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Background Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol formed by heating an e‐liquid. Some people who smoke use ECs to stop or reduce smoking, but some organizations, advocacy groups and policymakers have discouraged this, citing lack of evidence of efficacy and safety. People who smoke, healthcare providers and regulators want to know if ECs can help people quit and if they are safe to use for this purpose. This is an update conducted as part of a living systematic review. Objectives To examine the effectiveness, tolerability, and safety of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long‐term smoking abstinence. Search methods We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO to 1 May 2021, and reference‐checked and contacted study authors. We screened abstracts from the Society for Research on Nicotine and Tobacco (SRNT) 2021 Annual Meeting. Selection criteria We included randomized controlled trials (RCTs) and randomized cross‐over trials, in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention. Studies had to report abstinence from cigarettes at six months or longer or data on safety markers at one week or longer, or both. Data collection and analysis We followed standard Cochrane methods for screening and data extraction. Our primary outcome measures were abstinence from smoking after at least six months follow‐up, adverse events (AEs), and serious adverse events (SAEs). Secondary outcomes included the proportion of people still using study product (EC or pharmacotherapy) at six or more months after randomization or starting EC use, changes in carbon monoxide (CO), blood pressure (BP), heart rate, arterial oxygen saturation, lung function, and levels of carcinogens or toxicants or both. We used a fixed‐effect Mantel‐Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in meta‐analyses. Main results We included 61 completed studies, representing 16,759 participants, of which 34 were RCTs. Five of the 61 included studies were new to this review update. Of the included studies, we rated seven (all contributing to our main comparisons) at low risk of bias overall, 42 at high risk overall (including all non‐randomized studies), and the remainder at unclear risk. There was moderate‐certainty evidence, limited by imprecision, that quit rates were higher in people randomized to nicotine EC than in those randomized to nicotine replacement therapy (NRT) (risk ratio (RR) 1.53, 95% confidence interval (CI) 1.21 to 1.93; I2 = 0%; 4 studies, 1924 participants). In absolute terms, this might translate to an additional three quitters per 100 (95% CI 1 to 6). There was low‐certainty evidence (limited by very serious imprecision) that the rate of occurrence of AEs was similar (RR 0.98, 95% CI 0.80 to 1.19; I2 = 0%; 2 studies, 485 participants). SAEs were rare, but there was insufficient evidence to determine whether rates differed between groups due to very serious imprecision (RR 1.44, 95% CI 0.94 to 2.19: I2 = 0; 3 studies, 1183 participants). There was moderate‐certainty evidence, again limited by imprecision, that quit rates were higher in people randomized to nicotine EC than to non‐nicotine EC (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). In absolute terms, this might lead to an additional seven quitters per 100 (95% CI 2 to 16). There was moderate‐certainty evidence of no difference in the rate of AEs between these groups (RR 1.01, 95% CI 0.91 to 1.11; I2 = 0%; 3 studies, 601 participants). There was insufficient evidence to determine whether rates of SAEs differed between groups, due to very serious imprecision (RR 0.95, 95% CI 0.52 to 1.72; I2 = 0; 6 studies, 1033 participants). Compared to behavioural support only/no support, quit rates were higher for participants randomized to nicotine EC (RR 2.61, 95% CI 1.44 to 4.74; I2 = 0%; 6 studies, 2886 participants). In absolute terms this represents an additional six quitters per 100 (95% CI 2 to 15). However, this finding was of very low certainty, due to issues with imprecision and risk of bias. There was some evidence that non‐serious AEs were more common in people randomized to nicotine EC (RR 1.22, 95% CI 1.12 to 1.32; I2 = 41%, low certainty; 4 studies, 765 participants), and again, insufficient evidence to determine whether rates of SAEs differed between groups (RR 1.51, 95% CI 0.70 to 3.24; I2 = 0%; 7 studies, 1303 participants). Data from non‐randomized studies were consistent with RCT data. The most commonly reported AEs were throat/mouth irritation, headache, cough, and nausea, which tended to dissipate with continued use. Very few studies reported data on other outcomes or comparisons, hence evidence for these is limited, with CIs often encompassing clinically significant harm and benefit. Authors' conclusions There is moderate‐certainty evidence that ECs with nicotine increase quit rates compared to NRT and compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain. More studies are needed to confirm the effect size. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non‐nicotine ECs. Overall incidence of SAEs was low across all study arms. We did not detect evidence of harm from nicotine EC, but longest follow‐up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates, but further RCTs are underway. To ensure the review continues to provide up‐to‐date information to decision‐makers, this review is now a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available. Please refer to the Cochrane Database of Systematic Reviews for the review's current status.

The topic of e-cigarettes is controversial. Opponents focus on e-cigarettes’ risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking. Most US health organizations, media coverage, and policymakers have focused primarily on risks to youths. Because of their messaging, much of the public—including most smokers—now consider e-cigarette use as dangerous as or more dangerous than smoking. By contrast, the National Academies of Science, Engineering, and Medicine concluded that e-cigarette use is likely far less hazardous than smoking. Policies intended to reduce adolescent vaping may also reduce adult smokers’ use of e-cigarettes in quit attempts. Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, many scientists, including this essay’s authors, encourage the health community, media, and policymakers to more carefully weigh vaping’s potential to reduce adult smoking-attributable mortality. We review the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation, concerns about youth vaping, and the need to balance valid concerns about risks to youths with the potential benefits of increasing adult smoking cessation.

Background Cigarette smoking is a risk factor for severe COVID-19 disease. Understanding smokers’ responses to the pandemic will help assess its public health impact and inform future public health and provider messages to smokers. Objective To assess risk perceptions and change in tobacco use among current and former smokers during the COVID-19 pandemic. Design Cross-sectional survey conducted in May–July 2020 (55% response rate) Participants 694 current and former daily smokers (mean age 53, 40% male, 78% white) who had been hospitalized pre-COVID-19 and enrolled into a smoking cessation clinical trial at hospitals in Massachusetts, Pennsylvania, and Tennessee. Main Measures Perceived risk of COVID-19 due to tobacco use; changes in tobacco consumption and interest in quitting tobacco use; self-reported quitting and relapse since January 2020. Key Results 68% (95% CI, 65–72%) of respondents believed that smoking increases the risk of contracting COVID-19 or having a more severe case. In adjusted analyses, perceived risk was higher in Massachusetts where COVID-19 had already surged than in Pennsylvania and Tennessee which were pre-surge during survey administration (AOR 1.56, 95% CI, 1.07–2.28). Higher perceived COVID-19 risk was associated with increased interest in quitting smoking (AOR 1.72, 95% CI 1.01–2.92). During the pandemic, 32% (95% CI, 27–37%) of smokers increased, 37% (95% CI, 33–42%) decreased, and 31% (95% CI, 26–35%) did not change their cigarette consumption. Increased smoking was associated with higher perceived stress (AOR 1.49, 95% CI 1.16–1.91). Overall, 11% (95% CI, 8–14%) of respondents who smoked in January 2020 (pre-COVID-19) had quit smoking at survey (mean, 6 months later) while 28% (95% CI, 22–34%) of former smokers relapsed. Higher perceived COVID-19 risk was associated with higher odds of quitting and lower odds of relapse. Conclusions Most smokers believed that smoking increased COVID-19 risk. Smokers’ responses to the pandemic varied, with increased smoking related to stress and increased quitting associated with perceived COVID-19 vulnerability. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-06913-3.

Significance Increased rates of smoking cessation will be essential to maximize the population benefit of low-dose CT screening for lung cancer. The NCI’s Smoking Cessation at Lung Examination (SCALE) Collaboration includes eight randomized trials, each assessing evidence-based interventions among smokers undergoing lung cancer screening (LCS). We examined predictors of trial enrollment to improve future outreach efforts for cessation interventions offered to older smokers in this and other clinical settings. Methods We included the six SCALE trials that randomized individual participants. We assessed demographics, intervention modalities, LCS site and trial administration characteristics, and reasons for declining. Results Of 6285 trial- and LCS-eligible individuals, 3897 (62%) declined and 2388 (38%) enrolled. In multivariable logistic regression analyses, Blacks had higher enrollment rates (OR 1.5, 95% CI 1.2,1.8) compared to Whites. Compared to “NRT Only” trials, those approached for “NRT + prescription medication” trials had higher odds of enrollment (OR 6.1, 95% CI 4.7,7.9). Regarding enrollment methods, trials using “Phone + In Person” methods had higher odds of enrollment (OR 1.6, 95% CI 1.2,1.9) compared to trials using “Phone Only” methods. Some of the reasons for declining enrollment included “too busy” (36.6%), “not ready to quit” (8.2%), “not interested in research” (7.7%), and “not interested in the intervention offered” (6.2%). Conclusion Enrolling smokers in cessation interventions in the LCS setting is a major priority that requires multiple enrollment and intervention modalities. Barriers to enrollment provide insights that can be addressed and applied to future cessation interventions to improve implementation in LCS and other clinical settings with older smokers. Implications We explored enrollment rates and reasons for declining across six smoking cessation trials in the lung cancer screening setting. Offering multiple accrual methods and pharmacotherapy options predicted increased enrollment across trials. Enrollment rates were also greater among Blacks compared to Whites. The findings offer practical information for the implementation of cessation trials and interventions in the lung cancer screening context and other clinical settings, regarding intervention modalities that may be most appealing to older, long-term smokers.

Introduction Cytisinicline (known as cytisine), a nicotinic acetylcholine receptor partial agonist, is a smoking cessation aid currently marketed in Central and Eastern Europe using a 1.5-mg/tablet 25-day downward titration schedule. No prior studies have evaluated other doses or administration schedules. This study evaluated the effects of a higher dosage and simplified dosing schedule on drug efficacy and tolerability. Methods ORCA-1 was a double-blind, randomized, placebo-controlled clinical trial that provided cytisinicline or placebo tablets plus behavioral support for 25 days. Adult smokers (>10 cigarettes daily) committed to quitting smoking were randomized to compare 2 cytisinicline doses (1.5 mg and 3 mg) versus placebo, and 2 administration schedules [downward titration versus 3 times daily (TID)]. Primary outcome was a reduction in expected cigarettes smoked at end of treatment; secondary outcomes were biochemically confirmed 7-day abstinence at Week 4 and continuous abstinence from Weeks 5 to 8. Results Among 254 participants, those in cytisinicline arms (regardless of dose or schedule) had greater reductions in cigarettes smoked versus placebo, with differences observed in 3 cytisinicline arms statistically significant versus placebo. All cytisinicline arms had statistically significantly higher abstinence rates at Week 4 versus placebo. Both cytisinicline arms using TID schedules had statistically significantly higher continuous abstinence rates from Weeks 5 to 8 compared with placebo. Participants in the cytisinicline 3-mg TID arm had the highest abstinence rate. There were no safety concerns with either 1.5-mg or 3-mg cytisinicline. Conclusion Based on simpler dose scheduling, excellent tolerability, and best-continued abstinence rate, cytisinicline 3-mg TID was selected for future Phase 3 studies. Implications Although the 1.5-mg 25-day titration schedule has been marketed in Central and Eastern Europe for decades, this study explored using a higher dosage and a simplified dosing schedule for impact on cytisinicline efficacy and tolerability. Based on these results, a Phase 3 program was initiated using cytisinicline 3-mg tablets on a TID schedule for potential market approval in the United States.

Background Guidelines recommend offering cessation interventions to smokers eligible for lung cancer screening, but there is little data comparing specific cessation approaches in this setting. We compared the benefits and costs of different smoking cessation interventions to help screening programs select specific cessation approaches. Methods We conducted a societal-perspective cost-effectiveness analysis using a Cancer Intervention and Surveillance Modeling Network model simulating individuals born in 1960 over their lifetimes. Model inputs were derived from Medicare, national cancer registries, published studies, and micro-costing of cessation interventions. We modeled annual lung cancer screening following 2014 US Preventive Services Task Force guidelines plus cessation interventions offered to current smokers at first screen, including pharmacotherapy only or pharmacotherapy with electronic and/or web-based, telephone, individual, or group counseling. Outcomes included lung cancer cases and deaths, life-years saved, quality-adjusted life-years (QALYs) saved, costs, and incremental cost-effectiveness ratios. Results Compared with screening alone, all cessation interventions decreased cases of and deaths from lung cancer. Compared incrementally, efficient cessation strategies included pharmacotherapy with either web-based cessation ($555 per QALY), telephone counseling ($7562 per QALY), or individual counseling ($35 531 per QALY). Cessation interventions continued to have costs per QALY well below accepted willingness to pay thresholds even with the lowest intervention effects and was more cost-effective in cohorts with higher smoking prevalence. Conclusion All smoking cessation interventions delivered with lung cancer screening are likely to provide benefits at reasonable costs. Because the differences between approaches were small, the choice of intervention should be guided by practical concerns such as staff training and availability.

Background: Few studies have examined substance use disorders (SUDs) in cancer patients and it is unclear whether SUDs differentially impact cigarette smoking in patients with vs. without cancer. This study used epidemiological data to estimate current cigarette smoking prevalence and quit ratios among US adults with and without SUDs by cancer status. Methods: Data were drawn from the 2015–2018 National Survey on Drug Use and Health (n = 170,111). Weighted current smoking prevalence and quit ratios were estimated across survey years by SUDs (with vs. without) and by cancer status (with vs. without). Results: Among those with cancer, current smoking prevalence was higher for those with vs. without SUDs (47% vs. 13%, p < 0.001) and quit ratios lower for those with vs. without SUDs (45% vs. 71%, p = 0.002). A similar pattern was observed in adults without cancer, with higher smoking prevalence (56% vs. 21%, p < 0.001) and lower quit ratios (23% vs. 51%, p < 0.001) observed for those with vs. without SUDs, respectively. In adjusted logistic regressions, the SUD × cancer status interaction was not significant for smoking prevalence or quit ratios (AOR = 1.2; 95% CI: 0.7, 2.1, p = 0.56; AOR = 1.0; 95% CI: 0.5, 2.0, p = 0.91, respectively), though smoking prevalence was lower and quit ratios higher for adults with vs. without cancer (ps < 0.05). Conclusions: Among US adults with and without cancer, individuals with SUDs evidenced higher cigarette smoking and lower quit ratios than those without SUDs. Addressing SUDs and their impact on smoking cessation is critical in cancer patients with implications for improving health and treatment outcomes.

IntroductionLongitudinal surveys provide data to estimate transition probabilities between cigarette smoking, e-cigarette use, and dual use of both, facilitating projections of future use and the impact of policies.MethodsWe fit a continuous time Markov multi-state model for youth (ages 12-17y) and adults (≥18y) in Waves 1-4.5 of the Population Assessment of Tobacco and Health (PATH) longitudinal survey and estimated smoking and e-cigarette transition frequencies, including initiation, cessation, and relapse. We validated transition frequency results in a microsimulation model by projecting smoking and e-cigarette use prevalence over time.ResultsThere was more volatility in smoking and e-cigarette use among youth than among adults. For youth never smokers, annual smoking initiation among never/current/former e-cigarette users occurred in 0.4% (95% CI 0.2-0.6%)/8.8% (7.0-10.7%)/3.1% (2.1-4.2%), and current e-cigarette users were more likely to quit e-cigarettes than to initiate smoking (absolute difference in annual probability 46.5%, 38.7-54.2%). For adult current smokers, annual smoking cessation among never/current/former e-cigarette users occurred in 22.6% (20.9-24.3%)/14.5% (11.5-17.4%)/15.1% (12.1-18.2%). For adult current dual users, 14.5% quit smoking and 49.5% quit e-cigarettes annually. For adult former smokers, annual smoking relapse among never/current/former e-cigarette users occurred in 17.7% (15.8-19.6%)/29.3% (23.8-34.7%)/32.8% (27.1-38.6%). Using these transition probabilities in a microsimulation model accurately projected smoking and e-cigarette use prevalence at 12 and 24 months compared to PATH empirical data (root-mean-square error DiscussionPATH Waves 1-4.5 contain sufficient data to generate smoking and e-cigarette use transition frequency estimates for youth and adults in a microsimulation model. E-cigarette use among youth is especially volatile.IMPLICATIONSThis study estimates longitudinal transitions between nine cigarette smoking and e-cigarette use states among both youth and adults. Youth smoking and e-cigarette use was more volatile than that of adults. Smoking initiation, cessation, and relapse differed by e-cigarette use status, but it is not clear that e-cigarette use itself caused these differences. A tobacco and nicotine policy model parametrized with our estimates accurately predicted smoking and e-cigarette use prevalence over two years, enabling future work to project the outcomes and cost-effectiveness of policies targeting smoking and e-cigarette use.

Background E-cigarettes are growing in popularity. Dual use of e-cigarettes and cigarettes is an increasingly common practice, but little is known about patterns of dual use in parents. We sought to describe smoking-related behaviors among dual-users. Methods Parent exit surveys were conducted following their child's visit in 5 control pediatric practices in 5 states participating in the Clinical Effort Against Secondhand Smoke Exposure trial. We examined factors associated with dual use of e-cigarettes and cigarettes versus cigarette-only smokers, assessed by self-report. Results Of 1382 smokers or recent quitters screened after their child's visit between April and October 2017, 943 (68%) completed the survey. Of these, 727 parents reported current use of cigarettes; of those, 81 (11.1%) also reported e-cigarette use, meeting the definition of dual use. Compared with cigarette-only smokers, dual users were more likely to have a child younger than 1 year old, planned to quit in the next 6 months, and had tried to quit in the past (had a quit attempt in the past 3 months, called the quitline, or used medicine to quit in the past 2 years; P Conclusions Parents who use both e-cigarettes and cigarettes may have greater rates of contemplating smoking cessation than parents who only smoke cigarettes. These parents may be using e-cigarettes for harm reduction or as a step toward cessation. Identification of these parents may provide an opportunity to deliver effective treatment, including nicotine-replacement therapies that do not expose infants and children to e-cigarette aerosol.

(1) Background: COVID-19 has substantially altered individual environments and behaviors. We aim to explore the impact of COVID-19 on the smoking behavior of individuals trying to quit tobacco. (2) Methods: This study presents a qualitative analysis of individual interviews focused on perceived impacts of the COVID-19 pandemic on tobacco use among 39 participants in the Helping HAND 4 (HH4) post-hospitalization smoking cessation trial (NCT03603496). (3) Results: Emergent impacts of COVID-19 included change in routine, isolation, employment changes, and financial challenges, these in turn were associated with boredom, altered cravings and triggers, and increased stress. The availability of effective coping mechanisms instead of smoking to deal with stress heavily influenced subsequent smoking behavior. These results were triangulated with the Transactional Model of Stress, providing a framework to elucidate connections between factors such as perceived control, self-efficacy, and dispositional coping style, and highlighting potential areas for intervention. (4) Conclusions: Results suggest that stress during the COVID-19 pandemic may undermine effective coping skills among individuals enrolled in a post-hospitalization smoking cessation trial. Strengthening effective coping skills (e.g., minimizing the use of tobacco as a default stress response) and increasing perceived control and self-efficacy are promising intervention targets.

The impact of the COVID-19 pandemic on US adults&rsquo, smoking and quitting behaviors is unclear. We explored the impact of COVID-19 on smoking behaviors, risk perceptions, and reactions to text messages during a statewide stay-at-home advisory among primary care patients who were trying to quit. From May&ndash, June 2020, we interviewed smokers enrolled in a 12-week, pilot cessation trial providing text messaging and mailed nicotine replacement medication (NCT04020718). Twenty-two individuals (82% white, mean age 55 years), representing 88% of trial participants during the stay-at-home advisory, completed exit interviews, four (18%) of them reported abstinence. Interviews were thematically analyzed by two coders. COVID-19-induced environmental changes had mixed effects, facilitating quitting for some and impeding quitting for others. While stress increased for many, those who quit found ways to cope with stress. Generally, participants felt at risk for COVID-19 complications but not at increased risk of becoming infected. Reactions to COVID-19 and quitting behaviors differed across age groups, older participants reported difficulties coping with isolation (e.g., feeling disappointed when a text message came from the study and not a live person). Findings suggest that cessation interventions addressing stress and boredom are needed during COVID-19, while smokers experiencing isolation may benefit from live-person supports.

Introduction Though telephone counseling is a modality commonly used to promote health behavior change, including tobacco cessation, specific counselor and participant behaviors that indicate engagement and therapeutic alliance remain poorly characterized in the literature. We sought to explore smokers' and counselors' engagement and rapport-building behaviors in telephone counseling for smoking cessation and patterns of these behaviors by smokers' psychiatric symptoms. Methods The study team transcribed, audio-recorded tobacco cessation counseling calls for the presence of engagement and rapport-building behaviors among recently hospitalized participants enrolled in a smoking cessation randomized controlled trial (RCT). The study used baseline data from the RCT to explore frequencies of counselors' and smokers' behaviors among smokers who had reported more (vs. fewer) symptoms of depression (PHQ8 ≥ 10) or anxiety (GAD7 ≥ 10) at study entry. Results Participants (n = 37) were mostly female (23/37), White (26/37), with a median age of 58. At study entry while hospitalized, moderate-to-severe symptoms of depression (18/37) and anxiety (22/37) were common. Participant-led engagement behaviors included referencing past quit attempts, asking questions, elaborating response to yes/no questions, expressing commitment to behavior change, and assigning importance to nonautomated calls. Counselor-led behaviors included building off prior interaction, empathy, normalizing challenges, reframing and summarizing, validating achievements, and expressing shared experience. Both participants and counselors engaged via general discussion and humor. Participant-led engagement behaviors appeared more often in call transcripts among patients with higher baseline depression and anxiety symptoms compared to those with lower symptom scores. Conclusions This study classified participant-led, counselor-led, and shared engagement behaviors during tobacco cessation counseling calls. Increased engagement via telephone counseling may be important for individuals with psychiatric symptoms identified at the start of treatment.

Highlights • COVID-19 had heterogeneous impact on tobacco use of people in treatment for OUD. • Most believed that smoking and vaping increased their vulnerability to COVID-19. • Since COVID-19, half of smokers increased interest in quitting and 24 % tried to quit. • However, 35 % of smokers and 27 % of vapers increased tobacco product use., Background Cigarette smoking may increase the risk of COVID-19 complications, reinforcing the urgency of smoking cessation in populations with high smoking prevalence such as individuals with opioid use disorder (OUD). Whether the COVID-19 pandemic has altered perceptions, motivation to quit, or tobacco use among cigarette smokers and nicotine e-cigarette vapers with OUD is unknown. Methods A telephone survey was conducted in March-July 2020 of current cigarette smokers or nicotine vapers with OUD who were stable on buprenorphine treatment at five Boston (MA) area community health centers. The survey assessed respondents’ perceived risk of COVID-19 due to smoking or vaping, interest in quitting, quit attempts and change in tobacco consumption during the pandemic. Results 222/520 patients (43 %) completed the survey, and 145 were asked questions related to COVID-19. Of these, 61 % smoked cigarettes only, 13 % vaped nicotine only, and 26 % were dual users. Nearly 80 % of participants believed that smoking and vaping increased their risk of COVID-19 infection or complications. Smokers with this belief reported an increased interest in quitting (AOR 4.6, 95 % CI:1.7–12.4). Overall, 49 % of smokers and 42 % of vapers reported increased interest in quitting due to the pandemic; 24 % and 20 %, respectively, reported attempting to quit since the pandemic. However, 35 % of smokers and 27 % of vapers reported increasing smoking and vaping, respectively, during the pandemic. Conclusions Most patients with OUD believed that smoking and vaping increased their vulnerability to COVID-19, half reported increased interest in quitting, but others reported increasing smoking and vaping during the COVID-19 pandemic.

Background Tobacco smoking remains the leading preventable cause of death in the US. A hospital admission provides smokers with a unique opportunity to stop smoking because it requires temporary tobacco abstinence while illness may enhance motivation to quit. Hospital interventions must continue post-discharge to increase tobacco abstinence long-term, but how best to accomplish this remains unclear. Building on two previous randomized controlled trials, each of which tested smoking cessation interventions that began in hospital and continued after discharge, this trial compares two interventions that provide sustained smoking cessation treatment after hospital discharge with the goal of improving long-term smoking cessation rates among hospitalized smokers. Methods/design Helping HAND 4 is a three-site randomized controlled trial that compares the effectiveness of two active interventions for producing validated past 7-day tobacco abstinence 6 months after hospital discharge. Smokers who are admitted to three hospitals receive a standard in-hospital smoking intervention, and those who plan to quit smoking after discharge are recruited and randomly assigned to two interventions that begin at discharge, Personalized Tobacco Care Management (PTCM) or Quitline eReferral. Each lasts 3 months. At discharge, PTCM provides 8 weeks of free nicotine replacement (NRT; a participant’s choice of patch, gum, lozenge, or a combination) and then proactive smoking cessation support using an automated communication platform and live contact with a tobacco treatment specialist who is based in the health care system. In the eReferral condition, a direct referral is made from the hospital electronic health record to a community-based resource, the state’s telephone quitline. The quitline provides up to 8 weeks of free NRT and offers behavioral support via a series of phone calls from a trained coach. Outcomes are assessed at 1, 3, and 6 months after discharge. The study hypothesis is that PTCM will produce higher quit rates than eReferral. Discussion Helping HAND 4 is a pragmatic trial that aims to evaluate interventions in real-world conditions. This project will give hospital systems critical evidence-based tools for meeting National Hospital Quality Measures for tobacco treatment and maximizing their ability to improve cessation rates and overall health for the millions of smokers hospitalized annually in the US. Trial registration Prospectively registered prior to start of enrollment at Clinicaltrials.gov, NCT03603496 (July 27, 2018). https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S00084MJ&selectaction=Edit&uid=U00002G7&ts=2&cx=ff0oxn

Tobacco use is the leading preventable cause of death worldwide and is a major risk factor for cardiovascular disease (CVD). Both prevention of smoking initiation among youth and smoking cessation among established smokers are key for reducing smoking prevalence and the associated negative health consequences. Proven tobacco cessation treatment includes pharmacotherapy and behavioral support, which are most effective when provided together. First-line medications (varenicline, bupropion, and nicotine replacement) are effective and safe for patients with CVD. Clinicians who care for patients with CVD should give as high a priority to treating tobacco use as to managing other CVD risk factors. Broader tobacco control efforts to raise tobacco taxes, adopt smoke-free laws, conduct mass media campaigns, and restrict tobacco marketing enhance clinicians' actions working with individual smokers.

Hospitalization offers tobacco smokers an opportunity to quit smoking, but factors associated with abstinence from tobacco after hospital discharge are poorly understood. We analyzed data from a multisite, randomized controlled trial testing a smoking cessation intervention for 1,357 hospitalized cigarette smokers who planned to quit. Using multiple logistic regression, we assessed factors identifiable in the hospital that were independently associated with biochemically confirmed tobacco abstinence six months after discharge. Biochemically confirmed abstinence at six months (n = 218, 16%) was associated with a smoking-related primary discharge diagnosis (Adjusted Odds Ratio [AOR] = 1.98, 95% CI: 1.41–2.77), greater confidence in the ability to quit smoking (AOR = 1.31, 95% CI: 1.07–1.60), and stronger intention to quit (plan to quit after discharge vs try to quit; AOR=1.68, 95% CI: 1.19–2.38). In conclusion, smokers hospitalized with a tobacco-related illness and those with greater confidence and intention to quit after discharge are more likely to sustain abstinence in the long term. Hospital clinicians’ efforts to promote smoking cessation should target smokers’ confidence and motivation to quit.

Tobacco use is the leading preventable cause of death worldwide and is a major risk factor for cardiovascular disease (CVD). Both prevention of smoking initiation among youth and smoking ce...

INTRODUCTION: Cigarette smoking is substantially more prevalent and rates of smoking cessation are lower in low-SES adults. Financial strain may be one explanation for this. This study assessed the association between financial strain, quit attempts, and successful smoking cessation among adult smokers in the U.S. METHODS: Longitudinal data on adult current smokers (aged ≥18 years) from Waves 1 and 2 of the nationally representative Population Assessment of Tobacco and Health Study (2013–2015) were analyzed in 2017. Negative binomial regression and logistic regression models assessed the association between financial strain and (1) quit attempts and (2) cigarette abstinence, adjusting for important confounders. RESULTS: Smokers with financial strain made more quit attempts than smokers without financial strain (adjusted incidence-rate ratio=1.34, 95% CI=1.07, 1.68), but financial strain was not associated with smoking abstinence at follow-up (AOR=0.86, 95% CI=0.70, 1.05). Low income was associated with less smoking abstinence at follow-up (AOR=0.66, 95% CI=0.50, 0.87 for

Setting and objectives: Tobacco use compromises tuberculosis (TB) treatment outcomes. Tobacco cessation is beneficial to TB patients at the individual level and from the perspective of a larger spectrum of non-communicable diseases associated with tobacco use. We assessed feasibility, effectiveness and provider perceptions on integrating brief tobacco cessation advice into routine TB care by DOTS providers from 27 TB treatment centres run by three non-governmental organisations (NGOs) in urban India. Design: A mixed-methods study (triangulation design) involving analysis of programme data and semi-structured interviews (quantitative) and thematic analysis of focus group discussions of TB treatment providers (qualitative) regarding brief advice and cessation support provided to self-reported tobacco users from August 2015 to July 2017. Results: All 27 centres initiated tobacco cessation. Of 2132 registered TB patients, 377 (18%) were tobacco users, 333 (88%) of whom used smokeless tobacco. There was a progressive drop in documentation of tobacco status at each visit, reaching respectively 36% and 30% at the end of treatment for new and retreatment TB patients. Seven-day point prevalence abstinence at 6 months was 32% among new and 15% among retreatment cases. Enablers for integration included NGO collaboration, supervision and capacity building. Challenges included providers spending 15-45 min per patient (10 min recommended), multiple addictions, documentation load, self-reporting and social normalisation of tobacco. Conclusions: Integration of tobacco cessation into routine TB care in an urban NGO setting was feasible, although without continued support, rigour in documentation declined. This should be scaled up with special attention paid to tackling smokeless tobacco and related operational challenges.

Background Many smokers report using e-cigarettes to help them quit smoking, but whether e-cigarettes aid cessation efforts is uncertain. Objective To determine whether e-cigarette use after hospital discharge is associated with subsequent tobacco abstinence among smokers who plan to quit and are advised to use evidence-based treatment. Design Secondary data analysis of a randomized controlled trial. (ClinicalTrials.gov: NCT01714323 [parent trial]). Setting 3 hospitals. Participants 1357 hospitalized adult cigarette smokers who planned to stop smoking, received tobacco cessation counseling in the hospital, and were randomly assigned at discharge to a tobacco treatment recommendation (control) or free tobacco treatment (intervention). Measurements Self-reported e-cigarette use (exposure) was assessed 1 and 3 months after discharge; biochemically validated tobacco abstinence (outcome) was assessed 6 months after discharge. Results Twenty-eight percent of participants used an e-cigarette within 3 months after discharge. In an analysis of 237 propensity score-matched pairs, e-cigarette users were less likely than nonusers to abstain from tobacco use at 6 months (10.1% vs. 26.6%; risk difference, -16.5% [95% CI, -23.3% to -9.6%]). The association between e-cigarette use and quitting varied between intervention patients, who were given easy access to conventional treatment (7.7% vs. 29.8%; risk difference, -22.1% [CI, -32.3% to -11.9%]), and control patients, who received only treatment recommendations (12.0% vs. 24.1%; risk difference, -12.0% [CI, -21.2% to 2.9%]) (P for interaction = 0.143). Limitations Patients self-selected e-cigarette use. Unmeasured confounding is possible in an observational study. Conclusion During 3 months after hospital discharge, more than a quarter of smokers attempting to quit used e-cigarettes, mostly to aid cessation, but few used them regularly. This pattern of use was associated with less tobacco abstinence at 6 months than among smokers who did not use e-cigarettes. Additional study is needed to determine whether regular use of e-cigarettes aids or hinders smoking cessation. Primary funding source National Heart, Lung, and Blood Institute.

Highlights • We explored stress, distress, and smoking in a cessation trial for cancer patients. • Patients reported decreases in stress and distress over time in both study groups. • Anxiety negatively impacted smoking cessation success at 6-mo follow-up., Introduction Cancer patients who smoke report more stress and psychological distress than patients who do not smoke. It is unclear how these emotional symptoms may modify smoking behavior in cancer patients. We examined the influence of a smoking cessation intervention for cancer patients on stress and distress, and the effects of these symptoms on smoking abstinence. Methods Mixed-methods secondary analysis of data from the Smokefree Support Study, a two-site randomized controlled trial examining the efficacy of Intensive (IT; n = 153) vs. Standard Treatment (ST; n = 150) for smoking cessation in newly diagnosed cancer patients. Stress coping, perceived stress, distress, and anxiety were self-reported at baseline, 3, and 6 months. Abstinence was biochemically-confirmed at 6 months. A subset of patients (n = 72) completed qualitative exit-interviews. Results Patients were on average, 58 years old, 56% female, and smoked a median of 10 cigarettes/day. There were no significant treatment group × time interactions or main effects of treatment group on stress or distress measures (p’s > 0.05), however there were significant main effects of time suggesting symptom improvements on each measure in both study groups (p’s

We are grateful for the opportunity to reply to the commentary on our Cochrane review of electronic cigarettes (EC) for smoking cessation [1] posed by Pisinger and Vestbo [2] with subsequent commentary by McAlinden et al. [3]. Footnotes This manuscript has recently been accepted for publication in the European Respiratory Journal . It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJ online. Please open or download the PDF to view this article. Conflict of Interest: Caitlin Notley has nothing to disclose. Conflict of Interest: Ailsa Butler reports payments made to institution to fund her role on the living systematic review of e-cigarettes for smoking cessation from Cancer Research UK (CRUK). Conflict of Interest: Nicola Lindson reports that her salary is paid by the University of Oxford through a grant from the UK National Institute for Health Research (NIHR); she is co-PI on a grant to carry out a Living Systematic Cochrane Review of ‘Electronic Cigarettes for Smoking Cessation’ funded by CRUK (current); PI on a programme grant to carry out a systematic review and network meta-analysis to investigate the safety and efficacy of pharmalogical treatments and electronic cigarettes for smoking cessation funded by the NIHR (current); co-applicant on a grant to investigate youth uptake of electronic cigarettes funded by CRUK (current); co-applicant on an Infrastructure grant which funds the Cochrane Tobacco Addiction Group funded by NIHR (current); co-applicant on a grant to investigate the comparative effectiveness of behavioural smoking cessation treatments funded by NIHR (ended Jan 2021); and receives payment for teaching Cochrane Authors how to write Cochrane protocols on behalf of Cochrane UK (not for profit organisation) (current) funded by Oxford Universities NHS Foundation Trust. Conflict of Interest: Chris Bullen reports research grants paid to institution (University of Auckland) from Health Research Council of NZ; contract for smoking cessation guideline review, paid to institution from NZ Ministry of Health; Contract for smokefree plan, paid to institution from Auckland Council; contract for research, paid to institution from Pfizer; research grant paid to institution from Tencent; personal fees for consulting on new NRT product from Johnson & Johnson KK (Japan); lecture fees for Lecture at Ottawa Heart Institute Annual conference, and honoraria for Manuscript writing Simon Fraser University; is President of SRNT-Oceania (unpaid); and Tobacco expert advisory group member, Health Coalition Aotearoa (unpaid). Conflict of Interest: Annika Theodoulou has nothing to disclose. Conflict of Interest: Rachna Begh has nothing to disclose. Conflict of Interest: Hayden McRobbie reports grant payments made to institution from Health Research Council (NZ), NIHR (UK) and NHMRC (AUS), outside the submitted work; and received honoraria from Pfizer for speaking at smoking cessation educational events and an advisory board meeting in Oct 2018. Conflict of Interest: Peter Hajek reports honoraria from Pfizer for contributing to Pfizer Workshop at SRNT Conference. Conflict of Interest: Nancy Rigotti reports contract for clinical trial paid to institution from Achieve Life Sciences; personal royalties for review of e-cigarettes from UpToDate; personal consulting fee from Achieve Life Sciences. Conflict of Interest: Jamie Hartmann-Boyce reports grant funding, including to support the review which this letter refers to paid to institution from Cancer Research UK; grant funding unrelated to this work paid to institution from British Heart Foundation; grant funding, including to support the review which this letter refers to, paid to institution from NIHR.

Background Hospitalization presents a window of opportunity to treat smoking, and hospital-initiated smoking treatment has demonstrated effectiveness. Despite effective interventions, not all smokers will discontinue use, highlighting the need to better understand which patients achieve cessation. Traditional regression methods may not capture the complexity of inpatient smoker subgroups. Methods Latent class analysis (LCA) was conducted with data from 397 hospitalized adult cigarette smokers enrolled in a randomized trial. Six categorical indicator variables known to impact cessation were selected to estimate subgroups: health conditions (smoking-related disease [SRD], depressive symptoms, positive screen for alcohol problems) and smoking-related variables (time to first cigarette, cigarettes/day, smoking indoors). The probability of achieving biologically verified 7-day tobacco cessation 6 months after discharged was estimated. Results A 3-class model best fit the trial data: a Light Smokers subgroup had lower probability for most indicators; a High Health Burden subgroup had high smoking behavior probabilities and similar health problems to the Light Smokers subgroup; and a Heavy Smoking Drinking Depressed subgroup had high nicotine dependence, depressive symptoms, and alcohol misuse probabilities. Probability of biologically verified cessation conditional on class membership was significantly higher ( P < .001) for the High Health Burden and the Light Smokers subgroups compared with the Heavy Smoking Drinking Depressed subgroup. Conclusion Results suggest that subgroups with lower probabilities of alcohol misuse and depression and higher probability of SRD had higher probability of successful cessation after hospital discharge. Hospitalized patients with nicotine dependence combined with behavioral and mental health problems have additional cessation barriers that may require intervention focus.

Aims To estimate the prevalence and predictors of failed biochemical verification of self-reported abstinence among participants enrolled in trials of hospital-initiated smoking cessation interventions. Design Comparison of characteristics between participants who verified and those who failed to verify self-reported abstinence. Settings Multi-site randomized clinical trials conducted between 2010 and 2014 in hospitals throughout the United States. Participants Recently hospitalized smokers who reported tobacco abstinence 6 months post-randomization and provided a saliva sample for verification purposes (n = 822). Measurements Outcomes were salivary cotinine-verified smoking abstinence at 10 and 15 ng/ml cut-points. Predictors and correlates included participant demographics and tobacco use; hospital diagnoses and treatment; and study characteristics collected via surveys and electronic medical records. Findings Usable samples were returned by 69.8% of the 1178 eligible trial participants who reported 7-day point prevalence abstinence. The proportion of participants verified as quit was 57.8% [95% confidence interval (CI) = 54.4, 61.2; 10 ng/ml cut-off] or 60.6% (95% CI = 57.2, 63.9; 15 ng/ml). Factors associated independently with verification at 10 ng/ml were education beyond high school education [odds ratio (OR) = 1.51; 95% CI = 1.07, 2.11], continuous abstinence since hospitalization (OR = 2.82; 95% CI = 2.02, 3.94), mailed versus in-person sample (OR = 3.20; 95% CI = 1.96, 5.21) and race. African American participants were less likely to verify abstinence than white participants (OR = 0.64; 95% CI = 0.44, 0.93). Findings were similar for verification at 15 ng/ml. Verification rates did not differ by treatment group. Conclusions In the United States, high rates (40%) of recently hospitalized smokers enrolled in smoking cessation trials fail biochemical verification of their self-reported abstinence.

INTRODUCTION: Three-quarters of homeless people smoke cigarettes. Financial incentives for smoking abstinence have appeared promising in nonexperimental studies of homeless smokers, but randomized controlled trial (RCT) data are lacking. METHODS: We conducted a pilot RCT of financial incentives for homeless smokers. Incentive arm participants (N = 25) could earn escalating $15–$35 rewards for brief smoking abstinence (exhaled carbon monoxide

Hospitalization offers smokers an opportunity to quit smoking. Starting cessation treatment in hospital is effective, but sustaining treatment after discharge is a challenge. Automated telephone calls with interactive voice response (IVR) technology could support treatment continuance after discharge. To assess smokers’ use of and satisfaction with an IVR-facilitated intervention and to test the relationship between intervention dose and smoking cessation. Analysis of pooled quantitative and qualitative data from the intervention groups of two similar randomized controlled trials with 6-month follow-up. A total of 878 smokers admitted to three hospitals. All received cessation counseling in hospital and planned to stop smoking after discharge. After discharge, participants received free cessation medication and five automated IVR calls over 3 months. Calls delivered messages promoting smoking cessation and medication adherence, offered medication refills, and triaged smokers to additional telephone counseling. Number of IVR calls answered, patient satisfaction, biochemically validated tobacco abstinence 6 months after discharge. Participants answered a median of three of five IVR calls; 70% rated the calls as helpful, citing the social support, access to counseling and medication, and reminders to quit as positive factors. Older smokers (OR 1.36, 95% CI 1.20–1.54 per decade) and smokers hospitalized for a smoking-related disease (OR 1.65, 95% CI 1.21–2.23) completed more calls. Smokers who completed more calls had higher quit rates at 6-month follow-up (OR 1.49, 95% CI 1.30–1.70, for each additional call) after multivariable adjustment for age, sex, education, discharge diagnosis, nicotine dependence, duration of medication use, and perceived importance of and confidence in quitting. Automated IVR calls to support smoking cessation after hospital discharge were viewed favorably by patients. Higher IVR utilization was associated with higher odds of tobacco abstinence at 6-month follow-up. IVR technology offers health care systems a potentially scalable means of sustaining tobacco cessation interventions after hospital discharge. Clinical Trial Registration: ClinicalTrials.gov Identifiers NCT01177176, NCT01714323.

Introduction Smoking is a key determinant of mortality among people living with HIV (PLWH). Methods To better understand the effects of smoking cessation interventions in PLWH, we conducted a pooled analysis of four randomized controlled trials of hospital-initiated smoking interventions conducted through the Consortium of Hospitals Advancing Research on Tobacco (CHART). In each study, cigarette smokers were randomly assigned to usual care or a smoking cessation intervention. The primary outcome was self-reported past 30-day tobacco abstinence at 6-month follow-up. Abstinence rates were compared between PLWH and participants without HIV and by treatment arm, using both complete-case and intention-to-treat analyses. Multivariable logistic regression was used to determine the effect of HIV status on 6-month tobacco abstinence and to determine predictors of smoking cessation within PLWH. Results Among 5550 hospitalized smokers, there were 202 (3.6%) PLWH. PLWH smoked fewer cigarettes per day and were less likely to be planning to quit than smokers without HIV. At 6 months, cessation rates did not differ between intervention and control groups among PLWH (28.9% vs. 30.5%) or smokers without HIV (36.1% vs. 34.1%). In multivariable regression analysis, HIV status was not significantly associated with smoking cessation at 6 months. Among PLWH, confidence in quitting was the only clinical factor independently associated with smoking cessation (OR 2.0, 95% CI = 1.4 to 2.8, p < .01). Conclusions HIV status did not alter likelihood of quitting smoking after hospital discharge, whether or not the smoker was offered a tobacco cessation intervention, but power was limited to identify potentially important differences. Implications PLWH had similar quit rates to participants without HIV following a hospital-initiated smoking cessation intervention. The findings suggest that factors specific to HIV infection may not influence response to smoking cessation interventions and that all PLWH would benefit from efforts to assist in quitting smoking. Trial Registration (1) Using “warm handoffs” to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial: NCT01305928. (2) Web-based smoking cessation intervention that transitions from inpatient to outpatient: NCT01277250. (3) Effectiveness of smoking-cessation interventions for urban hospital patients: NCT01363245. (4) Effectiveness of Post-Discharge Strategies for Hospitalized Smokers (HelpingHAND2): NCT01714323.

BACKGROUND: Cessation counseling and pharmacotherapy are recommended for hospitalized smokers, but better coordination between cessation counselors and providers might improve utilization of pharmacotherapy and enhance smoking cessation. OBJECTIVE: To compare smoking cessation counseling combined with care coordination post-hospitalization to counseling alone on uptake of pharmacotherapy and smoking cessation. DESIGN: Unblinded, randomized clinical trial PARTICIPANTS: Hospitalized smokers referred from primarily rural hospitals INTERVENTIONS: Counseling only (C) consisted of telephone counseling provided during the hospitalization and post-discharge. Counseling with care coordination (CCC) provided similar counseling supplemented by feedback to the smoker’s health care team and help for the smoker in obtaining pharmacotherapy. At 6 months post-hospitalization, persistent smokers were re-engaged with either CCC or C. MAIN MEASURES: Utilization of pharmacotherapy and smoking cessation at 3, 6, and 12 months post-discharge. KEY RESULTS: Among 606 smokers randomized, 429 (70.8%) completed the 12-month assessment and 580 (95.7%) were included in the primary analysis. Use of any cessation pharmacotherapy between 0 and 6 months (55.2%) and between 6 and 12 months (47.1%) post-discharge was similar across treatment arms though use of prescription-only pharmacotherapy between months 6–12 was significantly higher in the CCC group (30.1%) compared with the C group (18.6%) (RR, 1.61 (95% CI, 1.08, 2.41)). Self-reported abstinence rates of 26.2%, 20.3%, and 23.4% at months 3, 6, and 12, respectively, were comparable across the two treatment arms. Of those smoking at month 6, 12.5% reported abstinence at month 12. Validated smoking cessation at 12 months was 19.3% versus 16.9% in the CCC and C groups, respectively (RR, 1.13 (95% CI, 0.80, 1.61)). CONCLUSION: Supplemental care coordination, provided by counselors outside of the health care team, failed to improve smoking cessation beyond that achieved by cessation counseling alone. Re-engagement of smokers 6 months post-discharge can lead to new quitters, at which time care coordination might facilitate use of prescription medications. TRIAL REGISTRATION: NCT01063972

Introduction Electronic cigarettes (e-cigarettes) could benefit public health if they help current smokers to stop smoking long term, but evidence that they do so is limited. We aimed to determine the association between e-cigarette use and subsequent smoking cessation in a nationally representative cohort of US smokers followed for 2 years. Methods We analyzed data from adult cigarette smokers in Waves 1 through 3 of the Population Assessment of Tobacco and Health study. The primary exposure was e-cigarette use at Wave 1. The primary outcome was prolonged cigarette abstinence, defined as past 30-day cigarette abstinence at Waves 2 and 3 (1- and 2-year follow-up). Results Among Wave 1 cigarette smokers, 3.6% were current daily e-cigarette users, 18% were current non-daily e-cigarette users, and 78% reported no current e-cigarette use. In multivariable-adjusted analyses, daily e-cigarette use at Wave 1 was associated with higher odds of prolonged cigarette smoking abstinence at Waves 2 and 3 compared to nonuse of e-cigarettes (11% vs. 6%, adjusted odds ratio [AOR] = 1.77, 95% confidence interval [CI] = 1.08 to 2.89). Non-daily e-cigarette use was not associated with prolonged cigarette smoking abstinence. Among Wave 1 daily e-cigarette users who were abstinent from cigarette smoking at Wave 3, 63% were using e-cigarettes at Wave 3. Conclusions In this longitudinal cohort study of US adult cigarette smokers, daily but not non-daily e-cigarette use was associated with higher odds of prolonged cigarette smoking abstinence over 2 years, compared to no e-cigarette use. Daily use of e-cigarettes may help some smokers to stop smoking combustible cigarettes. Implications In this nationally representative longitudinal cohort study of US adult cigarette smokers, daily e-cigarette use, compared to no e-cigarette use, was associated with a 77% increased odds of prolonged cigarette smoking abstinence over the subsequent 2 years. Regular use of e-cigarettes may help some smokers to stop smoking combustible cigarettes.

BackgroundChanges in tobacco products, use patterns, and assessment technology in the last 15 years led the Society for Research on Nicotine and Tobacco (SRNT) Treatment Research Network to call for an update to the 2003 SRNT recommendations for assessing abstinence in clinical trials of smoking cessation interventions.MethodsThe SRNT Treatment Research Network convened a group of investigators with decades of experience in conducting tobacco treatment clinical trials. To arrive at the updated recommendations, the authors reviewed the recommendations of the prior SRNT Workgroup as well as current literature. Ten additional experts in the field provided feedback on this paper and these recommendations.ResultsWith respect to defining abstinence, the authors recommend: (1) continuing to use the definition of no use of combustible tobacco products (regardless of use of noncombustible tobacco products [e.g., snus] and alternative products [e.g., e-cigarettes]) and collecting additional data to permit alternate abstinence definitions; (2) no use of combustible or smokeless tobacco products; and (3) no use of combustible or smokeless tobacco products or alternative products, as appropriate for the research question being addressed. The authors also recommend reporting point prevalence and prolonged abstinence at multiple timepoints (end of treatment, ≥3 months after the end of treatment, and ≥6 months postquit or posttreatment initiation).ConclusionsDefining abstinence requires specification of which products a user must abstain from using, the type of abstinence (i.e., point prevalence or continuous), and the duration of abstinence. These recommendations are intended to serve as guidelines for investigators as they collect the necessary data to accurately describe participants’ abstinence during smoking cessation clinical trials.ImplicationsThis paper provides updated recommendations for defining abstinence in the context of smoking cessation treatment clinical trials.

BACKGROUND: Population-based strategies can expand the reach of tobacco cessation treatment beyond clinical encounters. OBJECTIVE: To determine the effect of two population-based tobacco cessation strategies, compared with usual care, on providing tobacco treatment outside of clinical encounters. DESIGN: 3-arm pragmatic randomized controlled trial. PARTICIPANTS: Current smokers ≥ 18 years old with a primary care provider at one of five community health centers in Massachusetts were identified via the electronic health record (n = 5225) and recruited using automated phone calls. INTERVENTIONS: One intervention group involved engagement with a health system–based tobacco coach (internal care coordination), and the other connected patients to a national quitline (external community referral). MEASUREMENTS: Proportion of smokers with documentation of any evidence-based cessation treatment in the 6 months after enrollment. KEY RESULTS: Of 639 individuals who responded to the proactive treatment offer, 233 consented and were randomized 1:1:1 to study arm. At 6-month follow-up, the pooled intervention group, compared with usual care, had higher documentation of any smoking cessation treatment (63% vs. 34%, p

Addressing parental smoking in the child healthcare setting improves the health of all family members. Innovative approaches, such as mobilizing technology-based platforms, may streamline screening and motivate acceptance of behavioral health services to treat tobacco use and dependence. The obective of this study was to describe innovations added to the CEASE intervention and to track 2 year post-intervention implementation data on families who were screened for tobacco use. Child healthcare practices in five states (IN, NC, OH, TN, and VA) used an electronic tablet screener to identify tobacco use within families and deliver tobacco cessation assistance to smokers. Motivational/educational videos on cessation were displayed via the screener to enhance its utility. Five CEASE intervention practices screened 50,111 family members for tobacco use and identified 6,885 families with children exposed to tobacco smoke. The mean number of screeners per practice per month was 417; the mean number of households with smokers identified per month was 57. Of 2,764 smokers who were at visits and consented, 57% indicated that they wanted a prescription to reduce or quit smoking; 94% of these were given preprinted prescriptions. Of 41% who requested connection to the quitline, 93% were given enrollment forms. Electronic screening was used to routinely identify tobacco users, leading to increased potential for offering cessation assistance to all household members who smoke. Improved delivery of smoking cessation services to families may be achieved by integrating technological innovations into routine pediatric practice. CLINICAL TRIALS REGISTRATION: Trial Number NCT01882348

Background Homeless smokers want to quit smoking but face numerous barriers to doing so, including pervasive smoking among peers and a lack of social support for quitting. An SMS (short message service) text messaging intervention could address these challenges by providing virtual daily support for homeless smokers who are trying to quit but coping with multiple triggers to smoke. Objective This study aimed to assess whether a free SMS text messaging program, added to evidence-based pharmacotherapy and counseling, improved smoking abstinence among homeless adult smokers. Methods From October 2015 to June 2016, we conducted an 8-week pilot randomized controlled trial (RCT) of nicotine patch therapy and weekly in-person counseling with (n=25) or without (n=25) SmokefreeTXT, a free SMS text messaging service administered by the National Cancer Institute (NCI) at Boston Health Care for the Homeless Program. All participants were provided with a mobile phone and a 2-month prepaid voice and text plan at no cost. SmokefreeTXT enrollees were sent 1 to 5 automated SMS text messages daily for up to 8 weeks and could receive on-demand tips for managing cravings, mood symptoms, and smoking lapses. The primary outcome was smoking abstinence, defined as an exhaled carbon monoxide count of Results Of the SmokefreeTXT arm participants (n=25), 88% (22) enrolled in the program, but only 56% (14) had confirmed enrollment for ≥2 weeks. Among 2-week enrollees, the median response rate to interactive messages from SmokefreeTXT was 2.1% (interquartile range 0-10.5%). Across all time points, smoking abstinence did not differ significantly between SmokefreeTXT and control arm participants (odds ratio 0.92, 95% CI 0.30-2.84). Of SmokefreeTXT enrollees who completed exit surveys (n=15), two-thirds were very or extremely satisfied with the program. However, qualitative interviews (n=14) revealed that many participants preferred in-person intervention formats over phone-based, found the SMS text messages impersonal and robotic, and felt that the messages were too frequent and repetitive. Only 40% (10/25) of SmokefreeTXT arm participants retained their study-supplied mobile phone for the 8-week duration of the trial, with phone theft being common. Storing and charging phones were cited as challenges. Conclusions SmokefreeTXT, added to nicotine patch therapy and in-person counseling, did not significantly improve smoking abstinence in this 8-week pilot RCT for homeless smokers. SMS text messaging interventions for this population should be better tuned to the unique circumstances of homelessness and coupled with efforts to promote mobile phone retention over time. Trial Registration ClinicalTrials.gov NCT02565381; https://clinicaltrials.gov/ct2/show/NCT02565381 (Archived by WebCite at http://www.webcitation.org/78PLpDptZ)

Background Despite a high prevalence of smoking among individuals with substance use disorders, tobacco dependence in this vulnerable population is undertreated. Methods We analyzed data from 5592 adult ( ≥ 18 years old) respondents to the 2014 Health Center Patient Survey, a nationally representative cross-sectional survey of individuals who receive care at U.S. Federally Qualified Health Centers. We evaluated self-reported smoking status, smoking-related quit behaviors (having quit, wanting or attempting to quit in the past year, and planning to quit in the next 6 months), and receipt of advice to quit smoking among participants with and without alcohol use disorder (AUD) and drug use disorder (DUD). Results Current smoking was common among individuals with AUD (64.3%) and DUD (55.0%). Few patients with AUD or DUD had quit smoking (16.7% and 24.0%, respectively). Smokers with AUD had higher odds of wanting to quit smoking in the past year (adjusted odds ratio = 2.88; 95% confidence interval = 1.19, 7.05), but were not more likely to have made a past-year quit attempt. DUD was not significantly associated with smoking-related quit behaviors. Smokers with AUD or DUD, as well as those who engaged in treatment for AUD or DUD, did not differ significantly from other smokers in receipt of advice to quit smoking. Conclusions Smokers with AUD and DUD were unlikely to have quit smoking despite interest in quitting. Our findings suggest a need for individualized tobacco treatment approaches in patients with AUD and DUD and missed opportunities to provide tobacco cessation counseling during addiction treatment.

Background Individuals with serious mental illness (SMI) smoke at disproportionately higher rates than those without SMI, have lifespans 25–32 years shorter, and thus bear an especially large burden of tobacco-related morbidity and mortality. Several recent studies demonstrate that smokers with SMI can successfully quit smoking with adequate support. Further evidence shows that using technology to deliver sustained care interventions to hospitalized smokers can lead to smoking cessation up to 6 months after discharge. The current comparative effectiveness trial adapts a technology-assisted sustained care intervention designed for smokers admitted to a general hospital and tests whether this approach can produce higher cessation rates compared to usual care for smokers admitted to a psychiatric inpatient unit. Methods A total of 353 eligible patients hospitalized for psychiatric illness are randomized by cohort into one of two conditions, Sustained Care (SusC) or Usual Care (UC), and are followed for six months after discharge. Participants assigned to UC receive brief tobacco education delivered by a hospital nurse during or soon after admission. Those assigned to SusC receive a 40-min, in-hospital motivational counseling intervention. Upon discharge, they also receive up to 8 weeks of free nicotine patches, automated interactive voice response (IVR) telephone and text messaging, and access to cessation counseling resources lasting 3 months post discharge. Smoking cessation outcomes are measured at 1-, 3- and 6-months post hospital discharge. Conclusion Results from this comparative effectiveness trial will add to our understanding of acceptable and effective smoking cessation approaches for patients hospitalized with SMI.

Aims Among people with cancer, dual alcohol and tobacco use increases risk for morbidity and mortality. Most smoking cessation clinical trials with this patient population have excluded individuals with problematic alcohol use. This investigation examined whether problematic alcohol use affects smoking cessation in cancer patients. Methods Mixed-methods secondary analysis of data from the Smokefree Support Study, a randomized-controlled trial examining the efficacy of Intensive (IT; n = 153) vs. Standard Treatment (ST; n = 150) for smoking cessation in newly diagnosed cancer patients. Problematic alcohol use was assessed at enrollment using the Cut-Down-Annoyed-Guilty-Eye-Opener (CAGE), weekly frequency of alcohol use and binge drinking measures. Alcohol use was categorized as: no current alcohol use, moderate and problematic use. The primary outcome was biochemically-confirmed cigarette abstinence at 6-months. A subset of patients (n = 72) completed qualitative exit-interviews. Results Among all participants, biochemically-confirmed cigarette abstinence rates were 25% (n = 32), 28% (n = 27), and 36% (n = 20) for participants reporting no current alcohol use, moderate use, and problematic use, respectively (p = 0.33). In logistic regression analysis, neither problematic alcohol use (AOR = 0.96, 95% CI = 0.35–2.67, p = .94) nor the problematic use by study arm interaction (AOR = 2.22, 95% CI = 0.59–8.39, p = .24) were associated with biochemically-confirmed 6-month abstinence. Qualitatively, participants reported that drinking alcohol triggers urges to smoke. Conclusion Newly diagnosed cancer patients reporting problematic alcohol use were not less likely to quit smoking than those without. Additional research is needed to investigate whether problematic alcohol users may benefit from smoking and alcohol behavior change interventions at the time of cancer diagnosis.

Background. In the United States, >40% of people infected with human immunodeficiency virus (HIV) smoke cigarettes. Methods. We used a computer simulation of HIV disease and treatment to project the life expectancy of HIV-infected persons, based on smoking status. We used age- and sex-specific data on mortality, stratified by smoking status. The ratio of the non-AIDS-related mortality risk for current smokers versus that for never smokers was 2.8, and the ratio for former smokers versus never smokers was 1.0–1.8, depending on cessation age. Projected survival was based on smoking status, sex, and initial age. We also estimated the total potential life-years gained if a proportion of the approximately 248 000 HIV-infected US smokers quit smoking. Results. Men and women entering HIV care at age 40 years (mean CD4+ T-cell count, 360 cells/µL) who continued to smoke lost 6.7 years and 6.3 years of life expectancy, respectively, compared with never smokers; those who quit smoking upon entering care regained 5.7 years and 4.6 years, respectively. Factors associated with greater benefits from smoking cessation included younger age, higher initial CD4+ T-cell count, and complete adherence to antiretroviral therapy. Smoking cessation by 10%–25% of HIV-infected smokers could save approximately 106 000–265 000 years of life. Conclusions. HIV-infected US smokers aged 40 years lose >6 years of life expectancy from smoking, possibly outweighing the loss from HIV infection itself. Smoking cessation should become a priority in HIV treatment programs.

Background Despite the well-established risks of persistent smoking, 10–30% of cancer patients continue to smoke after diagnosis. Evidence-based tobacco treatment has yet to be integrated into routine oncology care. This paper describes the protocol, manualized treatment, evaluation plan, and overall study design of comparing the effectiveness and cost of two treatments across two major cancer centers. Methods/design A two-arm, two-site randomized controlled comparative effectiveness trial is testing the hypothesis that an Intensive Treatment (IT) intervention is more effective than a Standard Treatment (ST) intervention in helping recently diagnosed cancer patients quit smoking. Both interventions include 4 weekly counseling sessions and FDA-approved smoking cessation medication advice. The IT includes an additional 4 biweekly and 3 monthly booster sessions as well as dispensal of the recommended FDA-approved smoking cessation medication at no cost. The trial is enrolling patients with suspected or newly diagnosed cancer who have smoked a cigarette in the past 30 days. Participants are randomly assigned to receive the ST or IT condition. Tobacco cessation outcomes are assessed at 3 and 6 months. The primary study outcome is 7-day point prevalence biochemically-validated tobacco abstinence. Secondary study outcomes include the incremental cost-effectiveness of the IT vs. ST. Discussion This trial will answer key questions about delivering tobacco treatment interventions to newly diagnosed cancer patients. If found to be efficacious and cost-effective, this treatment will serve as a model to be integrated into oncology care settings nation-wide, as we strive to improve treatment outcomes and quality of life for cancer patients.

Objective We determined the prevalence and correlates of other tobacco product and electronic cigarette (e-cigarette) use in a clinic-based sample of homeless cigarette smokers. Methods In April–July 2014, we used time-location sampling to conduct a cross-sectional, in-person survey of 306 currently homeless adult cigarette smokers recruited from 5 clinical sites at Boston Health Care for the Homeless Program. We assessed past-month use of large cigars, little cigars, smokeless tobacco, and e-cigarettes. Among those who had used e-cigarettes, we assessed the reasons for doing so. We used logistic regression analysis to identify the participant characteristics associated with the use of each product. Results Eighty-six percent of eligible individuals participated in the survey. In the past month, 37% of respondents used large cigars, 44% used little cigars, 8% used smokeless tobacco, 24% used an e-cigarette, and 68% used any of these products. Reasons for e-cigarette use included curiosity (85%) and to help quit conventional cigarettes (69%). In multivariable regression analyses, homeless smokers with greater subsistence difficulties were more likely to use little cigars ( p = 0.01) and less likely to use e-cigarettes ( p = 0.001). Non-Hispanic black ( p = 0.01), Hispanic ( p p = 0.04) participants were more likely to use large cigars. Readiness to quit was not associated with other tobacco product use but was significantly associated with e-cigarette use to help quit smoking ( p = 0.02). Conclusions Health care providers who serve homeless people should consider routine screening for the use of other tobacco products and e-cigarettes to help guide smoking cessation discussions and tobacco treatment planning.

IMPORTANCE: Electronic cigarettes (e-cigarettes) for smoking cessation remain controversial. OBJECTIVE: To evaluate e-cigarettes with individual counseling for smoking cessation. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial enrolled adults motivated to quit smoking from November 2016 to September 2019 at 17 Canadian sites (801 individuals screened; 274 ineligible and 151 declined). Manufacturing delays resulted in early termination (376/486 participants, 77% of target). Outcomes through 24 weeks (March 2020) are reported. INTERVENTIONS: Randomization to nicotine e-cigarettes (n = 128), nonnicotine e-cigarettes (n = 127), or no e-cigarettes (n = 121) for 12 weeks. All groups received individual counseling. MAIN OUTCOMES AND MEASURES: The primary end point was point prevalence abstinence (7-day recall, biochemically validated using expired carbon monoxide) at 12 weeks, changed from 52 weeks following early termination. Participants missing data were assumed to be smoking. The 7 secondary end points, examined at multiple follow-ups, were point prevalence abstinence at other follow-ups, continuous abstinence, daily cigarette consumption change, serious adverse events, adverse events, dropouts due to adverse effects, and treatment adherence. RESULTS: Among 376 randomized participants (mean age, 52 years; 178 women [47%]), 299 (80%) and 278 (74%) self-reported smoking status at 12 and 24 weeks, respectively. Point prevalence abstinence was significantly greater for nicotine e-cigarettes plus counseling vs counseling alone at 12 weeks (21.9% vs 9.1%; risk difference [RD], 12.8 [95% CI, 4.0 to 21.6]) but not 24 weeks (17.2% vs 9.9%; RD, 7.3 [95% CI, –1.2 to 15.7]). Point prevalence abstinence for nonnicotine e-cigarettes plus counseling was not significantly different from counseling alone at 12 weeks (17.3% vs 9.1%; RD, 8.2 [95% CI, –0.1 to 16.6]), but was significantly greater at 24 weeks (20.5% vs 9.9%; RD, 10.6 [95% CI, 1.8 to 19.4]). Adverse events were common (nicotine e-cigarette with counseling: 120 [94%]; nonnicotine e-cigarette with counseling: 118 [93%]; counseling only: 88 [73%]), with the most common being cough (64%) and dry mouth (53%). CONCLUSIONS AND RELEVANCE: Among adults motivated to quit smoking, nicotine e-cigarettes plus counseling vs counseling alone significantly increased point prevalence abstinence at 12 weeks. However, the difference was no longer significant at 24 weeks, and trial interpretation is limited by early termination and inconsistent findings for nicotine and nonnicotine e-cigarettes, suggesting further research is needed. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02417467

The workplace is a key channel for delivering tobacco cessation treatment to a population. Employers can provide workplace-based programs and/or financial incentives such as health insurance benefits that cover the cost of treatment accessed outside the workplace. Little is known about the effect of combining these strategies. We tested the benefit of adding a workplace cessation program, Partners in Helping You Quit (PiHQ), to comprehensive health insurance coverage of smoking cessation medications by Partners HealthCare, a large Boston-based healthcare delivery system. PiHQ offers biweekly telephone-based behavioral support, additional automated calls, and medication care coordination for 3 months then monthly telephone monitoring for 9 months. In a pragmatic randomized trial, employees who smoked were informed about the insurance benefit, then randomly assigned (2:1) to PiHQ or to active referral to a free 3-month phone-based community program, Massachusetts Quitline (QL). Outcomes were assessed at 3, 6, and 12 months. During 2015-2018, 106 smokers (n = 73 PiHQ, n = 33 QL) enrolled (64% female; 75% white, 21% black; mean age 46 years, mean cigarettes/day = 13). More PiHQ than QL participants made a quit attempt by 3 months (82 vs. 61%, p .02) and achieved the primary outcome, verified past 7-day cigarette abstinence at 6 months (31 vs. 12%, odds ratio 3.34, 95% CI, 1.05-10.60). Among participants using behavioral support, PiHQ participants completed more scheduled calls and rated counseling helpfulness higher than did QL participants. These results suggest that employers can enhance the impact of providing comprehensive health insurance coverage of smoking cessation medication by adding a phone-based worksite cessation program.

IMPORTANCE: Persistent smoking may cause adverse outcomes among patients with cancer. Many cancer centers have not fully implemented evidence-based tobacco treatment into routine care. OBJECTIVE: To determine the effectiveness of sustained telephone counseling and medication (intensive treatment) compared with shorter-term telephone counseling and medication advice (standard treatment) to assist patients recently diagnosed with cancer to quit smoking. DESIGN, SETTING, AND PARTICIPANTS: This unblinded randomized clinical trial was conducted at Massachusetts General Hospital/Dana-Farber/Harvard Cancer Center and Memorial Sloan Kettering Cancer Center. Adults who had smoked 1 cigarette or more within 30 days, spoke English or Spanish, and had recently diagnosed breast, gastrointestinal, genitourinary, gynecological, head and neck, lung, lymphoma, or melanoma cancers were eligible. Enrollment occurred between November 2013 and July 2017; assessments were completed by the end of February 2018. INTERVENTIONS: Participants randomized to the intensive treatment (n = 153) and the standard treatment (n = 150) received 4 weekly telephone counseling sessions and medication advice. The intensive treatment group also received 4 biweekly and 3 monthly telephone counseling sessions and choice of Food and Drug Administration–approved cessation medication (nicotine replacement therapy, bupropion, or varenicline). MAIN OUTCOME AND MEASURES: The primary outcome was biochemically confirmed 7-day point prevalence tobacco abstinence at 6-month follow-up. Secondary outcomes were treatment utilization rates. RESULTS: Among 303 patients who were randomized (mean age, 58.3 years; 170 women [56.1%]), 221 (78.1%) completed the trial. Six-month biochemically confirmed quit rates were 34.5% (n = 51 in the intensive treatment group) vs 21.5% (n = 29 in the standard treatment group) (difference, 13.0% [95% CI, 3.0%-23.3%]; odds ratio, 1.92 [95% CI, 1.13-3.27]; P

Introduction Many smokers with chronic medical conditions use e-cigarettes. This study assessed the association between e-cigarette use and subsequent smoking-cessation efforts in adult smokers with and without chronic medical conditions. Methods This was a longitudinal cohort study of adult cigarette smokers using Waves 1 and 2 of the Population Assessment of Tobacco and Health Study (2013–2015), analyzed in 2018‒2019. The exposure was the initiation of e-cigarette use by Wave 2. The outcomes at Wave 2 were: (1) past 12-month attempts to quit, (2) cigarette abstinence, (3) ≥50% reduction in cigarette use, and (4) past 12–month use of evidence-based smoking-cessation treatment. Results E-cigarette use initiation was associated with increased odds of attempting to quit smoking at Wave 2 among smokers with any chronic medical condition (AOR=1.92, 95% CI=1.42, 2.59) and without chronic medical conditions (AOR=1.81, 95% CI=1.50, 2.18). E-cigarette use initiation was also significantly associated with Wave 2 smoking abstinence in smokers with (AOR=1.95, 95% CI=1.11, 3.43) and without chronic medical conditions (AOR=1.63, 95% CI=1.17, 2.28). Conclusions At a population level, e-cigarette use by smokers with chronic medical conditions is associated with more quitting activity and smoking abstinence. Future studies are needed to assess e-cigarette safety and efficacy to determine whether they may provide an alternative smoking-cessation or harm-reduction strategy for adults with smoking-sensitive disease who cannot achieve these goals with other methods.

Introduction Most smokers see a physician each year, but few use any assistance when they try to quit. Text messaging programs improve smoking cessation in community and school settings; however, their efficacy in a primary care setting is unclear. The current trial assesses the feasibility and preliminary clinical outcomes of text messaging and mailed nicotine replacement therapy (NRT) among smokers in primary care. Methods In this single-center pilot randomized trial, eligible smokers in primary care are offered brief advice by phone and randomly assigned to one of four interventions: (1) Brief advice only, (2) text messages targeted to primary care patients and tailored to quit readiness, (3) a 2-week supply of nicotine patches and/or lozenges (NRT), and (4) both text messaging and NRT. Randomization is stratified by practice and intention to quit. The text messages (up to 5/day) encourage those not ready to quit to practice a quit attempt, assist those with a quit date through a quit attempt, and promote NRT use. The 2-week supply of NRT is mailed to patients' homes. Results Feasibility outcomes include recruitment rates, study retention, and treatment adherence. Clinical outcomes are assessed at 1, 2, 6, and 12-weeks post-enrollment. The primary outcome is ≥1self-reported quit attempt(s). Secondary clinical outcomes include self-reported past 7- and 30-day abstinence, days not smoked, NRT adherence, and exhaled carbon monoxide. Conclusions This pilot assesses text messaging plus NRT, as a proactively offered intervention for smoking cessation support in smokers receiving primary care and will inform full-scale randomized trial planning. Trial registration ClinicalTrials.gov NCT03174158 .

Background Little is known about the safety of nicotine replacement therapy ( NRT ) in smokers hospitalized with coronary heart disease. Methods and Results We examined the short‐term safety of NRT use among smokers hospitalized for coronary heart disease in a geographically and structurally diverse sample of US hospitals in the year 2014. We compared smokers who started NRT in the first 2 days of hospitalization with smokers without any exposure to NRT and adjusted for baseline differences through propensity score matching. Outcomes included inpatient mortality, hospital length of stay, and 1‐month readmission. From 270 hospitals, we included 27 459 smokers (mean age, 58 years; 69% men; 56.9% in intensive care unit), of whom 4885 (17.8%) received NRT (97.2% used the nicotine patch, at a median dose of 21 mg/d for 3 days). After propensity matching, covariates were well balanced within each patient group. Among patients with myocardial infarction, compared with patients who did not receive NRT , those who received NRT showed no difference in mortality (2.1% versus 2.3%; P =0.98), mean length of stay (4.4±3.5 versus 4.3±3.3 days; P =0.60), or 1‐month readmission (15.8% versus 14.6%; P =0.31). Results were similar for patients undergoing percutaneous coronary intervention or coronary artery bypass surgery. Conclusions Among smokers hospitalized for treatment of coronary heart disease, use of NRT was not associated with any differences in short‐term outcomes. Given the known beneficial effects of NRT in treating nicotine withdrawal, reducing cravings, and promoting smoking cessation after discharge, our findings suggest that NRT is a safe and reasonable treatment option.

INTRODUCTION: US adults with serious mental illness (SMI), compared to those without SMI, have a higher prevalence of smoking, which contributes to a shorter life expectancy. This study compared current smoking and quitting-related characteristics of low-income US adults with and without SMI who received healthcare at federally funded health centers. METHODS: Using cross-sectional data from adults ≥ 18 years old in the nationally representative 2014 Health Center Patient Survey (n = 5592), we compared the prevalence of ever and current smoking among adults with and without SMI and calculated quit ratios as the percentage of ever smokers who have quit smoking. We examined the association between SMI and receiving advice to quit, making quit attempts, and having plans to quit in the next 30 days using multivariable logistic regression. RESULTS: A total of 1376 (23%) of participants had SMI. Ever smoking prevalence was 68% in adults with SMI and 41% in adults without SMI, and current smoking prevalence was 48% and 22%, respectively. The quit ratio was 30% and 46% among participants with and without SMI, respectively. Compared to smokers without SMI, more smokers with SMI reported receiving advice to quit in the past 12 months (aOR 2.47, 95% CI 1.20–5.07). Smokers with and without SMI did not differ significantly in their odds of having made a past-12-month quit attempt or plans to quit. CONCLUSIONS: Smokers with SMI seen in federally funded health centers were just as likely to have made a quit attempt and to have plans to quit as smokers without SMI. Despite a higher likelihood of receiving clinician advice to quit, the lower quit ratio in this population suggests that advice alone is unlikely to be sufficient. These results underscore the need for augmented strategies to promote smoking cessation and reduce the excess burden of tobacco-related disease in patients with SMI.

Background Three-quarters of homeless people smoke cigarettes. Competing priorities for shelter, food, and other subsistence needs may be one explanation for low smoking cessation rates in this population. We analyzed data from two samples of homeless smokers to examine the associations between subsistence difficulties and 1) smoking cessation readiness, confidence, and barriers in a cross-sectional study, and 2) smoking abstinence during follow-up in a longitudinal study. Methods We conducted a survey of homeless smokers (N = 306) in 4/2014–7/2014 and a pilot randomized controlled trial (RCT) for homeless smokers (N = 75) in 10/2015–6/2016 at Boston Health Care for the Homeless Program. In both studies, subsistence difficulties were characterized as none, low, or high based on responses to a 5-item scale assessing the frequency of past-month difficulty finding shelter, food, clothing, a place to wash, and a place to go to the bathroom. Among survey participants, we used linear regression to assess the associations between subsistence difficulty level and readiness to quit, confidence to quit, and a composite measure of perceived barriers to quitting. Among RCT participants, we used repeated-measures logistic regression to examine the association between baseline subsistence difficulty level and carbon monoxide-defined brief smoking abstinence assessed 14 times over 8 weeks of follow-up. Analyses adjusted for demographic characteristics, substance use, mental illness, and nicotine dependence. Results Subsistence difficulties were common in both study samples. Among survey participants, greater subsistence difficulties were associated with more perceived barriers to quitting (p