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Introduction The objective of this study was to examine access, engagement, and quitting behaviors of American Indian/Alaska Native (AIAN) callers to the California Smokers’ Helpline. Telephone counseling is the primary function of the quitline. The overarching theoretical framework for California’s quitline is social cognitive theory, although it also utilizes motivational interviewing and cognitive-behavioral strategies. Aims and Methods AIAN (n = 16 089) and White (n = 173 425) California quitline callers from 2009 to 2018 were compared on their characteristics, engagement, and quitting behaviors. Quitline callers responded to a telephone survey at intake. A random selection was called for evaluation 7 months later (White n = 8194, AIAN n = 764). Data from the 2009 to 2017 California Health Interview Survey (CHIS) were used as a reference point for AIANs (AIAN n = 1373). Results The quitline and CHIS had similar proportions of AIANs (4.6% vs. 4.3%, respectively). AIAN smokers were more likely than White smokers to report physical (53.6% vs. 44.9%) and mental (65.7% vs. 57.8%) health conditions at intake. AIANs were more likely to participate in counseling than White callers (67.1% vs. 65.7%). Among those who received counseling, AIANs had greater odds than White smokers of making a quit attempt (adjusted odds ratio = 1.39 [1.06, 1.81]) and similar odds of quitting for 180 days (adjusted odds ratio = 0.95 [0.69, 1.31]). Conclusions Rates of access, engagement, and quitting suggest that individualized quitline counseling was as effective with AIANs as it was with White smokers. Increasing efforts to refer AIANs to existing state quitlines can help more smokers quit. Implications This study showed that AIAN smokers were well represented among California quitline callers, even without a targeted campaign. It also found that AIAN smokers engaged in quitline services and were as able to quit as their White counterparts were, even after adjusting for other baseline characteristics. One implication is that public health programs can promote quitlines using broad-based campaigns knowing that they will still motivate AIAN smokers to seek help. Another implication is that a standard, individualized counseling protocol delivered by culturally competent quitline staff can effectively help AIAN smokers to quit.

Receiving offers of cigarettes or e-cigarettes can contribute to the progression from intention to actual use. However, there is a lack of data about the prevalence or characteristics of youth being offered cigarettes or e-cigarettes. A random sample of 91 high schools in the state of California (with 40,137 students) participated in the 2015&ndash, 16 California Student Tobacco Survey. Offers of cigarettes and e-cigarettes in the last 30 days were assessed. Separate multilevel logistical regression models identified student characteristics associated with being offered cigarettes and e-cigarettes. On average, 11.1% and 16.1% of all students reported being offered cigarettes and e-cigarettes in the last 30 days, respectively. Among those who received offers of cigarettes, 45.5% were never smokers. Among those who received offers of e-cigarettes, 29.6% were never vapers. Male students were more likely to report being offered an e-cigarette than female students (Adjusted Odds Ratio (AOR) 1.13), as were students with friends that used e-cigarettes (AOR 5.14&ndash, 23.31) and those with high sensation seeking tendencies (AOR 1.33). Similar characteristics were associated with offers of cigarettes. Including measures of offers of cigarettes and e-cigarettes in surveillance systems could help identify those at risk of future cigarette and e-cigarette use.

ObjectivesWe conducted two parallel studies evaluating the effectiveness of proactive and reactive engagement approaches to telephone treatment for smoking cessation.MethodsPatients who smoked and were interested in quitting were referred to this study and were eligible if they were current smokers and had an address and a telephone number. The data were collected at 35 Department of Veterans Affairs (VA) sites, part of four VA medical centres in both California and Nevada. In study 1, participants received multisession counselling from the California Smokers’ Helpline (quitline). In study 2, they received self-help materials only. Patients were randomly assigned by week to either proactive or reactive engagement, and primary care staff were blind to this assignment. Providers gave brief advice and referred them via the electronic health record to a tobacco co-ordinator. All patients were offered cessation medications.OutcomeUsing complete case analysis, in study 1 (quitline), patients in the proactive condition were more likely than those in the reactive condition to report abstinence at 6 months (21.0% vs 16.4%, p=0.03). No difference was found between conditions in study 2 (self-help) (16.9% vs 16.5%, p=0.88). Proactive outreach resulted in increased use of cessation medications in both the quitline (70.1% vs 57.6%, pConclusionProactive outreach with quitline intervention was associated with greater long-term abstinence. Both studies resulted in high rates of medication use. Sites should use a proactive outreach approach and provide counselling whenever possible.Trial registration numberNCT00123682.

Purpose. To examine the effects of a smoking cessation campaign. Design. Data from the 2010–2011 Taiwan Adult Tobacco Surveys were analyzed. Setting. The study was set among a nationally representative sample of adults in Taiwan. Subjects. The surveys included 16,282 and 16,886 adults in 2010 and 2011, respectively, while our analyses focused on current smokers, 2518 and 2507 adults in 2010 and 2011, respectively. Intervention. In 2010 the Taiwanese government launched a national smoking cessation campaign through mass media in conjunction with community-based smoking cessation programs throughout the nation. Measures. Outcome variables include awareness of cessation services, quit attempts, intention to quit, and use of quitting method. Analysis. Multivariate logistic regressions were used to analyze data. Results. The implementation of the national smoking cessation campaign was associated with an increase in awareness of cessation services (odds ratio [OR] = 1.36; 95% confidence interval [CI] = 1.20–1.53), in quit attempts (OR = 1.12; 95% CI = 1.01–1.25), in use of unassisted quitting methods (OR = 1.39; 95% CI = 1.13–1.72), and in intention to quit smoking (OR = 1.15; 95% CI = 1.02–1.30). Conclusion. The implementation of the national smoking cessation campaign through media and community programs was effective in increasing smokers’ awareness of cessation services, quit attempts, and intention to quit.

Background E-cigarettes have grown popular. The most common pattern is dual use with conventional cigarettes. Dual use has raised concerns that it might delay quitting of cigarette smoking. This study examined the relationship between long-term use of e-cigarettes and smoking cessation in a 2-year period. Methods A nationally representative sample of 2028 US smokers were surveyed in 2012 and 2014. Long-term e-cigarette use was defined as using e-cigarettes at baseline and follow-up. Use of e-cigarettes only at baseline or at follow-up was defined as short-term use. Non-users did not use e-cigarettes at either survey. Quit attempt rates and cessation rates (abstinent for 3 months or longer) were compared across the three groups. Results At 2-year follow-up, 43.7% of baseline dual users were still using e-cigarettes. Long-term e-cigarette users had a higher quit attempt rate than short-term or non-users (72.6% vs 53.8% and 45.5%, respectively), and a higher cessation rate (42.4% vs 14.2% and 15.6%, respectively). The difference in cessation rate between long-term users and non-users remained significant after adjusting for baseline variables, OR=4.1 (95% CI 1.5 to 11.4) as did the difference between long-term users and short-term users, OR=4.8 (95% CI 1.6 to 13.9). The difference in cessation rate between short-term users and non-users was not significant, OR=0.9 (95% CI 0.5 to 1.4). Among those making a quit attempt, use of e-cigarettes as a cessation aid surpassed that of FDA-approved pharmacotherapy. Conclusions Short-term e-cigarette use was not associated with a lower rate of smoking cessation. Long-term use of e-cigarettes was associated with a higher rate of quitting smoking.

Introduction Most smokers abstain from smoking during hospitalization but relapse upon discharge. This study tests the effectiveness of two proven treatments (i.e., nicotine patches and telephone counseling) in helping these patients stay quit after discharge from the hospital, and assesses a model of hospital−quitline partnership. Study design This study had a 2×2 factorial design in which participants were stratified by recruitment site and smoking rate and randomly assigned to usual care, nicotine patches only, counseling only, or patches plus counseling. They were evaluated at 2 and 6 months post-randomization. Setting/participants A total of 1,270 hospitalized adult smokers were recruited from August 2011 to November 2013 from five hospitals within three healthcare systems. Intervention Participants in the patch condition were provided 8 weeks of nicotine patches at discharge (or were mailed them post-discharge). Quitline staff started proactively calling participants in the counseling condition 3 days post-discharge to provide standard quitline counseling. Main outcome measures The primary outcome measure was self-reported 30-day abstinence at 6 months using an intention-to-treat analysis. Data were analyzed from September 2015 to May 2016. Results The 30-day abstinence rate at 6 months was 22.8% for the nicotine patch condition and 18.3% for the no-patch condition ( p =0.051). Nearly all participants (99%) in the patch condition were provided nicotine patches, although 36% were sent post-discharge. The abstinence rates were 20.0% and 21.1% for counseling and no counseling conditions, respectively ( p =0.651). Fewer than half of the participants in the counseling condition (47%) received counseling (mean follow-up sessions, 3.6). Conclusions Provision of nicotine patches proved feasible, although their effectiveness in helping discharged patients stay quit was not significant. Telephone counseling was not effective, in large part because of low rates of engagement. Future interventions will need to be more immediate to be effective. Trial Registration This study is registered at www.clinicaltrials.gov NCT01289275.

Introduction Pregnant smokers are advised to quit; however, many struggle to do so. Behavioral counseling can increase quitting success, but the efficacy of telephone counseling for pregnant smokers has not been established. This study tests the efficacy of pregnancy-specific counseling, embedded in the ongoing operations of a state quitline. Design In this two-group RCT, participants were randomly assigned to the intervention (telephone counseling plus self-help materials, n =584) or the control group (self-help materials only, n =589). Setting/participants Participants were pregnant smokers (N=1,173) in the first 27 weeks of gestation who called a state quitline between September 2000 and May 2003 for help with quitting. Intervention The primary component of the intervention was telephone counseling using a semi-structured protocol developed specifically for pregnant smokers. It drew its basic structure and clinical content from a previously tested counseling protocol for adult quitline callers, while including pregnancy-specific content and additional counseling sessions (nine rather than the standard five). Main outcome measures Subjects were evaluated on prolonged abstinence at the third trimester (about 29 weeks' gestation) and at 2 and 6 months postpartum. Data were analyzed in 2015. Results Abstinence was higher for the intervention than the control group at the end of pregnancy (30-day abstinence, 29.6% vs 20.1%; p p p p Conclusions A pregnancy-specific counseling protocol, embedded in a state quitline, was effective in helping pregnant smokers quit and stay quit postpartum. Wide adoption of this intervention could help reduce the rate of maternal smoking and prevent its devastating health consequences. Trial Registration This study is registered at www.clinicaltrials.gov NCT02144883.

Introduction Electronic cigarette (e-cigarette) designs may be described as "closed" or "open." Closed systems are disposable or reloadable with prefilled cartridges (cigalikes). Open systems feature a prominent chamber (tank), refillable with e-liquid. This study examined user design preference and its association with smoking cessation. Methods A probability sample of current e-cigarette users ( n =923) among adult ever smokers ( n =6,560) in the U.S. was surveyed online between February 28 and March 31, 2014, and analyzed in September 2014. Photos of e-cigarette devices were presented alongside survey questions to facilitate respondents' understanding of the questions. Results Most e-cigarette users were exclusive users of one design: 51.4% used only closed systems and 41.1% used only open systems, with 7.4% using both. Former smokers were more likely to use open systems than current smokers (53.8% vs 35.2%, p =0.002). Current smokers who attempted to quit in the last 12 months were more likely to use open systems than those who did not (41.4% vs 27.7%, p =0.029). Open system users were more likely than closed system users to use e-cigarettes daily (50.2% vs 22.9%, p p p p =0.001). Conclusions Preference of e-cigarette design is associated with smoking cessation. A device's ability to deliver more nicotine and its flexibility in use might contribute to users' success in quitting smoking.

Background: E-cigarettes are purchased through multiple channels, including general retail, online, and specialty smoke and vape shops. We examine how e-cigarette users&rsquo, primary purchase place relates to e-cigarette use and smoking cessation behaviors. Methods: Probability-based samples of the U.S. population who were current e-cigarette users were surveyed in 2014 (N = 879) and 2016 (N = 743), with responses combined for most analyses. E-cigarette use and smoking cessation behaviors were compared across users&rsquo, primary purchase place. Results: Higher percentages of vape shop (59.1%) and internet (42.9%) customers were current daily users of e-cigarettes compared to retail (19.7%) and smoke shop (23.2%) customers (p-values &lt, 0.001). Higher percentages of vape shop (40.2%) and internet (35.1%) customers were also former smokers, compared to 17.7% of retail and 19.3% of smoke shop customers (p&rsquo, s &lt, 0.001). Among those smoking 12 months prior to survey, smoking cessation rates were higher for vape shop (22.2%) and internet customers (22.5%) than for retail customers (10.7%, p = 0.010 and p = 0.022, respectively), even though retail customers were more likely to use FDA-approved smoking cessation aids. The percentage of customers purchasing from vape shops increased from 20.4% in 2014 to 37.6% in 2016, surpassing general retail (27.7%) as the most likely channel in 2016. Conclusions: E-cigarette customers differed in significant ways by channels of purchase, most notably in their smoking cessation behaviors. Previous population studies have relied mostly on retail channel data, which accounted for less than 30% of all products sold by 2016. Future studies of e-cigarette use should consider a broader set of channels.

Introduction This study examined survey data from before and after California expanded its Medicaid program under the Affordable Care Act. It assessed changes in the insurance status of smokers, the proportion of smokers in Medicaid, and the health and well-being of those smokers relative to their counterparts in other insurance groups. Methods The study compared two data sets from the California Health Interview Study, the 2011–2012 (N=42,935) and 2016 (N=21,055) surveys. Measures include health insurance status, smoking status, chronic health conditions, frequency of doctors’ visits, and psychological distress. Data were analyzed in 2018. Results From 2011–2012 to 2016, the estimated number of California smokers in Medicaid nearly doubled from 738,113 to 1,447,945, and the proportion of smokers covered by Medicaid increased from 19.3% to 41.5%. Compared with those with private insurance, smokers in Medicaid were more likely to have chronic disease, have made five or more doctors’ visits in the past year, and be in severe psychological distress. In 2016, a total of 51.4% of all adult smokers with chronic disease conditions and 57.8% of those in severe psychological distress were covered by Medicaid. Conclusions With Medicaid covering a much higher proportion of smokers, especially of those smokers with chronic disease and in psychological distress, state Medicaid programs and plans must make tobacco cessation a top priority. They should encourage clinicians to ask, advise, and assist all smokers, track progress in reducing smoking prevalence, employ mass communication strategies to drive quit attempts, improve access to medications, and develop or expand programs to help smokers quit. Supplement information This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

© 2018 Elsevier Ltd An RCT designed to increase Medicaid smokers’ quitting success was conducted in California during 2012–2013. In the trial, alternative cessation treatment strategies were embedded in the state's ongoing quitline services. It found that modest financial incentives of up to $60 per participant and sending nicotine patches induced significantly higher cessation rates compared with usual care alone and usual care plus nicotine patches. Building upon that study, this study assessed potential population-level costs and benefits of integrating financial incentives and nicotine patches in a quitline setting for Medicaid smokers. A cost–benefit analysis was undertaken from the Medicaid program's perspective. The Cardiovascular Disease Policy Model was used to simulate future healthcare expenditures over a 10-year horizon for each treatment strategy for a study cohort of California Medicaid enrollees who were aged 35–64 years in 2014 (n=2,452,000). To simulate potential population-level benefits under each treatment strategy, each treatment was applied to all active smokers in the study cohort (n=478,300). Sensitivity analyses were conducted by varying key parameters, such as cessation costs, discount rate, relapse rates, and time horizon. Adding both financial incentives and nicotine patches to usual quitline care would result in $15 million net savings over 10 years, with a benefit–cost ratio of 1.30 compared with the usual care plus nicotine patches strategy. It would yield $44 million net savings, with a benefit–cost ratio of 1.90 compared with usual care alone. The strategy of providing financial incentives and mailing nicotine patches directly to Medicaid smokers who call the quitline is cost saving. Supplement information: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

INTRODUCTION:Most successful trials of financial incentives for smoking cessation have offered large rewards contingent on outcomes. This study examines whether more modest incentives to encourage engagement, non-contingent on outcomes, also increase cessation; whether sending medications directly to participants boosts quitting; and whether these strategies are effective in Medicaid. STUDY DESIGN:Three-group RCT of usual care (UC); nicotine patch (NP); and NP and financial incentive (NP+FI). SETTING/PARTICIPANTS:Medicaid beneficiaries calling the California Smokers' Helpline, 2012-2013 (N=3,816). Data were analyzed in 2017. INTERVENTION:All participants enrolled in evidence-based, multisession telephone counseling. All received proof of enrollment with which they could obtain free quitting aids at their pharmacy. NP and NP+FI also received nicotine patches sent to their homes. NP+FI received up to $60 for completing counseling calls. MAIN OUTCOME MEASURES:Quit attempt rate, 7-day and 30-day abstinence at 2 and 7 months, and 6-month prolonged abstinence (primary outcome). RESULTS:In both complete-case and intention-to-treat analyses, outcomes trended upward from UC to NP to NP+FI. Differences between NP and UC were generally nonsignificant. By contrast, the NP+FI group significantly outperformed the other groups on all measures. In intention-to-treat analysis, compared with UC, NP+FI was more likely to make a quit attempt (68.4% vs 54.3%, p

© 2018 Elsevier Ltd Introduction: Previous studies found that offering free nicotine patches significantly increases calls to quitlines, although most used pre–post designs and did not directly compare the effects of patches and other incentives. The current study with California Medicaid members used a 2 × 2 design to directly assess the effects of offering free patches and incentives on calls to a quitline. The hypotheses were that offering either would make members more likely to call, and that offering both would increase demand even further. Methods: Flyers were inserted into a mailing sent to 4,268,696 Medicaid households, with one of four offers: (1) free counseling; (2) counseling plus patches; (3) counseling plus a $20 gift card; and (4) counseling plus patches and gift card. Ninety percent received the first offer and 10% received one of the other three offers, in equal proportions. The mailers shipped late 2013 to early 2014. Data were collected 2013–2015 and analyzed 2018. Results: Response rates were 0.029% for counseling, 0.115% for counseling plus patches, 0.122% for counseling plus gift card, and 0.200% for counseling, patches, and gift card. Both patches and gift cards had statistically significant effects (both p

Introduction Little is known about how incentives may encourage low income smokers to call for quitline services. This study evaluates the impact of outreach through health channels on California Medicaid (Medi-Cal) quitline caller characteristics, trends, and reach. Study design Longitudinal study. Setting/participants Medi-Cal quitline callers. Intervention Statewide outreach was conducted with health providers, Medi-Cal plans (all-household mailings with tracking codes), and public health organizations (March 2012–July 2015). For incentives, Medi-Cal callers could ask for a $20 gift card; in September 2013, callers were offered free nicotine patches. Main outcome measures Caller characteristics were compared with chi-square analyses, joinpoint analysis of call trends was performed accounting for Medi-Cal population growth, referral source among Medi-Cal and non–Medi-Cal callers was documented, and the annual percentage of the population reached who called the Helpline was calculated. Analyses were conducted 2016–2018. Results Total Medi-Cal callers were 92,900, a 70% increase from prior annual averages: 12.4% asked for the financial incentive, 17.3% reported the mailing code, and 73.3% received nicotine patches while offered. Among the two thirds of callers who completed counseling, 15.5% asked for the financial incentive, and 13.6% reported the mailing code. A joinpoint analysis showed call trends increased 23% above expected for the Medi-Cal population growth after mailings to providers and members began, and decreased after outreach ended. Annual reach increased from 2.3% (95% CI=2.1, 2.6) in 2011 to peak at 4.5% (95% CI=3.6, 5.3) in 2014. Among subgroups with higher reach rates, some also had higher rates of asking for the financial incentive (African Americans, American Indian), reporting the tracking code (whites), or both (aged 45–64 years). Medi-Cal callers were more likely than non–Medi-Cal callers to report providers (32.3% vs 23.8%) and plans (19.7% vs 1.4%) as their referral source, and less likely to cite media (20.2% vs 44.4%, p Conclusions Statewide outreach through health channels incentivizing Medi-Cal members increased the utilization and reach of quitline services. Supplement information This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Introduction Social support from nonsmokers may have a role in prompting smokers to use evidence-based cessation treatment. Prior studies found that an intervention for nonsmoking support persons (SPs) was effective for promoting smokers' use of free, state quitline services. This pilot study adapted and assessed feasibility of this intervention for a racially diverse, low-income population. Methods Single group, non-randomized design enrolling SP-smoker dyads with low income status enrolled in one of three study “waves” of 10 pairs each. Participants were recruited using flyers and in-person outreach methods. The SP intervention included a 1-session coaching call and written materials; study waves 2 and 3 also included text messaging and a monetary incentive for smokers who used quitline services. Using content analysis, the intervention was iteratively adapted based on SP feedback. Baseline measures assessed socio-demographics, dyad and tobacco use characteristics. Follow-up assessments were conducted among SPs at 1-month follow-up and among smokers at 3-months follow-up. Feasibility indicators were recruitment, retention, and SP intervention acceptability and adherence. Secondary outcomes were smokers' use of any quitline service verified by quitline staff and 7-day, point prevalence, biochemically verified smoking abstinence at 3 months. Results Recruitment of 30 dyads was feasible; in-person recruitment methods were the most successful. SPs who completed follow-up assessments found the intervention acceptable, suggesting only minor content modifications, and they perceived the quitline information as novel. But the study had some feasibility challenges (e.g., SP coaching call completion: 60% and SP study retention: 53%). At 3 months, 2 smokers (7%) had used any quitline service and 13% were biochemically confirmed smoking abstinent. Conclusions This pilot study demonstrated feasibility of recruiting SP-smoker dyads from diverse, low-income communities. While the intervention was well received, its delivery was not feasible in this population. Results suggest that further consumer adaptation of the intervention is needed among both SPs and smokers., Highlights • Recruitment of low-income, nonsmoker-smoker dyads was feasible. • Nonsmokers found the support person intervention to be acceptable. • Support persons perceived the quitline information as novel. • The study had challenges with intervention implementation and study retention. • The intervention was not effective in prompting quitline use in this population.

Primary care-based approaches to address concurrent obesity and cardiovascular disease risk factors (CVDRFs) that begin with a high intensity intervention that is subsequently decreased (i.e., stepped-down) if weight loss is achieved have not been rigorously examined. Our study is a 20-month, single-blind randomized controlled trial at five primary care clinics in San Diego, CA, in 2013, where 262 obese adults (aged 25–70 years; 32.1% male; 59.2% white) with at least one CVDRF were enrolled into planned care for obesity and risk reduction (PCORR) using a stepped-down approach or enhanced usual care (EUC). All patients received physician recommendations for weight loss and CVDRFs. EUC patients (n = 132) received an individual session with a health educator every 4 months. PCORR patients (n = 130) received individual and group sessions (in-person, mail, telephone, and email) in three steps, characterized by less contact if success was achieved. At 20 months, 40.7%, 23.8%, and 15.4% of PCORR patients were in steps 1, 2, and 3, respectively (25.2% were lost to follow-up). PCORR resulted in a between-group difference in reduction in body weight of 6.1% [95% CI, 5.3 to 6.9] compared to EUC 2.8% [95% CI, 2.0 to 3.6] p = 0.007, with a greater reduction in BMI (35.2 [95% CI, 34.4 to 35.9] to 33.7 [95% CI, 32.9 to 34.5] kg/m2) than EUC (36.0 [95% CI, 35.3 to 36.8] to 35.1 [95% CI, 34.3 to 35.9] kg/m2), as indicated by a significant treatment by time interaction (p = 0.009). PCORR resulted in greater weight loss over 20 months than EUC. Trial Registration: ClinicalTrials.gov, NCT01134029

Author(s): Conway, Mike; Mowery, Danielle L; South, Brett R; Stoddard, Gregory J; Chapman, Wendy W; Patterson, Olga V; Zhu, Shu-Hong

© 2016, BMJ Publishing Group. All rights reserved. Background Varenicline is known to have greater efficacy than other pharmacotherapy for treating nicotine dependence and has gained popularity since its introduction in 2006. This study examines if adding varenicline to existing pharmacotherapies increased the population cessation rate. Methods Data are from two cross-sectional US Current Population Surveys—Tobacco Use Supplements (2003 and 2010–2011). Smokers and recent quitters 18 or older (N=34 869 in 2003, N=27 751 in 2010–2011) were asked if they had used varenicline, bupropion or nicotine replacement therapies (NRT) in their most recent quit attempt. The annual cessation rate, as well as the per cent of smokers who had quit for ≥3 months, was compared between surveys. Results Varenicline use increased from 0% in 2003 to 10.9% in 2010–2011, while use of bupropion decreased from 9.1% to 3.5%, and NRT from 24.5% to 22.4%. Use of any pharmacotherapy increased by 2.4 percentage points. Varenicline users stayed on cessation aids longer and were less likely to relapse than users of other pharmacotherapies in the first 3 months of a quit attempt, after which the difference was no longer significant. The change in annual cessation rate was negligible, from 4.5% in 2003 to 4.7% in 2010–2011 (p=0.36). Conclusions Addition of varenicline to the list of approved cessation aids has mainly led to displacement of other therapies. As a result, there was no meaningful change in population cessation rate despite a remarkable increase in varenicline use. The population impact of a new therapy is a function of more than efficacy or reach of the therapy.

Background: Use of smokeless tobacco (moist snuff and chewing tobacco) is a significant public health problem but smokeless tobacco users have few resources to help them quit. Web programs and telephone-based programs (Quitlines) have been shown to be effective for smoking cessation. We evaluate the effectiveness of a Web program, a Quitline, and the combination of the two for smokeless users recruited via the Web. Objectives: To test whether offering both a Web and Quitline intervention for smokeless tobacco users results in significantly better long-term tobacco abstinence outcomes than offering either intervention alone; to test whether the offer of Web or Quitline results in better outcome than a self-help manual only Control condition; and to report the usage and satisfaction of the interventions when offered alone or combined. Methods: Smokeless tobacco users (N = 1683) wanting to quit were recruited online and randomly offered one of four treatment conditions in a 2 × 2 design: Web Only, Quitline Only, Web + Quitline, and Control (printed self-help guide). Point-prevalence all tobacco abstinence was assessed at 3- and 6-months post enrollment. Results: 69% of participants completed both the 3- and 6-month assessments. There was no significant additive or synergistic effect of combining the two interventions for Complete Case or the more rigorous Intent To Treat (ITT) analyses. Significant simple effects were detected, individually the interventions were more efficacious than the Control in achieving repeated 7-day point prevalence all tobacco abstinence: Web (ITT, OR = 1.41, 95% CI = 1.03, 1.94, p = .033) and Quitline (ITT: OR = 1.54, 95% CI = 1.13, 2.11, p = .007). Participants were more likely to complete a Quitline call when offered only the Quitline intervention (OR = 0.71, 95% CI = .054, .093, p = .013), the number of website visits and duration did not differ when offered alone or in combination with Quitline. Rates of program helpfulness (p

Objectives. We examined smoking cessation rate by education and determined how much of the difference can be attributed to the rate of quit attempts and how much to the success of these attempts. Methods. We analyzed data from the National Health Interview Survey (NHIS, 1991–2010) and the Tobacco Use Supplement to the Current Population Survey (TUS-CPS, 1992–2011). Smokers (≥ 25 years) were divided into lower- and higher-education groups (≤ 12 years and > 12 years). Results. A significant difference in cessation rate between the lower- and the higher-education groups persisted over the last 2 decades. On average, the annual cessation rate for the former was about two thirds that of the latter (3.5% vs 5.2%; P Conclusions. Smokers in the lower-education group have consistently lagged behind their higher-education counterparts in quitting. In addition to the usual concern about improving their success in quitting, tobacco control programs need to find ways to increase quit attempts in this group.

Objective To investigate and compare the demographics of California smokers seeking assistance to quit and those of smokers who called the California Smokers’ Helpline, a large scale state-wide smoking cessation service. Data sources The 1990, 1992, and 1993 California Tobacco Surveys, and screening interviews conducted with callers to the California Smokers’ Helpline in its first 30 months of operation. Design For the California Tobacco Surveys, random digit dialled surveys of 24296 California adults in 1990, 8224 in 1992, and 30716 in 1993 were conducted, which included measures of smokers’ attitudes toward their smoking and of their help-seeking behaviour for smoking cessation. In the California Smokers’ Helpline, 23346 adult callers from August 1992 to January 1995 were surveyed. Demographic information was obtained on all surveys. Main outcome measure Seeking assistance to quit smoking. Results In the general smoking population, males were less likely to seek help in quitting smoking than females. The youngest group of adult smokers (18-24 years) was least likely to seek help. Hispanic, black and Asian smokers in California were only 40% as likely as white smokers to seek assistance. However, an ethnic breakdown of callers to the California Smokers’ Helpline shows that His- panics were as well represented in that programme as in the smoking population of the state. Blacks were actually over-represented by a factor of 2. The Helpline also attracted younger smokers than those who sought assistance in general. Smokers from rural counties were as likely to call the Helpline as those from urban counties. The former were usually referred by health care providers, whereas the latter most often heard about the Helpline through the mass media. Conclusions The California Smokers’ Helpline reached an ethnically and geographically representative sample of smokers. It appears suitable as a model for future programmes providing accessible smoking cessation service on a large scale.

Purpose We aimed to examine the availability of medical marijuana dispensaries, price of medical marijuana products, and variety of medical marijuana products in school neighborhoods and their associations with adolescents' use of marijuana and susceptibility to use marijuana in the future. Methods A representative sample of 8th, 10th, and 12th graders (N = 46,646) from 117 randomly selected schools in California participated in the cross-sectional 2015–2016 California Student Tobacco Survey (CSTS). Characteristics of medical marijuana dispensaries in California were collected and combined with school locations to compute availability, price, and product variety of medical marijuana in school neighborhoods. Multilevel logistic regressions with random intercepts at school level were conducted to test the associations, accounting for individual and school socioeconomic characteristics. Results The distance from school to the nearest medical marijuana dispensary (within 0- to 1-mi and 1- to 3-mi bands) was not associated with adolescents' use of marijuana in the past month or susceptibility to use marijuana in the future, nor was the weighted count of medical marijuana dispensaries within the 3-mi band of school. Neither the product price nor the product variety in the dispensary nearest to school was associated with marijuana use or susceptibility to use. The results were robust to different specifications of medical marijuana measures. Conclusions There was no evidence supporting the associations of medical marijuana availability, price, or product variety around school with adolescents' marijuana use and susceptibility to use.

Evidence-based treatments (e.g. quitlines) are greatly underutilized by smokers limiting their public health impact. A three-session phone intervention for nonsmoking family members and friends (i.e. support persons) was successful for increasing smoker quitline enrollment. To enhance the intervention’s potential translatability, in this study, we delivered treatment for the non-smoker within ongoing quitline services and compared the efficacy of the three-call intervention to a streamlined version (one call). A total of 704 adult non-smokers (85% female, 95% White) wanting to help a smoker quit and recruited statewide in Minnesota participated in this randomized controlled trial with parallel groups. Non-smokers received mailed written materials and were randomly assigned to a control condition (no additional treatment, n = 235), or to a one- (n = 233) or three-call (n = 236) intervention delivered by quitline coaches. The main outcome was smoker quitline enrollment through 7-month follow-up. Smoker quitline enrollment was similar for those linked to non-smokers in the one- and three-call interventions (14.6% [34/233] and 14.8% [35/236]), and higher than for smokers linked to control participants (6.4% [15/235]), P = 0.006. Just one quitline coaching call delivered to non-smokers increased treatment enrollment among smokers. The reach of quitlines could be enhanced by targeting the social support network of smokers.

ObjectiveTo examine whether the increase in use of electronic cigarettes in the USA, which became noticeable around 2010 and increased dramatically by 2014, was associated with a change in overall smoking cessation rate at the population level.DesignPopulation surveys with nationally representative samples.SettingFive of the US Current Population Survey-Tobacco Use Supplement (CPS-TUS) in 2001-02, 2003, 2006-07, 2010-11, and 2014-15.ParticipantsData on e-cigarette use were obtained from the total sample of the 2014-15 CPS-TUS (n=161 054). Smoking cessation rates were obtained from those who reported smoking cigarettes 12 months before the survey (n=23 270). Rates from 2014-15 CPS-TUS were then compared with those from 2010-11 CPS-TUS (n=27 280) and those from three other previous surveys.Main outcome measuresRate of attempt to quit cigarette smoking and the rate of successfully quitting smoking, defined as having quit smoking for at least three months.ResultsOf 161 054 respondents to the 2014-15 survey, 22 548 were current smokers and 2136 recent quitters. Among them, 38.2% of current smokers and 49.3% of recent quitters had tried e-cigarettes, and 11.5% and 19.0% used them currently (every day or some days). E-cigarette users were more likely than non-users to attempt to quit smoking, 65.1% v 40.1% (change=25.0%, 95% confidence interval 23.2% to 26.9%), and more likely to succeed in quitting, 8.2% v 4.8% (3.5%, 2.5% to 4.5%). The overall population cessation rate for 2014-15 was significantly higher than that for 2010-11, 5.6% v 4.5% (1.1%, 0.6% to 1.5%), and higher than those for all other survey years (range 4.3-4.5%).ConclusionThe substantial increase in e-cigarette use among US adult smokers was associated with a statistically significant increase in the smoking cessation rate at the population level. These findings need to be weighed carefully in regulatory policy making regarding e-cigarettes and in planning tobacco control interventions.

Background Although most US states prohibit cigarette smoking in public places and worksites, fewer jurisdictions regulate indoor use of electronic cigarettes (e-cigarettes). Given the dramatic increase in e-cigarette use and concern about its impact on non-users, there is a need to examine the use of e-cigarettes in smoke-free environments and related attitudes and perceptions. Methods Recruited from a nationally representative adult panel (GfK9s KnowledgePanel), 952 current users of e-cigarettes completed a cross-sectional online survey in 2014. Multivariate logistic regressions were conducted to examine the factors associated with ever using e-cigarettes in smoke-free environments. Results Overall, 59.5% of e-cigarette users had vaped where cigarette smoking was not allowed. Young adults (18–29 years) were most likely to do so, 74.2%. The places of first-time use most often mentioned were service venues (bar, restaurant, lounge and club), 30.7%, followed by worksites, 23.5%. Daily e-cigarette users were more likely to have vaped in smoke-free environments than non-daily users (OR=2.08, p=0.012). Only 2.5% of those who used e-cigarettes in smoke-free environments reported negative reactions from other people. Most e-cigarette users did not think e-cigarettes are harmful to themselves or to by-standers, and thus should not be banned where smoking is; those who had used e-cigarettes where smoking is banned were even more likely to hold these views. Conclusions E-cigarette use in smoke-free environments was common, suggesting that most e-cigarette users do not consider smoke-free laws to apply to e-cigarettes. Explicit laws should be considered if jurisdictions want to prohibit e-cigarette use in public places.

© 2014, BMJ Publishing Group. All rights reserved. Introduction E-cigarettes are largely unregulated and internet sales are substantial. This study examines how the online market for e-cigarettes has changed over time: in product design and in marketing messages appearing on websites. Methods Comprehensive internet searches of Englishlanguage websites from May–August 2012 and December 2013–January 2014 identified brands, models, flavours, nicotine strengths, ingredients and product claims. Brands were divided into older and newer groups (by the two searches) for comparison. Results By January 2014 there were 466 brands (each with its own website) and 7764 unique flavours. In the 17 months between the searches, there was a net increase of 10.5 brands and 242 new flavours per month. Older brands were more likely than newer brands to offer cigalikes (86.9% vs 52.1%, p

Introduction: Tobacco quitlines are evidence-based cessation resources that have been underutilized. The purpose of this study is to provide population-level data about quitline awareness and utilization in the United States and to assess correlates of awareness and utilization. Methods: Data were from the 2009-2010 National Adult Tobacco Survey. Descriptive statistics were produced for nationaland state-level quitline awareness and for national quitline utilization. Bivariate and multivariable logistic regressions were used to identify correlates of quitline awareness and utilization. Results: Quitline awareness among the total sample was 33.9% (current smokers 53.9%, former smokers 34.0%, never-smokers 27.0%). Awareness varied by state (range: 35.8%-84.6% for current smokers). Among current smokers who tried to quit in the past year, correlates of lower awareness included being Black, non-Hispanic, and making

Author(s): Chang, FC; Sung, HY; Zhu, SH; Chiou, ST | Abstract: Aims: In January 2009, the government of Taiwan amended the 1997 Tobacco Hazards Prevention Act by extending smoke-free areas to include almost all enclosed work-places and public places, adding graphic health warnings to cigarette packages, totally banning tobacco advertisements, promotion and sponsorship and increasing tobacco taxes. This study examined the impact of the 2009 amended Act on smoking cessation in Taiwan. Design: Taiwan Adult Tobacco Surveys 2007 and 2010, each with a nationally representative sample of adults aged 18 years and older (n=16588, and n=16295, respectively). Participants: All recent active smokers (current smokers plus former smokers who quit smoking within the past 12 months) were used for the analyses (n=3783 in 2007, and n=2777 in 2010). Measurements: Quit attempt rate and annual cessation rate (defined as having succeeded in quitting for at least 3 months) among recent active smokers were compared between the pre-Act (2007) and post-Act (2010) periods. Findings: The quit attempt rate increased significantly from 39.4% in 2007 to 42.9% in 2010. The annual cessation rate increased significantly from 7.1 to 8.9%. A multivariate analysis, controlling for demographic characteristics, showed that the implementation of the 2009 Act was associated with an increase in the quit attempt rate [odds ratio (OR)=1.14; 95% confidence interval (CI)=1.03-1.25] and the annual cessation rate (OR=1.28; 95% CI=1.08-1.53). Conclusions: The comprehensive tobacco control programme introduced in 2009 in Taiwan, which combined smoke-free legislation with a tobacco tax increase, graphic health warning labels and a total ban on tobacco advertisements, was associated with increases in quit attempt rate and annual cessation rate. © 2013 Society for the Study of Addiction.

Background: The popularity and use of electronic cigarettes (e-cigarettes) has increased across all demographic groups in recent years. However, little is currently known about the readability of health information and advice aimed at the general public regarding the use of e-cigarettes. Objective: The objective of our study was to examine the readability of publicly available health information as well as advice on e-cigarettes. We compared information and advice available from US government agencies, nongovernment organizations, English speaking government agencies outside the United States, and for-profit entities. Methods: A systematic search for health information and advice on e-cigarettes was conducted using search engines. We manually verified search results and converted to plain text for analysis. We then assessed readability of the collected documents using 4 readability metrics followed by pairwise comparisons of groups with adjustment for multiple comparisons. Results: A total of 54 documents were collected for this study. All 4 readability metrics indicate that all information and advice on e-cigarette use is written at a level higher than that recommended for the general public by National Institutes of Health (NIH) communication guidelines. However, health information and advice written by for-profit entities, many of which were promoting e-cigarettes, were significantly easier to read. Conclusions: A substantial proportion of potential and current e-cigarette users are likely to have difficulty in fully comprehending Web-based health information regarding e-cigarettes, potentially hindering effective health-seeking behaviors. To comply with NIH communication guidelines, government entities and nongovernment organizations would benefit from improving the readability of e-cigarettes information and advice. [JMIR Public Health Surveill 2017;3(1):e1]

Author(s): Zhu, Shu-Hong; Anderson, Christopher M; Zhuang, Yue-Lin; Gamst, Anthony C; Kohatsu, Neal D | Abstract: BackgroundIn recent decades the overall smoking prevalence in the US has fallen steadily. This study examines whether the same trend is seen in the Medicaid population.Methods and findingsNational Health Interview Survey (NHIS) data from 17 consecutive annual surveys from 1997 to 2013 (combined N = 514,043) were used to compare smoking trends for 4 insurance groups: Medicaid, the Uninsured, Private Insurance, and Other Coverage. Rates of chronic disease and psychological distress were also compared.ResultsAdjusted smoking prevalence showed no detectable decline in the Medicaid population (from 33.8% in 1997 to 31.8% in 2013, trend test P = 0.13), while prevalence in the other insurance groups showed significant declines (38.6%-34.7% for the Uninsured, 21.3%-15.8% for Private Insurance, and 22.6%-16.8% for Other Coverage; all P'sl0.005). Among individuals who have ever smoked, Medicaid recipients were less likely to have quit (38.8%) than those in Private Insurance (62.3%) or Other Coverage (69.8%; both P'sl0.001). Smokers in Medicaid were more likely than those in Private Insurance and the Uninsured to have chronic disease (55.0% vs 37.3% and 32.4%, respectively; both P'sl0.01). Smokers in Medicaid were also more likely to experience severe psychological distress (16.2% for Medicaid vs 3.2% for Private Insurance and 7.6% for the Uninsured; both P'sl0.001).ConclusionsThe high and relatively unchanging smoking prevalence in the Medicaid population, low quit ratio, and high rates of chronic disease and severe psychological distress highlight the need to focus on this population. A targeted and sustained campaign to help Medicaid recipients quit smoking is urgently needed.

In this paper, we present pilot work on characterising the documentation of electronic cigarettes (e-cigarettes) in the United States Veterans Administration Electronic Health Record. The Veterans Health Administration is the largest health care system in the United States with 1,233 health care facilities nationwide, serving 8.9 million veterans per year. We identified a random sample of 2000 Veterans Administration patients, coded as current tobacco users, from 2008 to 2014. Using simple keyword matching techniques combined with qualitative analysis, we investigated the prevalence and distribution of e-cigarette terms in these clinical notes, discovering that for current smokers, 11.9% of patient records contain an e-cigarette related term.

Detailed descriptions of effective intervention protocols for Asian smokers are uncommon which makes it difficult for others to successfully implement a protocol that has been proven to be effective. This article fills a gap by detailing such a protocol, specifically a telephone counselling intervention for Asian smokers. The protocol was tested in a large randomised trial with Chinese-, Korean-, and Vietnamese-speaking smokers and was shown to significantly increase quit rates. The article describes the approach used to develop the protocol and critical components of the intervention. In addition, the paper compares data on programme participation and satisfaction among Chinese-, Korean-, and Vietnamese-speaking smokers with those for English- and Spanish-speaking smokers from two studies conducted in the US and shows that the former are no less likely to engage in counselling and no less likely to be satisfied with the process.

Introduction Smokers are asking health practitioners for guidance about using e-cigarettes as an aid to quitting. Several studies have surveyed physicians. However, in North America many smokers seek help from telephone quitlines rather than physicians. The objective of the current study was to assess quitline counselors’ perceptions of e-cigarettes and what they tell callers about these products. Methods An online cross-sectional survey, conducted in 2014 with 418 quitline counselors in the U.S. and Canada, measured perceptions of e-cigarettes: (1) use as a quitting aid; (2) safety; (3) professional guidance given and organizational guidance received; (4) regulation. The response rate was 90.1%. Analyses included calculating standard errors and 95% confidence intervals around summary statistics. Results Nearly 70% of counselors believed that e-cigarettes are not effective quitting aids. Most believed e-cigarettes are addictive (87%) and that secondhand exposure to vapor is harmful (71%). Counselors reported that callers ask for advice about e-cigarettes, but few counselors recommended e-cigarettes (4%). Counselors (97%) reported being instructed by quitline employers to explain to clients that e-cigarettes are not FDA-approved; 74% were told to recommend approved quitting aids instead. Most counselors (> 87%) believed e-cigarettes should be regulated like cigarettes in terms of advertising, taxation, access by minors, and use in public places. Conclusions Quitline counselors view e-cigarettes as ineffective quitting aids, potentially dangerous, and in need of greater regulations. Counselors can influence how treatment seekers view e-cigarettes, therefore it is imperative that quitlines stay abreast of emerging data and communicate about these products in ways that best serve clients.

Most smokers abstain from smoking during hospitalization but relapse upon discharge. This study tests the effectiveness of two proven treatments (i.e., nicotine patches and telephone counseling) in helping these patients stay quit after discharge from the hospital, and assesses a model of hospital-quitline partnership.This study had a 2×2 factorial design in which participants were stratified by recruitment site and smoking rate and randomly assigned to usual care, nicotine patches only, counseling only, or patches plus counseling. They were evaluated at 2 and 6 months post-randomization.A total of 1,270 hospitalized adult smokers were recruited from August 2011 to November 2013 from five hospitals within three healthcare systems.Participants in the patch condition were provided 8 weeks of nicotine patches at discharge (or were mailed them post-discharge). Quitline staff started proactively calling participants in the counseling condition 3 days post-discharge to provide standard quitline counseling.The primary outcome measure was self-reported 30-day abstinence at 6 months using an intention-to-treat analysis. Data were analyzed from September 2015 to May 2016.The 30-day abstinence rate at 6 months was 22.8% for the nicotine patch condition and 18.3% for the no-patch condition (p=0.051). Nearly all participants (99%) in the patch condition were provided nicotine patches, although 36% were sent post-discharge. The abstinence rates were 20.0% and 21.1% for counseling and no counseling conditions, respectively (p=0.651). Fewer than half of the participants in the counseling condition (47%) received counseling (mean follow-up sessions, 3.6).Provision of nicotine patches proved feasible, although their effectiveness in helping discharged patients stay quit was not significant. Telephone counseling was not effective, in large part because of low rates of engagement. Future interventions will need to be more immediate to be effective.This study is registered at www.clinicaltrials.gov NCT01289275.

This paper reviews the literature on smoking cessation interventions, with a focus on the last twenty years (1991 to 2010). These two decades witnessed major development in a wide range of cessation interventions, from pharmacotherapy to tobacco price increases. It was expected that these interventions would work conjointly to increase the cessation rate on the population level. This paper examines population data from the U.S., from 1991 to 2010, using the National Health Interview Surveys. Results indicate there is no consistent trend of increase in the population cessation rate over the last two decades. Various explanations are presented for this lack of improvement, and the key concept of Impact = Effectiveness × Reach is critically examined. Finally, it suggests that the field of cessation has focused so much on developing and promoting interventions to improve smokers’ odds of success that it has largely neglected to investigate how to get more smokers to try to quit and to try more frequently. Future research should examine whether increasing the rate of quit attempts would be key to improving the population cessation rate.

Methods A culturally tailored counseling protocol was developed in English and translated into Chinese, Korean, and Vietnamese. We conducted a single randomized trial embedded in the California quitline service. Smokers who called the quitline’s Chinese, Korean, and Vietnamese telephone lines between August 2, 2004, and April 4, 2008, were recruited to the trial. Subjects (N = 2277) were stratified by language and randomly assigned to telephone counseling (self-help materials and up to six counseling sessions; n = 1124 subjects) or self-help (self-help materials only; n = 1153 subjects) groups: 729 Chinese subjects (counseling = 359, self-help = 370), 848 Korean subjects (counseling = 422, self-help = 426), and 700 Vietnamese subjects (counseling = 343, self-help = 357). The primary outcome was 6-month prolonged abstinence. Intention-to-treat analysis was used to estimate prolonged abstinence rates for all subjects and for each language group. All statistical tests were two-sided. Results In the intention-to-treat analysis, counseling increased the 6-month prolonged abstinence rate among all smokers compared with self-help (counseling vs self-help, 16.4% vs 8.0%, difference = 8.4%, 95% confidence interval [CI] = 5.7% to 11.1%, P < .001). Counseling also increased the 6-month prolonged abstinence rate for each language group compared with self-help (counseling vs self-help, Chinese, 14.8% vs 6.0%, difference = 8.8%, 95% CI = 4.4% to 13.2%, P < .001; Korean, 14.9% vs 5.2%, difference = 9.7%, 95% CI = 5.8% to 13.8%, P < .001; Vietnamese, 19.8% vs 13.5%, difference = 6.3%, 95% CI = 0.9% to 11.9%, P = .023). Conclusions Telephone counseling was effective for Chinese-, Korean-, and Vietnamese-speaking smokers. This protocol should be incorporated into existing quitlines, with possible extension to other Asian languages.

This study examined the perceived barriers to adopting an Asian-language quitline service among agencies that fund current state quitline services across the U.S. A self-administered survey on organizational readiness was sent to the funding agencies of 47 states plus Washington D.C. that currently fund state quitlines in English and Spanish, but not in Asian languages (response rate = 58%). The 2010 Census and the 2009 North American Quitline Consortium Survey were used to obtain the proportion of Asians among the state population and state quitline funding level, respectively. The most frequently cited reasons for not adopting an Asian quitline are: the Asian population in the state would be too small (71.4%), costs of service would be too high (57.1%), and the belief that using third-party translation for counseling is sufficient (39.3%). However, neither the actual proportion of Asians among the state population (range = 0.7% to 7.3%), nor the quitline funding level (range = $0.17 to $20.8 per capita) predicts the reported reasons. The results indicate that quitline funding agencies need more education on the necessity and the feasibility of an Asian-language quitline. Three states are currently participating in a multi-state Asian-language quitline in which each state promotes the service to its residents and one state (CA) provides the services for all the states. This centralized multi-state Asian-language quitline operation, which helps reduce practical barriers in adoption and disparity in access to service, could be extended.

Background Quitlines and other evidence-based cessation treatments are greatly underutilized by smokers, limiting their public health impact. Social support is correlated with successful cessation. Thus, efforts targeting the social network of smokers could be a potential avenue to promote quitline utilization. Purpose This study examined the efficacy of an intervention for nonsmokers interested in helping a smoker (i.e., support people) to promote smoker utilization of the Minnesota QUITPLAN® Helpline. Data were collected from 2007 to 2010, and analyses were conducted from 2010 to 2011. Design Two-group randomized design evaluating the support-person intervention (n=267) compared with a control condition (written materials, n=267). Setting/participants Enrolled were 534 support people (91% female, 93% Caucasian) residing in Minnesota. Intervention Written materials plus three weekly telephone sessions lasting 10–30 minutes each. Based on Cohen's theory of social support, the intervention provided participants with information and skills needed to encourage their smoker to call the QUITPLAN Helpline. Main outcome measures Participants completed the Support Provided Measure (SPM) by mail at baseline and Week 4 (end-of-treatment). Helpline intake staff documented smoker calls to the Helpline through 6 months of follow-up. Results The proportion of calls to the Helpline was significantly (p=0.012) greater for smokers linked to support people in the intervention group (16.1%, 43/267) than in the control group (8.6%, 23/267). The treatment effect remained significant after adjusting for support person residing with the smoker (OR=2.04, 95% CI=1.19, 3.49, p=0.010). Among support people randomly assigned to the intervention group, greater number of sessions completed was associated with increased smokers' calls to the Helpline (p=0.004). After adjusting for the baseline score, the M±SD SPM score at Week 4 was significantly higher for support people in the intervention group (16.4±3.3) than for those in the control group (15.3±3.6), p=0.002. Conclusions A support-person intervention is effective in increasing smoker utilization of the QUITPLAN Helpline. There is potential for increasing the reach of quitlines by targeting the social network of smokers. Trial registration # NCT01311830

Purpose. To compare the utilization rate of a statewide tobacco quitline by African-American smokers to that of white smokers. Design, Setting, and Subjects. Observational study of 18 years of state quitline operation in California. Subjects were 61,096 African-American and 279,042 white smokers who called the quitline from August 1992 to December 2009. Data from six California Tobacco Surveys, 1993, 1996, 1999, 2002, 2005, and 2008 were also used. Measure. Callers' answers to the question how they heard about the quitline were grouped into four categories: media, health care providers, friends/family, and others. Analysis. The averaged annual quitline call volume for each ethnic group was divided by the total number of smokers in that group, based on California Tobacco Surveys, to produce the annual quitline utilization rate. Results. In five out of six periods of comparison, African-American smokers had a higher annual utilization rate than white smokers. The odds ratios [ORs] ranged from 1.44 to 2.40 (all p < .05). In the 1996 comparison, the OR was .90 (p < .05). The difference in utilization rates that is attributed to media, accounts for most of the difference in total utilization rates between the two ethnic groups. Conclusions. Within the context of California's comprehensive tobacco control program, which includes a strong media campaign, African-American smokers were significantly more likely to call the state quitline than white smokers were. Promoting the quitline as part of antismoking media campaigns can help reduce disparity in cessation service utilization. (Am J Health Promot 2011;25[5 Supplement]:S51–S58.)

Introduction As many as half of intermittent (i.e., nondaily) smokers once smoked daily. Little is known about their transition from daily to intermittent smoking, a process that eventually leads them to forego smoking on some days. Method The present study attempted to gain insight by analyzing situations in which these individuals were likely to smoke. It used data from a California population tobacco survey with a supplemental questionnaire on smoking situations of young adults (aged 18-29 years, n = 1,581). The analysis in the present study divided smokers into three groups: daily smokers, intermittent smokers who never smoked daily (never-daily intermittent), and intermittent smokers who formerly smoked daily (former-daily intermittent). Results Former-daily intermittent smokers were more similar to never-daily intermittent smokers than to daily smokers in seven types of smoking situation, regardless of whether the situations were more social and episodic, such as "at parties," or more routine, such as while "driving." This held true even though these former-daily intermittent smokers were daily smokers only about 22 months on average before the survey. It appears that former-daily intermittent smokers reduce their probability of smoking across all situations. Discussion We propose a simple model to explain how a reduction in smoking probability across all situations might lead former-daily intermittent smokers to first forego smoking on days with no social events. The fact that smokers frequently go from daily to nondaily smoking has both theoretical and practical implications for nicotine research and for public health campaigns to reduce tobacco-related diseases.

Background Telephone quitlines are utilized by diverse individuals and represent an effective tobacco-cessation modality. Quitlines allow tobacco users to seek support for multiple quit attempts. Little is known about how frequently tobacco users take advantage of this opportunity. No studies have been conducted to determine how communication strategies affect quitline re-enrollments. This study aimed to determine the rates of quitline re-enrollment and to compare the responses of people of varying racial/ethnic identities to invitations utilizing different communication strategies. Design Four-cell RCT. Setting/ participants Random sample of 2400 tobacco users who enrolled into services during 2006, with oversampling of ethnic populations. Intervention Between November 2006 and January 2007, participants received either no invitation to re-enroll or were invited to re-enroll into services via a letter, a letter with ethnic-specific content, or a letter and a telephone call. Main outcome measures Re-enrollment into quitline services. Results Analysis of the 252 days prior to the intervention resulted in a spontaneous re-enrollment rate of 0.54% per 30 days. Recruitment using mailers did not significantly change this rate; the addition of telephone calls increased re-enrollment to 6.93% per 30 days. No significant differences were found among the subpopulations studied. Invalid addresses (16%); invalid telephone numbers (29.1%); and the inability to reach subjects after five call attempts (37.9%) were barriers to recruitment. Conclusions For those who have previously called quitlines for help, proactive re-enrollment can be one way to initiate a new quit attempt after relapse. This study has shown that it is feasible to re-enroll former quitline participants, making the test of effectiveness the next logical step.

Background: Quitlines have become an integral part of tobacco control efforts in the United States and Canada. The demonstrated efficacy and the convenience of telephone based counselling have led to the fast adoption of quitlines, to the point of near universal access in North America. However, information on how these quitlines operate in actual practice is not often readily available. Objectives: This study describes quitline practice in North America and examines commonalities and differences across quitlines. It will serve as a source of reference for practitioners and researchers, with the aim of furthering service quality and promoting continued innovation. Design: A self administered questionnaire survey of large, publicly funded quitlines in the United States and Canada. A total of 52 US quitlines and 10 Canadian quitlines participated. Descriptive statistics are provided regarding quitline operational structures, clinical services, quality assurance procedures, funding sources and utilisation rates. Results: Clinical services for the 62 state/provincial quitlines are supplied by a total of 26 service providers. Nine providers operate multiple quitlines, creating greater consistency in operation than would otherwise be expected. Most quitlines offer services over extended hours (mean 96 hours/week) and have multiple language capabilities. Most (98%) use proactive multisession counselling—a key feature of protocols tested in previous experimental trials. Almost all quitlines have extensive training programmes (>60 hours) for counselling staff, and over 70% conduct regular evaluation of outcomes. About half of quitlines use the internet to provide cessation information. A little over a third of US quitlines distribute free cessation medications to eligible callers. The average utilisation rate of the US state quitlines in the 2004–5 fiscal year was about 1.0% across states, with a strong correlation between the funding level of the quitlines and the smokers’ utilisation of them (r = 0.74, p Conclusions: Quitlines in North America display core commonalities: they have adopted the principles of multisession proactive counselling and they conduct regular outcome evaluation. Yet variations, tested and untested, exist. Standardised reporting procedures would be of benefit to the field. Shared discussion of the rationale behind variations can inform future decision making for all North American quitlines.

Counselling pregnant smokers to quit is as difficult as it is essential. This article discusses a telephone counselling protocol designed to promote tobacco cessation among pregnant smokers. The protocol, validated in a large randomised, controlled trial, addresses three key elements of change for addictive behaviour — motivation, cognition and skill building — in ways tailored to pregnant smokers' unique needs. Details concerning scheduling, counsellor training and broader applicability are also presented.

Pregnant smokers are advised to quit; however, many struggle to do so. Behavioral counseling can increase quitting success, but the efficacy of telephone counseling for pregnant smokers has not been established. This study tests the efficacy of pregnancy-specific counseling, embedded in the ongoing operations of a state quitline.In this two-group RCT, participants were randomly assigned to the intervention (telephone counseling plus self-help materials, n=584) or the control group (self-help materials only, n=589).Participants were pregnant smokers (N=1,173) in the first 27 weeks of gestation who called a state quitline between September 2000 and May 2003 for help with quitting.The primary component of the intervention was telephone counseling using a semi-structured protocol developed specifically for pregnant smokers. It drew its basic structure and clinical content from a previously tested counseling protocol for adult quitline callers, while including pregnancy-specific content and additional counseling sessions (nine rather than the standard five).Subjects were evaluated on prolonged abstinence at the third trimester (about 29 weeks' gestation) and at 2 and 6 months postpartum. Data were analyzed in 2015.Abstinence was higher for the intervention than the control group at the end of pregnancy (30-day abstinence, 29.6% vs 20.1%; p0.001); 2 months postpartum (90-day abstinence, 22.1% vs 14.8%; p0.001); and 6 months postpartum (180-day abstinence, 14.4% vs 8.2%; p0.001). Cotinine-corrected (≤13 ng/mL) 7-day abstinence rates at the end of pregnancy supported the intervention effect (35.8% vs 22.5%, p0.001).A pregnancy-specific counseling protocol, embedded in a state quitline, was effective in helping pregnant smokers quit and stay quit postpartum. Wide adoption of this intervention could help reduce the rate of maternal smoking and prevent its devastating health consequences.This study is registered at www.clinicaltrials.gov NCT02144883.

Author(s): Kuiper, Nicole; Zhang, Lei; Lee, Joann; Babb, Stephen D; Anderson, Christopher M; Shannon, Curt; Welton, MaryBeth; Lew, Rod; Zhu, Shu-Hong | Abstract: IntroductionUntil recently, in-language telephone quitline services for smokers who speak Asian languages were available only in California. In 2012, the Centers for Disease Control and Prevention (CDC) funded the national Asian Smokers' Quitline (ASQ) to expand this service to all states. The objective of this study was to examine characteristics of ASQ callers, how they heard about the quitline, and their use of the service.MethodsCharacteristics of callers from August 2012 through July 2014 were examined by using descriptive statistics. We examined demographics, cigarette smoking status, time to first cigarette, how callers heard about the quitline, and service use (receipt of counseling and medication) by using ASQ intake and administrative data. We analyzed these data by language and state.ResultsIn 2 years, 5,771 callers from 48 states completed intake; 31% were Chinese (Cantonese or Mandarin), 38% were Korean, and 31% were Vietnamese. More than 95% of all callers who used tobacco were current daily cigarette smokers at intake. About 87% of ASQ callers were male, 57% were aged 45 to 64 years, 48% were uninsured, and educational attainment varied. Most callers (54%) were referred by newspapers or magazines. Nearly all eligible callers (99%) received nicotine patches. About 85% of smokers enrolled in counseling; counseled smokers completed an average of 4 sessions.ConclusionASQ reached Chinese, Korean, and Vietnamese speakers nationwide. Callers were referred by the promotional avenues employed by ASQ, and most received services (medication, counseling, or both). State quitlines and local organizations should consider transferring callers and promoting ASQ to increase access to cessation services.

Author(s): Nagelhout, Gera E; Wolfson, Tanya; Zhuang, Yue-Lin; Gamst, Anthony; Willemsen, Marc C; Zhu, Shu-Hong | Abstract: IntroductionSeveral states implemented comprehensive smoke-free laws in workplaces (14 states), restaurants (17 states), and bars (13 states) between 2002 and 2007. We tested the hypothesis that public support for smoke-free laws increases at a higher rate in states that implemented smoke-free laws between 2002 and 2007 (group A) than in states that implemented smoke-free laws after that time or not at all (group B). The period before the implementation (1992-2001) was also considered.MethodsData was used from the Current Population Survey (CPS) Tobacco Use Supplements (TUS), which is representative for the U.S. adult population. Respondents were asked whether they thought smoking should not be allowed in indoor work areas, restaurants, and bars and cocktail lounges. Differences in trends were analyzed with binomial mixed effects models.ResultsPopulation support for smoke-free restaurants and bars was higher among group A than among group B before 2002. After 2002, support for smoke-free restaurants and bars increased at a higher rate among group A than among group B. Population support for smoke-free workplaces did not differ between group A and B, and the increase in support for smoke-free workplaces also did not differ between these groups.ConclusionsThe positive association between the implementation of smoke-free restaurant and bar laws and the rate of increase in support for these laws partly supported the hypothesis. The implementation of the laws may have caused support to increase, but also states that have higher support may have been more likely to implement smoke-free laws.