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North American Quitline Consortium
July 2015

For quick navigation, please click on the titles below of the topics featured in this month's issue of Connections
  Time-Sensitive News


NAQC News

NAQC Conference 2015 The Conference is a Month Away!
Join us for the upcoming conference, The Future of Quitlines: Refining and Redefining Our Practices for Success! taking place on  August 17thand 18thin Atlanta, Georgia. Space is limited so secure your spot today!

Important dates to keep in mind:
July 31 – deadline for booking rooms at Crowne Plaza Atlanta Perimeter at Ravinia
August 10 – registration deadline click here for more details

Preliminary conference agenda is now available here and we have a few exhibitor spaces that you can reserve (find out more here).

If you have any questions about the upcoming conference or need assistance with the registration, please contact NAQC at membership@naquitline.org. Hope to see you in Atlanta!

NAQC Membership Drive Renewal Deadline is Extended until August 14! 
Thanks to all NAQC members who have already renewed their membership dues for FY16! Many of you have reached out to us asking for an extension of the membership renewal deadline and to accommodate your requests, we have extended the deadline from July 1 to August 14. To avoid interruption in your membership services, please submit your membership dues (payments are accepted in a form of a check, credit card payment, and online renewal) prior to 5 pm ET on August 14.

For questions regarding membership, please contact Natalia Gromov at 800-398-5489 ext. 701 or membership@naquitline.org.

New! Enhancing eReferral Capacity Project Website and Resources Are Now Available!
In May 2015, North American Quitline Consortium, in collaboration with the Smoking Cessation Leadership Center and with funding from Pfizer Independent Grants for Learning & Change launched a project to establish national capacity among state quitlines for engaging in eReferral with healthcare organizations. This project focuses on improving the performance of health professionals (i.e., quitline and healthcare professionals) and  healthcare systems (i.e., enhancing the capacity of both quitlines and healthcare organizations to conduct eReferral) so that more smokers receive effective cessation treatment. We have developed a NEW webpage for this project which will update over the grant project to include resources, materials and trainings on eReferral. Check out the new website HERE.

We are also pleased to announce that on July 9, 2015, a webinar was hosted for Enhancing eReferral Capacity Project participants. This webinar on "Selecting Healthcare Partners for eReferral and Strategies for Building Successful Partnership” is the first in a series of six training sessions designed to help project participants enhance their eReferral knowledge and capacity. During the training we learned from two colleagues who have experience selecting and partnering with healthcare organizations on systems change, integration and partnership to implement eReferrals for quitlines. Strategies that have been effective in selecting and engaging healthcare organizations for eReferral, and challenges, success factors and lessons learned during implementation were explored. NAQC members are invited to view the webinar slides and recorded archive by visiting the new project webpage at http://www.naquitline.org/?page=EEC.  An audio file will be posted SOON!
 

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Time-Sensitive News

WEBINAR on JULY 14!  Building Excellence in Evaluation: Examples in Chronic Disease Prevention from Alabama!
The Alabama Department of Public Health and Washington University in St. Louis are presenting a satellite conference on evidence-based public health practices including program evaluation on July 14.

Program objectives include the following:
1. Introduce the Brownson evidence-based public health (EBPH) framework.
2. Provide an overview of types of program evaluation.
3. Describe the ADPH WISEWOMAN evaluation framework.
4. Share lessons learned from ADPH Quitline evaluations.
5. Identify benefits and uses of qualitative program evaluation approaches.
6. Promote the online availability of EBPH training modules for further learning.

Register for the upcoming satellite conference and live webcast, Building Excellence in Evaluation: Examples in Chronic Disease Prevention from Alabama. This program will be broadcast on Tuesday, July 14, 2015; 10:00-11:30 a.m. (Central Time).
To see the conference flyer for this program click here.
To register for this program click here.
To view all upcoming programs, visit our website: www.adph.org/alphtn

New York State Smokers' Quitline- RFP# 15598 - DEADLINE of AUGUST 3!
The New York State Department of Health (Department), Bureau of Tobacco Control (BTC) is requesting proposals to provide telephonic and internet-based information and tobacco use cessation services to New York State residents seeking 1) information on quitting smoking or quitting use of other tobacco products; and 2) coaching, support, and assistance with quitting smoking or other tobacco use; and smoking or other tobacco use relapse prevention.
 
This RFP seeks an awardee that will provide Quitline and Quitsite interventions to promote and support cessation among New York's smokers by providing evidenced-based services such as coaching and counseling by phone, approved and effective medications to callers without the financial resources to purchase over-the-counter medication at no cost (e.g., nicotine replacement therapies), and informational services for those New Yorkers trying to quit smoking or who have recently quit smoking.
 
Proposals will be accepted through August 3, 2015, from companies or organizations located within the continental United States, Hawaii or Puerto Rico that have at least three (3) years of experience providing tobacco cessation call center services and at least three (3) years of experience providing web-based tobacco use cessation services.
 
The RFP is posted on the New York State Department of Health website at: http://www.health.ny.gov/funding/rfp/15598/index.htm

Tackling Tobacco Use in Vulnerable Populations - ABSTRACT SUBMISSION DEADLINE of AUGUST 3!
The Central East Addiction Technology Transfer Center a program of the Danya Institute is pleased to invite the submission of poster abstracts for the 2015 National Conference on Tackling Tobacco Use in Vulnerable Populations Poster Presentation, to be held in Bethesda, Maryland, October 5-6, 2015.
Please complete the online form to submit a poster abstract for consideration at the 2015 Conference. Completed forms should be submitted online by August 3, 2015. Notification of your submission’s status will be emailed by August 24, 2015, together with presentation instructions. Click here to submit your poster abstract.

BHWP Opens Registration for Tobacco Treatment Specialist Program!
BHWP has opened registration for its fall Rocky Mountain Tobacco Treatment Specialist Certification (RMTTS-C) Program. The RMTTS-C Program is being offered October 12 through October 15, 2015 at the Anschutz Medical Campus in Aurora, Colorado. The cost of the program is $1,200 and includes the training, examination, and certification. 
 
The fully accredited RMTTS-C Program provides a comprehensive and convenient process by which interdisciplinary healthcare providers and community and public health professionals can become TTS-certified. This program offers the highest quality tobacco cessation training based on the latest evidence-based research and treatment strategies. 
» learn more

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Tobacco Control

Electronic Referral Gets Pennsylvania Smokers Help Quitting!
UPMC has launched a pilot program giving its physicians the ability to refer hospitalized patients who use tobacco to the Pennsylvania Free Quitline directly through UPMC’s electronic health record (EHR). It is the first electronic tobacco cessation referral program in the nation that has been integrated into EHRs that are certified for Stage 2 Meaningful Use.

The eReferral system is bi-directional, which allows the PA Free Quitline, operated by National Jewish Health, to receive eReferrals and to send progress reports on patients’ treatment outcomes back to referring physicians and primary care teams. Once a patient referral is received, a quitline counselor reaches out to the patient and attempts to enroll him or her in the quitline program. The quitline includes telephone coaching, nicotine replacement therapy, an integrated website, text messaging, email support, and a mobile app, and is founded in behavioral change, motivational interviewing and Cognitive Behavioral Therapy."

The UPMC eReferral system is the result of collaboration among the Pennsylvania Department of Health, National Jewish Health and UPMC.
» learn more

NCI Funds $3.1M Fred Hutch Clinical Trial of Smoking-Cessation Smartphone App!
Jonathan Bricker, Ph.D., a behavioral scientist at Fred Hutchinson Cancer Research Center and the University of Washington, has received a $3.1 million, five-year grant from the National Cancer Institute to conduct a randomized, controlled clinical trial of SmartQuit, a smoking-cessation smartphone app.

The new trial follows on the heels of a pilot randomized trial of SmartQuit he conducted in collaboration with UW and 2Morrow Mobile – the first randomized, controlled trial comparing the effectiveness of smoking-cessation programs delivered via mobile apps.
» learn more

FDA: Advance Notice of Proposed Rulemaking (ANPRM)!
DEADLINE: This ANPRM will be available for comment for 60 days, beginning July 1, 2015.
FDA is seeking comments, data, research, and/or other information related to nicotine exposure warnings and child-resistant packaging for liquid nicotine, nicotine-containing e-liquid(s), and potentially for other tobacco products including, but not limited to novel tobacco products such as dissolvables, lotions, gels, and drinks.
 
FDA has evaluated data and science related to the risks, especially to infants and children, from accidental exposure to nicotine, including exposure to liquid nicotine and nicotine-containing e-liquid (s). The continuing rise in popularity of electronic nicotine devices (ENDS), such as e-cigarettes, which often use liquid nicotine and nicotine-containing e-liquids, has coincided with an increase in calls to poison control centers and visits to emergency rooms related to liquid nicotine poisoning and other nicotine exposure risks. FDA’s assessment of these recent trends has led the agency to seek additional information on whether, based on the acute toxicity of nicotine (up to and including nicotine poisoning), it would be appropriate for the protection of the public health to:

  • Warn the public about the dangers of nicotine exposure (especially due to inadvertent nicotine exposure in infants and children); and/or
  • Require some tobacco products be sold in child-resistant packaging.                                         

FDA values the public’s input through the comment process and will consider all input, data, research, and other information submitted to the docket to help the agency make the best decisions about possible regulatory actions. If FDA decides to issue a rule, the first step in that process would be to issue a Notice of Proposed Rulemaking in the Federal Register, which would give the public an opportunity to comment on the proposal.
» learn more

CDC Press Release: Three out of 4 American Adults Favor Making 21 the Minimum Age of Sale for Tobacco Product!
Three out of 4 American adults—including 7 in 10 cigarette smokers—favor raising the minimum age of sale for all tobacco products to 21, according to an article by CDC published in the American Journal of Preventive Medicine.  While an overwhelming majority of adults favored the policy overall, favorability is slightly higher among adults who never smoked and older adults. In contrast, 11 percent of adults strongly opposed making 21 the legal age of sale, while 14 percent somewhat opposed such measures.
» learn more

CVS Health Demonstrates Integrity and Corporate Leadership With its Decision to Resign From U.S. Chamber of Commerce!
Demonstrating true corporate leadership, today CVSHealth announced it is resigning from the US Chamber of Commerce because of the Chamber’s activities supporting the tobacco industry in the U.S. and across the globe. When the leaders of CVS Health decided last year to stop selling tobacco products, CEO Larry Merlo explained it well. “Put simply,” he said, “the sale of tobacco products is inconsistent with our purpose.”
The New York Times story about CVS’ decision to resign from the US Chamber of Commerce - http://www.nytimes.com/2015/07/08/business/cvs-health-quits-us-chamber-over-stance-on-smoking.html?_r=1
 » learn more

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Research
 
Jidong Huang, Kimp Walton, Robert B. Gerzoff, Brian A. King, Frank J. Chaloupka
State Tobacco Control Program Spending — United States, 2011.
MMWR / June 26, 2015 / Vol. 64 / No. 24

Evidence-based, statewide tobacco control programs that are comprehensive, sustained, and accountable reduce smoking rates and tobacco-related diseases and deaths. States that made larger investments in tobacco prevention and control saw larger declines in cigarettes sales than the United States as a whole. The prevalence of smoking has declined faster as spending for tobacco control programs has increased. In fiscal year 2011, for tobacco prevention and control activities, all 50 states and the District of Columbia combined spent $658 million ($2.11 per capita) in the following categories: 41.4% on state and community interventions ($272 million [$0.87 per capita]); 18.8% on health communication interventions ($124 million [$0.40 per capita]); 20.4% on cessation interventions ($134 million [$0.43 per capita]); 9.3% on surveillance and evaluation ($61 million [$0.20 per capita]); and 10.1% on surveillance and evaluation ($67 million [$0.21 per capita]). The total spent was 17.8% of CDC’s recommended amount.

State investments in tobacco prevention and control programs in fiscal year 2011 were considerably less than levels recommended in CDC’s Best Practices. Full implementation of comprehensive tobacco control policies and evidence-based interventions at CDC-recommended funding levels could result in a substantial reduction in tobacco-related morbidity and mortality and billions of dollars in savings from averted medical costs and lost productivity in the United States.

Margarete C. Kulik, Stanton A. Glantz.
The Smoking Population in the USE and EU is Softening Not Hardening.
Tob Control doi:10.1136/tobaccocontrol-2015-052329
 
It has been argued that as smoking prevalence declines in countries, the smokers that remain include higher proportions of those who are unwilling or unable to quit (a process known as ‘hardening’). Smokeless tobacco and e-cigarettes have been promoted as a strategy to deal with such smokers. If hardening is occurring, there would be a positive association between smoking prevalence and quitting, with less quitting at lower prevalence. There would also be a neutral or negative association between prevalence and the number of cigarettes smoked. We examined US state-level associations using the Tobacco Use Supplement (1992/1993–2010/2011) and Eurobarometer surveys for 31 European countries (2006–2009–2012) using regressions of quit attempts, quit ratios, and number of cigarettes smoked on smoking prevalence over time.
 
For each 1% drop in smoking prevalence, quit attempts increase by 0.55%±.07 (p<0.001) in the USA and remain stable in Europe (p=0.53), US quit ratios increase by 1.13%±0.06 (p<0.001), and consumption drops by 0.32 cig/day±0.02 (p<0.001) in the USA and 0.22 cig/day±0.05 (p<0.001) in Europe. These associations remain stable over time (p>0.24), with significantly lower consumption at any given prevalence level as time passed in the USA (−0.15 (cig/day)/year±0.06, p<0.05). Consistent with prior research using different data and methods, these population-level results reject the hypothesis of hardening as smoking prevalence drops, instead supporting softening of the smoking population as prevalence declines.
 
Jennifer S. Haas, MD, MSc; Jeffrey A. Linder, MD, MPH; Elyse R. Park, PhD, MPH; Irina Gonzalez, MD, TTS; Nancy A. Rigotti, MD; Elissa V. Klinger, ScM; Emily Z. Kontos, ScD; Alan M. Zaslavsky, PhD; Phyllis Brawarsky, MPH; Lucas X. Marinacci, BA; Stella St Hubert, AB; Eric W. Fleegler, MD, MPH; David R. Williams, PhD, MPH
Proactive Tobacco Cessation Outreach to Smokers of Low Socioeconomic Status A Randomized Clinical Trial.
JAMA Internal Medicine February 2015 Volume 175, Number 2
 
Widening socioeconomic disparities in mortality in the United States are largely explained by slower declines in tobacco use among smokers of low socioeconomic status (SES) than among those of higher SES, which points to the need for targeted tobacco cessation interventions. Documentation of smoking status in electronic health records (EHRs) provides the tools for health systems to proactively offer tobacco treatment to socioeconomically disadvantaged smokers. Proactive, IVR-facilitated outreach enables engagement with low-SES smokers. Providing counseling, NRT, and access to community-based resources to address sociocontextual mediators among smokers reached in this setting is effective.
 
Elyse R. Park, PhD, MPH; Ilana F. Gareen, PhD; Sandra Japuntich, PhD; Inga Lennes, MD; Kelly Hyland, BA; Sarah DeMello, MS; JoRean D. Sicks, MS; Nancy A. Rigotti, MD
Primary Care Provider-Delivered Smoking Cessation Interventions and Smoking Cessation Among Participants in the National Lung Screening Trial. 
JAMA Intern Med. doi:10.1001/jamainternmed.2015.2391 Published online June 15, 2015.
 
The National Lung Screening Trial (NLST) found a reduction in lung cancer mortality among participants screened with low-dose computed tomography vs chest radiography. In February 2015, Medicare announced its decision to cover annual lung screening for patients with a significant smoking history. These guidelines promote smoking cessation treatment as an adjunct to screening, but the frequency and effectiveness of clinician-delivered smoking cessation interventions delivered after lung screening are unknown. Assist and arrange follow-up delivered by primary care providers to smokers who were participating in the NLST were associated with increased quitting; less intensive interventions (ask, advise, and assess) were not. However, rates of assist and arrange follow-up were relatively low. Our findings confirm the need for and benefit of clinicians taking more active intervention steps in helping patients who undergo screening to quit smoking.
 
Rebecca L. Siegel, MPH Eric J. Jacobs, PhD Christina C. Newton, MSPH Diane Feskanich, ScD Neal D. Freedman, PhD Ross L. Prentice, PhD Ahmedin Jemal, DVM, PhD
Research Letter: Deaths Due to Cigarette Smoking for 12 Smoking-Related Cancers in the United States.
JAMA Internal Medicine Published online June 15, 2015
 
The 2014 US Surgeon General’s Report provided the estimated annual number of smoking-attributable deaths during 2005 to 2009 from cancer overall and lung cancer specifically but not separately for the 11 other cancers found to be caused by smoking.1 Current estimates of smoking attributable mortality for specific cancer sites are based on data from 2000 to 2004.2 Updated estimates are needed because smoking patterns and the magnitude of the association between smoking and cancer death have changed in the past decade. From 2000 to 2012, smoking prevalence decreased from 23.2% to 18.1%.3 In contrast to this favorable trend, recently published data revealed that the risk of cancer death among smokers can increase over time.4 Therefore, we estimated the number and proportion of deaths in the United States in 2011 attributable to cigarette smoking for 12 cancers caused by smoking.
 
Michael K. Ong, MD, PhD
Invited Commentary: Tobacco Cessation—We Can Do Better. 
JAMA Internal Medicine Published online June 15, 2015
 
Tobacco use continues to be the leading preventable cause of mortality in the United States, despite a decrease in the overall prevalence of cigarette smoking. In this issue of JAMA Internal Medicine, Siegel et al1 report that cigarette smoking continues to be the attributable cause of death for nearly half of people dying of 12 different cancers and notably 80% of people dying of lung cancer. Recent data also suggest that focusing only on mortality from conditions in which causal relationships have been established underestimates smoking-related mortality because an additional 17% of excess smoking-related mortality is associated with causes not formally established as attributable to smoking.
 
Despite continued promotional efforts by the tobacco industry, the silver lining for cessation efforts is that most smokers want to quit; national surveys consistently reveal that 70% of smokers want to quit and 50% of smokers have had a quit attempt in the past year.8 We need to ensure that we are offering tobacco cessation assistance, whether counseling or medication prescription or referral to a tobacco cessation resource, to every tobacco user every time that user encounters the health care system.
 
Michael S. Amato, Raymond G. Boyle, David Levy
How to Define E-cigarette Prevalence? Finding Clues in the Use Frequency Distribution.
Tob Control 2015;0:1–6. doi:10.1136/tobaccocontrol-2015-052236
 
E-cigarette use has rapidly increased. Recent studies define prevalence using a variety of measures; competing definitions challenge cross-study comparison. We sought to understand patterns of use by investigating the number of days out of the past 30 days when adults had used e-cigarettes. We used the 2014 Minnesota Adult Tobacco Survey, a random digit dial population survey (n=9304 adults). Questions included ever using e-cigarettes, number of days used in the past 30 days and reasons for use. Smoking status was determined by combustible cigarette use. Histograms of e-cigarette use were visually inspected for current, former and never smokers with any 30-day e-cigarette use. Different definitions of current use were compared.
 
Use ≤5 days in the past 30 days demarcated a cluster of infrequent users at the low end of the distribution. Among those with use in the past 30 days, infrequent users were the majorities of current (59%) and never smokers (89.5%), but fewer than half of former smokers (43.2%). Infrequent users were more likely to cite curiosity and less likely to cite quitting/ cutting down other tobacco use as reasons for use. Defining adult prevalence as any use in the past 30 days may include experimenters unlikely to continue use, and is of questionable utility for population surveillance of public health trends over time. Defining prevalence as >5 days excludes those infrequent users.
 
Hyaneyoung Olvera, Jafar Bakhshaie, Lorra Garey, Charles Jardin, Norman B. Schmidt, and Michael J. Zvolensky
The Role of Anxiety Sensitivity in the Relation Between Trait Worry and Smoking Behavior.
Nicotine Tob Res (2015) 17 (6): 682-689 doi:10.1093/ntr/ntu233
 
Smoking and anxiety disorders frequently co-occur. Trait worry is a core symptom of anxiety disorders. While research suggests worry processes may be important to certain smoking behaviors, the mechanisms explicating these relations remain unknown. The current study examined anxiety sensitivity (AS) as a potential mediator for the relation between trait worry and number of years being a daily smoker, latency to first cigarette of the day, smoking rate, heaviness of smoking, and nicotine dependence among treatment-seeking daily smokers (N = 376; 47% female; M age = 37.76, SD = 13.46).

Consistent with prediction, AS significantly mediated the relations between trait worry and the studied smoking variables. The present findings suggest it may be useful to clinically address AS among worry-prone, treatment-seeking daily smokers in order to address smoking behavior.
 
Jessica M. Rath, Andrea C. Villanti, Valerie F. Williams, Amanda Richardson, Jennifer L. Pearson, Donna M. Vallone.
Patterns of Longitudinal Transitions in Menthol Use Among U.S. Young Adult Smokers.
Nicotine Tob Res. 2015 Jul;17(7):839-46.
 
Menthol is the only characterizing flavor in cigarettes that was not banned as part of the 2009 Family Smoking Prevention and Tobacco Control Act. This longitudinal study explores the role of menthol in smoking initiation and progression. Purpose (a) to examine young adult patterns of menthol cigarette use including switching between menthol and non-menthol and (b) to describe associations between these patterns of menthol use and cessation related intentions and behaviors. Additional data on the role of menthol in cigarettes on smoking uptake and maintenance is needed to inform proposed policy making at the local, state, and national levels.

Using 3 time points from a longitudinal national sample of young adults aged 18–34 years (N = 267 smokers), patterns of menthol use over 1 year were defined among smokers as: (a) remained menthol smoker; (b) remained non-menthol smoker; (c) switched from menthol to non-menthol; and (d) switched from non-menthol to menthol. Associations were assessed between current menthol cigarette use and cessation intentions and behaviors.
 
Significant predictors of current menthol cigarette use at 1 year included initiation with menthol (OR = 8.26), Black race (OR = 23.60), and higher scores on the Allen menthol taste subscale (OR = 1.53). Menthol smokers were more likely to report intention to quit but no differences existed between menthol and non-menthol users in ever making a quit attempt. Most young adults stay with the product that they start smoking with. Menthol smokers were interested in quitting, but less interested in next 30-day action than non-menthol smokers.
 
Grace Kong, Meghan E. Morean, Dana A Cavallo, Deena R Camenga, Suchitra Krishnan-Sarin.
Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults.
Nicotine Tob Res (2015) 17 (7):847-854.doi: 10.1093/ntr/ntu257
 
Understanding why young people try and stop electronic cigarette (e-cigarette) use is critical to inform e-cigarette regulatory efforts. We conducted 18 focus groups (N = 127) in 1 middle school (MS), 2 high schools (HSs), and 2 colleges in Connecticut to assess themes related to e-cigarette experimentation and discontinuation. We then conducted surveys to evaluate these identified themes in 2 MSs, 4 HSs, and 1 college (N = 1,175) to explore whether reasons for e-cigarette experimentation and/or discontinuation differed by school level or cigarette smoking status.

From the focus groups, we identified experimentation themes (i.e., curiosity, flavors, family/peer influence, easy access, and perceptions of e-cigarettes as “cool” and as a healthier/better alternative to cigarettes) and discontinuation themes (i.e., health concerns, loss of interest, high cost, bad taste, and view of e-cigarettes as less satisfying than cigarettes). The survey data showed that the top reasons for experimentation were curiosity (54.4%), appealing flavors (43.8%), and peer influences (31.6%), and the top reasons for discontinuation were responses related to losing interest (23.6%), perceiving e-cigarettes as “uncool” (16.3%), and health concerns (12.1%). Cigarette smokers tried e-cigarettes because of the perceptions that they can be used anywhere and to quit smoking and discontinued because they were not as satisfying as cigarettes. School level differences were detected. E-cigarette prevention efforts toward youth should include limiting e-cigarette flavors, communicating messages emphasizing the health risks of use, and changing social norms surrounding the use of e-cigarettes. The results should be interpreted in light of the limitations of this study.
 
David R. Strong, Sean P. David, Elaine C. Johnstone, Paul Avevard, Michael F. Murphy, Marcus R. Munafo
Differential Efficacy of Nicotine Replacement Among Overweight and Obese Women Smokers.
Nicotine Tob Res. 2015 Jul;17(7):855-61
 
Rates of obesity are higher among more dependent smokers and 37%–65% of smokers seeking cessation treatment are overweight or obese. Overweight or obese smokers may possess metabolic and neurobiological features that contribute to difficulty achieving cessation using front-line nicotine replacement products. Attention to factors that facilitate effective cessation treatment in this vulnerable population is needed to significantly reduce mortality risk among overweight and obese smokers. This secondary analysis of 2 large trials of transdermal nicotine replacement in general medical practices evaluated the hypothesis that higher body mass index (BMI) would moderate the efficacy of the nicotine patch. We examined the potential for gender to further moderate the relationship between BMI and treatment efficacy.
 
In the placebo controlled trial (N = 1,621), 21-mg patch was no more effective than placebo for assisting biochemically verified point prevalence abstinence up to 1 year after quitting for women with higher BMI, but appeared to be effective for men at normal or high BMI (gender × BMI beta = −0.22, p = .004). We did not find differential long-term cessation outcomes among male or female smokers in the 15-mg patch trial (n = 705). However, we observed significantly higher rates of early lapse among women with higher BMI treated with nicotine patch across both trials. These results suggest that increased BMI may affect the efficacy of nicotine patch on reducing risk of early lapse in women. Additional research is needed to explore mechanisms of risk for decreased efficacy of this commonly used cessation aid.
 
Hillel R. Alpert, Isreal T. Agaku, Gregory N. Connolly
A Study of Pyrazines in Cigarettes and How Additives Might be Used to Enhance Tobacco Addiction.
Tob Control doi:10.1136/tobaccocontrol-2014-051943
 
Nicotine is known as the drug that is responsible for the addicted behaviour of tobacco users, but it has poor reinforcing effects when administered alone. Tobacco product design features enhance abuse liability by (A) optimising the dynamic delivery of nicotine to central nervous system receptors, and affecting smokers’ withdrawal symptoms, mood and behaviour; and (B) effecting conditioned learning, through sensory cues, including aroma, touch and visual stimulation, to create perceptions of pending nicotine reward. This study examines the use of additives called ‘pyrazines’, which may enhance abuse potential, their introduction in ‘lights’ and subsequently in the highly market successful Marlboro Lights (Gold) cigarettes and eventually many major brands. We conducted internal tobacco industry research using online databases in conjunction with published scientific literature research, based on an iterative feedback process.
 
Tobacco manufacturers developed the use of a range of compounds, including pyrazines, in order to enhance ‘light’ cigarette products’ acceptance and sales. Pyrazines with chemosensory and pharmacological effects were incorporated in the first ‘full-flavour, low-tar’ product achieving high market success. Such additives may enhance dependence by helping to optimise nicotine delivery and dosing and through cueing and learned behaviour. Cigarette additives and ingredients with chemosensory effects that promote addiction by acting synergistically with nicotine, increasing product appeal, easing smoking initiation, discouraging cessation or promoting relapse should be regulated by the US Food and Drug Administration. Current models of tobacco abuse liability could be revised to include more explicit roles with regard to non-nicotine constituents that enhance abuse potential.

Amanda Richardon, Ollie Ganz, Donna Vallone
Tobacco on the Web: Surveillance and Characterization of Online Tobacco and E-cigarette Advertising.
Tob Control 2015;24:341-347 doi:10.1136/tobaccocontrol-2013-051246
 
Despite the internet's broad reach and potential to influence consumer behaviour, there has been little examination of the volume, characteristics, and target audience of online tobacco and e-cigarette advertisements. A full-service advertising firm was used to collect all online banner/video advertisements occurring in the USA and Canada between 1 April 2012 and 1 April 2013. The advertisement and associated meta-data on brand, date range observed, first market, and spend were downloaded and summarised. Characteristics and themes of advertisements, as well as topic area and target demographics of websites on which advertisements appeared, were also examined.
 
Over a 1-year period, almost $2 million were spent by the e-cigarette and tobacco industries on the placement of their online product advertisements in the USA and Canada. Most was spent promoting two brands: NJOY e-cigarettes and Swedish Snus. There was almost no advertising of cigarettes. About 30% of all advertisements mentioned a price promotion, discount coupon or price break. e-Cigarette advertisements were most likely to feature messages of harm reduction (38%) or use for cessation (21%). Certain brands advertised on websites that contained up to 35% of youth (<18 years) as their audience. Online banner/video advertising is a tactic used mainly to advertise e-cigarettes and cigars rather than cigarettes, some with unproven claims about benefits to health. Given the reach and accessibility of online advertising to vulnerable populations such as youth and the potential for health claims to be misinterpreted, online advertisements need to be closely monitored.
 
John P. Jasek, Michael Johns, Ijeoma Mbamalu, Kari Auer, Elizabeth A. Kilgore, Susan M. Kansagra
One Cigarette is One too Many: Evaluation a Light Smoker-targeted Media Campaign.
Tob Control 2015;24:362-368 doi:10.1136/tobaccocontrol-2013-051348
 
Light smokers represent an increasing share of adult smokers in various parts of the world including New York City (NYC). Since 2007, the NYC Department of Health and Mental Hygiene has aired hard-hitting antitobacco media campaigns paired with time-limited nicotine replacement therapy (NRT) giveaways. We evaluated an original antitobacco media campaign, developed to increase awareness of smoking risks and encourage cessation service use among light smokers in NYC. We compared cessation service request volume during the campaign to historical periods without ads targeting light smokers. We used a cross-sectional online panel survey to assess the ad's perceived effectiveness and its impact on learning something new, quit intentions and concern for smoking-related health risks among non-daily, light daily and heavy daily smokers.
 
The proportion of light smokers among smokers requesting cessation services increased 50% (from 13% to 20%) relative to previous time-limited NRT giveaways. Compared to heavy daily smokers, non-daily (aOR: 1.95, p<0.05) and light daily (aOR: 2.27, p<0.05) smokers were more likely to express increased concern about smoking-related health risks after viewing the ad. Perceived effectiveness of the ad did not differ by smoker type. This study provides evidence that light smokers were receptive to a targeted antitobacco message encouraging use of cessation services. The campaign appears to have been particularly effective in increasing smoking-related health concerns in this group. The lack of difference in perceived ad effectiveness by smoker type suggests the potential to develop such ads without sacrificing broad impact.

Christine D. Delnevo, Daniel P. Giovenco, Bridget K. Ambrose, Catherine G. Corey, Kevin P. Conway.
Preference for Flavoured Cigar Brands Among Youth, Young Adults and Adults in the USA.
Tob Control 2015;24:389-394 doi:10.1136/tobaccocontrol-2013-051408
 
While cigarette consumption in the USA continues to decline, cigar consumption has increased. Tobacco-trade publications suggest that flavoured cigars are driving the recent growth in cigar consumption. Limited survey data exist to explore flavoured cigar preferences among youth and adults. This study used the 2010–2011 National Survey on Drug Use and Health (NSDUH) and Nielsen market scanner data. The NSDUH sample consisted of 6678 past 30-day cigar smokers who reported smoking a usual brand of cigars. NSDUH contains a measure on usual cigar brand smoked and was merged with Nielsen data to estimate the per cent of each cigar brand's market share that is flavoured.
 
Multivariate analyses indicate that youth, young adults, females, blacks, cigarette smokers, blunt users and daily cigar smokers are significantly more likely to report a usual cigar brand that is flavoured. Preference for a usual brand that produces flavoured cigars decreases significantly with age. This study finds recent growth in flavoured cigar consumption and preference among youth and young adults for cigar brands that are flavoured. These findings underscore the need to expand monitoring of product attributes as well as individual-level cigar use behaviours captured through population surveillance.
 
Joshua C. Magee, Daniel F. Lewis, Theresa Winhusen.
Evaluating Nicotine Craving, Withdrawal, and Substance Use as Mediators of Smoking Cessation in Cocaine and Methamphetamine Dependent Patients.
Nicotine Tob Res (2015)doi: 10.1093/ntr/ntv121.
 
Smoking is highly prevalent in substance dependence, but smoking-cessation treatment (SCT) is more challenging in this population. To increase the success of smoking cessation services, it is important to understand potential therapeutic targets like nicotine craving that have meaningful but highly variable relationships with smoking outcomes. This study characterized the presence, magnitude, and specificity of nicotine craving as a mediator of the relationship between SCT and smoking abstinence in the context of stimulant-dependence treatment. This study was a secondary analysis of a randomized, 10-week trial conducted at 12 outpatient SUD treatment programs. Adults with cocaine and/or methamphetamine dependence (N = 538) were randomized to SUD treatment as usual (TAU) or TAU+SCT. Participants reported nicotine craving, nicotine withdrawal symptoms, and substance use in the week following a uniform quit attempt of the TAU+SCT group, and self-reported smoking 7-day point prevalence abstinence (verified by carbon monoxide) at end-of-treatment.

Bootstrapped regression models indicated that, as expected, nicotine craving following a quit attempt mediated the relationship between SCT and end-of-treatment smoking point prevalence abstinence (mediation effect = 0.09, 95% CI = 0.04% to 0.14%, P < .05, 14% of total effect). Nicotine withdrawal symptoms and substance use were not significant mediators (Ps > .05, <1% of total effect). This pattern held for separate examinations of cocaine and methamphetamine dependence. Nicotine craving accounts for a small but meaningful portion of the relationship between smoking-cessation treatment and smoking abstinence during SUD treatment. Nicotine craving following a quit attempt may be a useful therapeutic target for increasing the effectiveness of smoking-cessation treatment in substance dependence.
 
Hayden McRobbie, Dunia Przuli, Katherine Myers Smith, Danielle Cornwall.
Complementing the Standard Multicomponent Treatment for Smokers with Denicotinized Cigarettes: A Randomized Trial.
Nicotine Tob Res (2015)doi: 10.1093/ntr/ntv122
 
Standard treatments (STs) for smoking cessation typically combine pharmacotherapy and behavioral support but do not address the sensory and behavioral aspects of smoking which may play a role in maintaining smoking behavior. Replacing such sensations temporarily after cessation may enhance treatment efficacy. We hypothesized that denicotinized cigarettes (DNCs), which have a very low nicotine content but provide these sensory and behavioral stimuli, could help alleviate urges to smoke and tobacco withdrawal symptoms and in turn enhance the efficacy of ST. Two hundred smokers seeking treatment received nine weekly behavioral support sessions and pharmacotherapy (100 used varenicline, 100 used nicotine replacement therapy). They were randomized on the target quit day to receive 280 DNCs (used ad libitum over 2 weeks in addition to ST) or ST alone.

Urge-to-smoke frequency (2.61 vs. 2.96, P = .03) but not strength (2.85 vs. 3.10, P = .20) in the first week of abstinence was significantly lower in DNC users versus ST alone. There were no differences in composite withdrawal scores between groups. Abstinence was significantly higher among DNC users versus ST alone at 1 (OR = 2.07; 95% CI: 1.63% to 3.70%) and 4 weeks (OR = 1.83; 95% CI: 1.05% to 3.21%), but not at 12 weeks (OR = 1.42; 95% CI: 0.79% to 2.55%). DNC use was a significant predictor of abstinence at 1 and 4 weeks (OR = 2.63; 95% CI: 1.40% to 4.93% and OR = 2.38; 95% CI: 1.26% to 4.46%), but not at 12 weeks. Adding DNCs to ST has the potential to assist smokers early in their quit attempt, but research is needed to determine how best to utilize DNCs in treatment.
 
Neill Bruce Baskerville, Sunday Azagba, Cameron Norman, Kyle McKeown, K. Stephen Brown.
Effect of a Digital Social Media Campaign on Young Adult Smoking Cessation.
Nicotine Tob Res (2015)doi: 10.1093/ntr/ntv119
 
Social media (SM) may extend the reach and impact for smoking cessation among young adult smokers. To-date, little research targeting young adults has been done on the use of SM to promote quitting smoking. We assessed the effect of an innovative multicomponent web-based and SM approach known as Break-it-Off (BIO) on young adult smoking cessation. The study employed a quasi-experimental design with baseline and 3-month follow-up data from 19 to 29-year old smokers exposed to BIO (n = 102 at follow-up) and a comparison group of Smokers’ Helpline (SHL) users (n = 136 at follow-up). Logistic regression analysis assessed differences between groups on self-reported 7-day and 30-day point prevalence cessation rates, adjusting for ethnicity, education level, and cigarette use (daily or occasional) at baseline.

The campaign reached 37 325 unique visitors with a total of 44 172 visits. BIO users had significantly higher 7-day and 30-day quit rates compared with users of SHL. At 3-month follow-up, BIO participants (32.4%) were more likely than SHL participants (14%) to have quit smoking for 30 days (odds ratio = 2.95, 95% CI = 1.56 to 5.57, P < .001) and BIO participants (91%) were more likely than SHL participants (79%) to have made a quit attempt (odds ratio = 2.69, 95% CI = 1.03 to 6.99, P = .04). The reach of the campaign and findings on quitting success indicate that a digital/SM platform can complement the traditional SHL cessation service for young adult smokers seeking help to quit.
 
Todd Pagano, A. Gary DiFrancesco, Susan B. Smith, Jerrin George, Gloria, Wink, Irfan Rahman.
Determination of Nicotine Content and Delivery in Disposable Electronic Cigarettes Available in the United States by Gas Chromatography-Mass Spectrometry.
Nicotine Tob Res (2015)doi: 10.1093/ntr/ntv120
 
Electronic cigarettes (E-Cigs) are popular alternatives to conventional tobacco cigarettes. Disposable E-Cigs are single-use devices that emit aerosols from a nicotine-containing solution (e-liquid) by activating a heating coil during puffing. However, due to lack of regulations and standards, it is unclear how product claims are aligning with actual content and performance. Some analytical methods for characterizing E-Cigs are still in an exploratory phase. Five products of disposable E-Cigs (purchased March–April, 2014 from a local smoke shop and an on-line US distributor) were studied for nicotine content, number of puffs obtained before depletion, portion of nicotine delivered via aerosolization, and e-liquid pH. Protocols were developed to consistently extract e-liquid from puffed and unpuffed E-Cigs. An in-house mechanical puffing machine was used to consistently puff E-Cig aerosols onto filter pads. A gas chromatography-mass spectrometry method was developed that produced sensitive and repeatable nicotine determinations.

Under our experimental parameters, results showed a disparity between nicotine content and number of puffs achieved relative to what was claimed on product packaging. The portion of nicotine delivered to filter pads was often less than half that which was available, indicating much of the nicotine may be left in the E-Cig upon depletion. Analyses of unpuffed E-Cigs by gas chromatography-mass spectrometry indicate the nicotine content of these products can be considerably different from manufacture’s labeling. Furthermore, a large portion of the nicotine in E-Cigs may not be transferred to the user, and that which is transferred, may often be in the less bioavailable form.

Thurgood SL, McNeill A., Clark-Carter D. and Brose LS.
A Systematic Review of Smoking Cessation Interventions for Adults in Substance Abuse Treatment or Recovery.
Nicotine Tob Res (2015)doi: 10.1093/ntr/ntv127

The aim was to evaluate the effectiveness of smoking cessation interventions for patients with substance use disorders. The secondary aim was to evaluate impact on substance use treatment outcomes. Randomised controlled trials involving adult smokers, recently or currently receiving inpatient or outpatient treatment for substance use disorders were reviewed. Databases, grey literature, reference lists and journals were searched for relevant studies between 1990 and August 2014. Two authors extracted data and assessed quality. The primary outcome was biochemically verified continuous abstinence from smoking at 6 or 12 months, secondary outcomes were biochemically verified seven-day point prevalence smoking abstinence (ppa) at 6 or 12 months and substance use outcomes. Heterogeneity between studies precluded pooled analyses of the data.
 
Seventeen of 847 publications were included. Five studies reported significant effects on smoking cessation: 1) Nicotine patches improved continuous abstinence at six months. 2) Nicotine gum improved continuous abstinence at 12 months. 3) Counselling, contingency management and relapse prevention improved continuous abstinence at six and 12 months. 4) Cognitive behavioural therapy, plus nicotine replacement therapy, improved ppa at six months. 5) A combination of bupropion, nicotine replacement therapy, counselling and contingency management improved ppa at six months. Two studies showed some evidence of improved substance use outcomes with the remaining eight studies measuring substance use outcomes showing no difference. Nicotine replacement therapy, behavioural support and combination approaches appear to increase smoking abstinence in those treated for substance use disorders. Higher quality studies are required to strengthen the evidence base.
 
Clark MA, Gorelick JJ, Sicks JD, Park ER, Graham AL, Abrams DB, Gareen IF. 
The Relations between False Positive and Negative Screens and Smoking Cessation and Relapse in the National Lung Cancer Screening Trial: Implications for Public Health.
Nicotine Tob Res. 2015 Mar 6. [Epub ahead of print].
 
Lung screening is an opportunity for smoking cessation and relapse prevention, but smoking behaviors may differ across screening results. Changes in smoking were evaluated among 18,840 current and former smokers, aged 55-74, scheduled to receive three annual lung screenings. Participants were randomized to low-dose CT or single-view chest radiography in the American College of Radiology / National Lung Screening Trial (NLST). During five years of follow-up, annual point prevalence quit rates ranged from 11.6 percent to 13.4 percent. About half (48 percent) of current smokers reported a quit attempt and seven percent of long-term former smokers relapsed. A false positive screen was associated with increased smoking cessation and less relapse among recent quitters. Consistently negative screens were not associated with greater relapse among long-term former smokers. Given that the Affordable Care Act requires most health plans to cover smoking cessation and lung screening, the impact and cost-effectiveness of lung screening could be further enhanced with the addition of smoking cessation interventions.

Monica E. Cornelius, Pete Driezen, Andrew Hyland, Geoffrey T. Fong, Frank J. Chaloupka, K. Michael Cummings.
Trends in Cigarette Pricing and Purchasing Patterns in a Sample of US Smokers: Findings From the ITC US Surveys (2002-2011).
Tob Control 2015;24:iii4-iii10 doi:10.1136/tobaccocontrol-2013-051376 

This paper examines trends in cigarette prices and corresponding purchasing patterns over a 9-year period and explores characteristics associated with the quantity and location of cigarettes purchased by adult smokers in the USA. The data for this paper come from a nationally representative longitudinal survey of 6669 adult smokers (18 years and older) who were recruited and surveyed between 2002 and 2011. Telephone interviews were conducted annually, and smokers were asked a series of questions about the location, quantity (ie, single vs multiple packs or cartons) and price paid for their most recent cigarette purchase. Generalised estimating equations were used to assess trends and model characteristics associated with cigarette purchasing behaviours.
 
Between 2002 and 2011, the reported purchase of cigarette cartons and the use of coupons declined while multipack purchases increased. Compared with those purchasing by single packs, those who purchased by multipacks and cartons saved an average of $0.53 and $1.63, respectively. Purchases in grocery and discount stores declined, while purchases in tobacco only outlets increased slightly. Female, older, white smokers were more likely to purchase cigarettes by the carton or in multipacks and in locations commonly associated with tax avoidance (ie, duty free shops, Indian reservations). As cigarette prices have risen, smokers have begun purchasing via multipacks instead of cartons. As carton sales have declined, purchases from grocery and discount stores have also declined, while an increasing number of smokers report low tax sources as their usual purchase location for cigarettes.
 
Ce Shang, Frank J. Chaloupka, Geoffrey T. Fong, Mary Thompson, Mohammad Siahpush.
Weight Control Belief and its Impact on the Effectiveness of Tobacco Control Policies on Quit Attempts: Findings from the ITC 4 Country Survey.
Tob Control 2015;24:iii41-iii47 doi:10.1136/tobaccocontrol-2014-051886
 
Weight concerns are widely documented as one of the major barriers for girls and young adult women to quit smoking. Therefore, it is important to investigate whether smokers who have weight concerns respond to tobacco control policies differently than smokers who do not in terms of quit attempts, and how this difference varies by gender and country. This study aims to investigate, by gender and country, whether smokers who believe that smoking helps control weight are less responsive to tobacco control policies with regards to quit attempts than those who do not.
 
We use longitudinal data from the International Tobacco Control Policy Evaluation Project in the USA, Canada, the UK and Australia to conduct the analysis. We first constructed a dichotomous indicator for smokers who have the weight control belief and then examined the disparity in policy responsiveness in terms of quit attempts by directly estimating the interaction terms of policies and the weight control belief indicator using generalised estimating equations. We find that weight control belief significantly attenuates the policy impact of tobacco control measures on quit attempts among US female smokers and among UK smokers. This pattern was not found among smokers in Canada and Australia. Although our results vary by gender and country, the findings suggest that weight concerns do alter policy responsiveness in quit attempts in certain populations. Policy makers should take this into account and alleviate weight concerns to enhance the effectiveness of existing tobacco control policies on promoting quitting smoking.
 
Eun-Ja Park, Susan Park, Sung-il Cho, Yeol Kim, Hong Gwan Seo, Pete Driezen, Anne C K Quah, Geoffrey T. Fong.
What Cigarette Price is Required for Smokers to Attempt to Quit Smoking? Findings From the ITC Korea Waves 2 and 3 Survey.
Tob Control 2015;24:iii48-iii55 doi:10.1136/tobaccocontrol-2015-052232
 
We assess the cigarette price that would motivate smokers to quit. We also explore the factors associated with the required price, including exposures to non-tax tobacco control policies. Cross-sectional analysis was conducted on data from 1257 male smokers, who participated in either Wave 2 or 3 of the ITC Korea Survey. Information was obtained on what cigarette price per pack would make them try to quit (‘price to quit’). Tobit regression on log-transformed price and logistic regression on non-quitting were conducted to identify associated factors.
 
The median price to quit was KRW5854 (US$5.31)/pack, given the current price of KRW2500 (US$2.27)/pack. Younger age, higher education, lack of concern about the health effects of smoking, lack of quit attempts and more cigarettes consumed per day were related to a higher price needed for a quit attempt. Exposures to combinations of non-tax policies were significantly associated with lower price levels to be motivated to quit. Considering the large price increase required for quit attempts, tax policy needs to be combined with other policies, particularly for certain groups, such as heavy smokers. Strengthening non-tax policies is likely to facilitate greater responsiveness to tax policy.
 
Marissa G. Hall, Nancy L. Fleischer, Luz Myriam Reynales-Shigematsu, Edna Arillo-Santillan, James F. Thrasher.
Increasing Availability and Consumption of Single Cigarettes: Trends and Implications for Smoking Cessation from the ITC Mexico Survey.
Tob Control 2015;24:iii64-iii70 doi:10.1136/tobaccocontrol-2014-051690
 
Determine (1) trends in single cigarette availability and purchasing in Mexico and (2) the association between neighbourhood access to singles and cessation behaviour among adult Mexican smokers. We analysed data from Wave 4 (2010), Wave 5 (2011) and Wave 6 (2012) of the Mexican International Tobacco Control Policy Evaluation Survey. We used data from all three waves to examine time trends in singles availability and purchasing. To explore the association between neighbourhood access to singles and cessation behaviour, we used data from participants who were smokers at Wave 5 and followed up at Wave 6 (n=1272).
 
The percentage of participants who saw singles sold daily (45.2% in 2010; 51.4% in 2011; 64.9% in 2012), who bought singles at least once a week (22.3% in 2010; 29.1% in 2011; 29.1% in 2012) and whose last cigarette purchase was a single (16.6% in 2010; 20.7% in 2011; 25.8% in 2012) increased significantly from 2010 to 2012 (all p<0.001). The average percentage of residents who reported seeing singles sold daily in their neighbourhood in 2012 was 60% (SD=25%). In adjusted analyses, smokers living in neighbourhoods with higher access to singles were less likely to make a quit attempt (risk ratio (RR)=0.72; 95% CI 0.46 to 1.12), and more likely to relapse (RR=1.30; CI 0.94 to 1.82), but these results were not statistically significant. Single cigarettes appear widely accessible in Mexico and growing in availability. Future research should explore potential explanations, consequences and effective methods for reducing the availability of single cigarettes.
 
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The Geographic Health Equity Symposium is the signature-training event that presents strategies to address tobacco and cancer health disparities through a geographic lens. 2015 marks the second year this event has taken place and has attracted academic and public health professionals, community wellness and substance abuse prevention coalitions, non-governmental organizations and youth from all around the country. The Geographic Health Equity Alliance is pleased to invite you to engage with their staff and featured trainers during this year’s Symposium, to be held in New Orleans, LA, on September 10 – 11, 2015, at the Tulane University School of Public Health and Tropical Medicine.
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