of standard operating procedures for smoking cessation advice was effective with physicians but not nurses. Analysis of barriers to implementation highlighted lack of motivation rather than capability or opportunity as a major factor that would need to be addressed.

Randomized trial of nicotine replacement therapy (NRT), bupropion and NRT plus bupropion for smoking cessation: effectiveness in clinical practice.

BACKGROUND AND AIMS: Bupropion was introduced for smoking cessation following a pivotal trial showing that it gave improved efficacy over the nicotine patch and also suggesting combination treatment was beneficial. We tested in clinical practice for an effectiveness difference between bupropion and nicotine replacement therapy (NRT), whether the combination improves effectiveness and whether either treatment might be more beneficial for certain subgroups of smokers. DESIGN: Open-label randomized controlled trial with 6-month follow-up. SETTING: Four UK National Health Service (NHS) smoking cessation clinics. PARTICIPANTS: Smokers (n = 1071) received seven weekly behavioural support sessions and were randomized to an NRT product of their choice (n = 418), bupropion (n = 409) or NRT plus bupropion (n = 244). MEASURES: The primary outcome was self-reported cessation over 6 months, with biochemical verification at 1 and 6 months. Also measured were baseline demographics, health history, smoking characteristics and unwanted events during treatment. FINDINGS: Abstinence rates for bupropion (27.9%) and NRT (24.2%) were not significantly different (odds ratio = 1.21, 95% confidence interval = 0.883-1.67), and the combination rate (24.2%) was similar to that for either treatment alone. There was some evidence that the relative effectiveness of bupropion and NRT differed according to depression (χ(2) = 2.86, P = 0.091), with bupropion appearing more beneficial than NRT in those with a history of depression (29.8 versus 18.5%). Several unwanted symptoms were more common with bupropion. CONCLUSION: There is no difference in smoking cessation effectiveness among bupropion, nicotine replacement therapy and their combination when used with behavioural support in clinical practice. There is some evidence that bupropion is more beneficial than nicotine replacement therapy for smokers with a history of depression.

The use of nicotine replacement therapy for smoking reduction and temporary abstinence: an interview study.

INTRODUCTION: Nicotine replacement therapy (NRT) is commonly used to aid smoking reduction (SR) or in situations of enforced temporary abstinence (TA). National Surveys have suggested that in the general population of smokers, the use of NRT in these ways has little effect on cigarette consumption and that use of the nicotine patch is common. This study aimed to gain a better understanding of what might underlie this. METHODS: Semistructured telephone interviews were conducted with 36 smokers who reported that they were using NRT for SR and/or TA. Open-ended questions explored smokers' knowledge, beliefs, and experience of using NRT for SR and/or TA. Interviews were analyzed using a variant of framework analysis. RESULTS: Smokers reported using a variety of methods to reduce their cigarette consumption, including increasing the interval between cigarettes and attempting nondaily or social smoking. Smokers also modified how they smoked their cigarettes by trying to inhale less, not inhaling at all, or only smoking part of the cigarette. Nicotine patches appeared to be popular because they were discreet, easy to use, provided a prolonged effect, and had an established history. Smokers had little knowledge of the regulatory restrictions on the use of NRT. CONCLUSIONS: Smokers used a wide variety of means of reducing smoke exposure without stopping completely, including ones that did not involve reducing consumption. Nicotine patches were considered convenient to help with this, and there appeared to be little awareness of regulatory restrictions on their use.

Transition towards a 'non-smoker' identity following smoking cessation: an interpretative phenomenological analysis.

OBJECTIVE: A recent theory of motivation (PRIME theory) has proposed that the formation of a 'non-smoker' identity is necessary for long-term abstinence. This study aimed to explore how a smoker's sense of identity changes following smoking cessation. DESIGN: This was a qualitative, semi-structured interview study with a purposive sample of individuals who had quit smoking. An interpretative phenomenological approach was taken to elicit in-depth accounts of the participants' understanding of smoking, stopping, and maintaining abstinence. METHODS: Ten participants who quit smoking with the support of a National Health Service (NHS) stop-smoking service in England and were still abstinent a year later were interviewed. An interpretative phenomenological analysis of the interview transcripts was conducted. Prospective contextual detail of motivational and other variables pre-quit were also obtained from the clinic assessment form that participants completed at the first group session. RESULTS: A process of identity change was observed towards that of a 'non-smoker', assisted initially by a transient identity of 'team stop-smoker' accompanied by a sense of achievement. All participants retained a residual attraction to smoking suggesting that the process was not complete and reflecting an 'ex-smoker' identity. Participants labelled themselves as non-smokers regardless of how much transition had occurred. CONCLUSIONS: It appears useful to distinguish two levels of 'non-smoker' identity: a surface level comprising the simple label and a deep level made up of often conflicting thoughts and feelings about oneself in relation to smoking. A total coherent 'non-smoker' identity does not appear to be necessary for long-term abstinence.

Predictors of attempts to stop smoking and their success in adult general population samples: a systematic review.

AIMS: To identify the predictors of attempts to stop smoking and the predictors of quit attempt success in adult general population samples. METHODS: We performed an electronic search of EMBASE, Pubmed, Web of Science, PsychINFO and the Cochrane Tobacco Addiction Group specialized register for articles that examined, in prospective adult general population samples, predictors of quit attempts and the success of quit attempts. Experts were contacted for knowledge of other relevant studies. Eight studies met the inclusion criteria and results were extracted independently by two researchers. RESULTS: There was considerable methodological heterogeneity between studies. Motivational factors dominated the prediction of quit attempts, whereas only cigarette dependence consistently predicted success after an attempt had been made. Social grade also appeared to predict success but was only examined in two studies. None of the other socio-demographic factors consistently predicted making a quit attempt or success. CONCLUSIONS: Population-level studies from a number of countries show that past quit attempts and measures of motivation to stop are highly predictive of quit attempts, whereas only measures of dependence are consistently predictive of success of those attempts. Gender, age and marital status and educational level are not related consistently to quit attempts or quit success across countries.

'The smoking toolkit study': a national study of smoking and smoking cessation in England.

BACKGROUND: Up-to-date data tracking of national smoking patterns and cessation-related behaviour is required to evaluate and inform tobacco control strategies. The Smoking Toolkit Study (STS) was designed for this role. This paper describes the methodology of the STS and examines as far as possible the representativeness of the samples. METHODS: The STS consists of monthly, cross sectional household interviews of adults aged 16 and over in England with smokers and recent ex-smokers in each monthly wave followed up by postal questionnaires three and six months later. Between November 2006 and December 2010 the baseline survey was completed by 90,568 participants. STS demographic, prevalence and cigarette consumption estimates are compared with those from the Health Survey for England (HSE) and the General Lifestyle Survey (GLF) for 2007-2009. RESULTS: Smoking prevalence estimates of all the surveys were similar from 2008 onwards (e.g 2008 STS=22.0%, 95% C.I.=21.4% to 22.6%, HSE=21.7%, 95% C.I.=20.9% to 22.6%, GLF=20.8%, 95% C.I.=19.7% to 21.9%), although there was heterogeneity in 2007 (chi-square=50.30, p<0.001). Some differences were observed across surveys within sociodemographic sub-groups, although largely in 2007. Cigarette consumption was virtually identical in all surveys and years. CONCLUSION: There is reason to believe that the STS findings (see http://www.smokinginengland.info) are generalisable to the adult population of England.

Residual attraction to smoking and smoker identity following smoking cessation.

INTRODUCTION: Anecdotal reports suggest that some long-term ex-smokers retain a residual attraction to smoking and a "smoker identity," although little systematic data on this exist. These are important because they may increase the likelihood of relapse. This study aimed to quantify the extent of these characteristics in relation to length of abstinence. METHODS: A postal questionnaire on residual attraction to smoking, smoker identity, and vulnerability to relapse was sent to 1,390 adults known to have been abstinent for 4 weeks after treatment support with a large stop smoking service in England. Time since the end of treatment varied between 6 weeks and 3 years. Three hundred and fifty-seven ex-smokers responded and were included in the analysis. RESULTS: The proportion of ex-smokers reporting a residual attraction to smoking, a smoker identity, and a vulnerability to relapse declined with duration of abstinence (all p < .001), although even among those having 2 years or more of abstinence, 37.4% (95% CI = 27.9%-47.7%) reported some residual attraction and 16.3% (95% CI = 9.6%-25.2%) retained a smoker identity. By contrast, after 2 or more years of abstinence, only 7% thought they would ever return to smoking (95% CI = 2.9%-14.2%). DISCUSSION: The findings suggest that residual attraction to cigarettes is common among long-term ex-smokers, and a significant minority retain a smoker identity. Further studies are needed to determine how far these characteristics are associated with late relapse.

Smoking intentions and mood preceding lapse after completion of treatment to aid smoking cessation.

OBJECTIVE: To examine the situation preceding "late" smoking relapse, particularly the availability of tobacco, mood and intentions at first lapse. METHODS: A questionnaire was sent to 1439 adults identified as abstinent after treatment with a National Health Service stop-smoking clinic over the previous 3 years. Relapsers were asked where they had obtained their first cigarette, their mood and intentions immediately before first lapse. RESULTS: 40% (n = 556) responded, of whom 35.8% (n = 199) had relapsed. At the time of first lapse, only 27.1% had made a decision to return to smoking while 48.9% intended to smoke only one or two cigarettes before stopping again. In 45.7% of cases, respondents bought cigarettes to smoke again. Prior to lapse the majority (53.8%) reported "really needing a cigarette". Similarly 53.8% reported being miserable at the time, while only 16% were happy. CONCLUSION: The most common pattern of late lapse appears to be intending to suspend the quit attempt temporarily in circumstances of needing to smoke and of negative emotional state, and in many cases cigarettes are actually sought out. PRACTICE IMPLICATIONS: Promoting strong 'not a puff' rules, a non-smoker identity and identifying negative mood as a potential vulnerability are important components of relapse prevention intervention.

A randomised trial of glucose tablets to aid smoking cessation.

RATIONALE: Oral glucose has been found to decrease tobacco craving among abstaining smokers. One study has demonstrated an effect of glucose on short-term abstinence. There is a need to examine any long-term benefit of glucose on abstinence. OBJECTIVES: To assess whether glucose tablets improve 6-month continuous abstinence rates compared with low-calorie placebo tablets. METHODS: Smokers attempting to stop (n = 928) were randomised to receive glucose or sorbitol (placebo) in a double-blind placebo-controlled trial. All participants received group-based psychological support, and approximately half (n = 474) received nicotine replacement therapy (NRT), buproprion, or both. Smokers were seen weekly for 5 weeks and used tablets ad libitum, with a recommended minimum of 12 per day. Participants were recruited through general practitioner referral, word of mouth, and advertising. The participants were 38% male, smoked an average of 23.5 cigarettes per day, and had a mean age of 44 years. There were no significant pretreatment differences between groups. The primary outcome measure was continuous, CO-verified abstinence from the target quit date for 6 months. RESULTS: No significant effect of glucose tablets on abstinence was found (14.6% vs 13.4% abstinence in the glucose and placebo groups, respectively). However, there was a significant interaction with a glucose effect observed in smokers also receiving other medication (18.2% vs 12.6%, p < 0.05) but not otherwise (10.7% vs 14.3% ; p < 0.05 for the interaction). CONCLUSIONS: No significant effect of glucose tablets over and above sweet tasting tablets could be detected overall, but the possibility of an effect as an adjunct to NRT or bupropion merits further investigation.