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Motivational interviewing may help people quit smoking, but more research is needed

by Olivia Maynard @OliviaMaynard17

This blog originally appeared on the Mental Elf site on 30th April 2015.

Both pharmacological (i.e. bupropion and varenicline) and non-pharmacological (i.e. brief advice from physicians) interventions have been shown to be effective in assisting people to stop smoking. Evidence also suggests that combining both these types of interventions can help people to stop smoking and both are considered equally important in quitting success.

Motivational interviewing (MI) is a counselling-based intervention which focusses on encouraging behaviour change by helping people to explore and resolve their uncertainties about changing their behaviour. MI avoids an aggressive or confrontational approach and aims to increase the self-belief of the individual. MI was initially developed to treat alcohol abuse, but may be helpful in encouraging smoking cessation.

In a recent Cochrane systematic review, Lindson-Hawley and colleagues from the Cochrane Tobacco Addiction Group aimed to determine whether or not MI is an effective method of smoking cessation (Lindson-Hawley et al, 2015).

Motivational interviewing focusses on encouraging behaviour change by helping people to explore and resolve their uncertainties about changing their behaviour.

Methods

The authors searched online databases and studies were included if:

  • Participants were tobacco users and were not pregnant or adolescents;
  • The intervention was based on MI techniques;
  • The control group received brief advice or usual care;
  • Some monitoring of the quality of the MI intervention was included;
  • Smoking abstinence was reported at least 6 months after the start of the programme.

The main outcome measure was smoking abstinence, using the most rigorous definition of abstinence for each study. Biochemically-validated measures of abstinence (i.e., carbon monoxide breath testing or saliva cotinine samples) were also used where available. Those participants lost to follow-up were considered to be continuing to smoke.

Results across studies were combined in a meta-analysis.

Results

Twenty eight studies published between 1997 and 2014 were found to match the strict inclusion criteria.

The total dataset included over 16,000 participants and studies varied in:

  • The length of the MI sessions (ranging from 10 to 60 minutes)
  • The number of sessions (one to six sessions)
  • Who the sessions were delivered by (primary care physicians, hospital clinicians, nurses or counsellors)

Some of the main findings included:

  • A modest (26%) increase in quitting among those receiving MI as compared with control (although the true value is likely to lie between 16-36%).
  • Sub-group analyses found that:
    • MI delivered by primary care physicians increased the likelihood of successful quitting by 349% (53-794%) as compared with control
    • When it was delivered by counsellors, quit rates increased by only 25% as compared with control
    • MI delivered by nurses was not found to be more effective than control
  • Shorter sessions (less than 20 minutes) increased the chances of quitting relative to control by 69%, as compared with longer sessions, which only increased the chances of quitting by 20%.
  • There was little difference in the likelihood of quitting between single MI sessions (26%) and multiple sessions (20%) as compared with control.
  • There was little difference between MI delivered face-to-face as compared with via the telephone only.
  • There was no evidence for a difference for MI delivered to smokers who were motivated to quit as compared with those with low levels of motivation.

Compared with brief advice or usual care, motivational interviewing yielded a significant increase in quitting. However, study quality means that these results should be interpreted with caution.

Strengths

This review adds 14 additional studies to a previous review conducted in 2010. The addition of these new studies altered the results of the original review very little, providing strong support for the validity of these findings.

Two previous systematic reviews have also examined the effectiveness of MI for smoking cessation, observing modest positive effects of MI (Heckman et al., 2010, Hettema and Hendricks, 2010), although these studies used a broader inclusion criteria than used here and therefore may have underestimated the effects of MI.

The majority of studies included in this review adequately reported their design and methods. Some studies did not report information about blinding of the outcome assessment or how participants were allocated to conditions. However, sensitivity analyses indicated that these factors did not influence the findings of the review.

Limitations

The authors report some evidence for publication bias, such that studies reporting a positive effect of MI were more likely to be published, potentially compromising the results of this systematic review.

Eight of the 24 studies did not use biochemically-validated measures of abstinence. When analyses excluded these studies, the size of the beneficial effect of MI increased. Future research should use the biochemically-validated abstinence measures so as to ensure that smoking cessation is reliably reported.

Conclusions

These results indicate that MI is more effective at promoting smoking cessation than usual care or brief advice, although the effect is modest.

Some components of MI counselling appear to increase the effectiveness of MI for smoking cessation, including delivery by a primary care physician. The reviewers suggest that physicians may be better placed to use the MI approach given their established rapport with the patient. However, this effect is based on only two studies and therefore the importance of physician delivery should not be overstated.

Shorter sessions and fewer follow-ups were also found to be more effective than longer sessions with more follow-up sessions. One explanation given by the authors is that a single session is enough to motivate someone to quit smoking. Prolonging the time before the quit date may mean participants lose focus on their goal to stop smoking.

While MI seems to be effective in promoting smoking cessation, future research should continue to explore the components of MI which optimise the success of this intervention. The relationship between non-pharmacological interventions such as MI and pharmacological interventions should also be considered.

This review confirms that motivational interviewing for smoking cessation is supported by moderate level evidence.

Links

Primary paper

Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD006936. DOI: 10.1002/14651858.CD006936.pub3.

Other references

Heckman, C. J., Egleston, B. L. & Hofman, M. T. (2010). Efficacy of motivational interviewing for smoking cessation: a systematic review and meta-analysisTobacco Control, 19, 410-416.

Hettema, J. E. & Hendricks, P. S. (2010). Motivational interviewing for smoking cessation: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 868-884. [DARE summary]

 

Researching abroad: Cannabis and decision making in the Big Apple

by Michelle Taylor @chelle_bluebird

Setting off for TARGs 2013 annual retreat to Cumberland Lodge in Great Windsor Park, I was looking forward to hearing a talk from an invited guest speaker. Gill had flown in from Columbia University to talk to the group about a recent drug administration study her lab group had completed. The research being conducted by their lab was very different to the epidemiological research that I am used to. Now don’t get me wrong, I thoroughly enjoy the research that I do, but these studies sounded new and exciting. After listening to the talk, the evening activities began with dinner and a quiz. Luckily, I ended up on the same quiz team as Gill, giving me the opportunity to ask more about her research. I decided to grab the bull by the horns and offer my help in one of her future studies, and so my trip to the Big Apple began…

central park 1Nine months later I was on my way to Heathrow for a two month stint collecting data on a cannabis administration study. I was both excited and apprehensive. I have never lived more than a 3 hour drive away from family, and have always been in a city where I have known people. I didn’t know whether I would get homesick, or whether I would make friends on my trip abroad. These feelings of apprehension soon disappeared in the first few hours of my first day at the New York Psychiatric Institute. Everyone I met was so friendly and welcoming, even the many morning commuters who stopped to help the lone Brit who was obviously puzzled by the subway map at 7.30am.

yankeesI was to spend the next six weeks collecting data for a study examining the neuro-behavioural mechanisms of decisions to smoke cannabis at the Substance Use Research Center in the New York Psychiatric Institute at Columbia University. This research centre is unique; it is one of the largest drug administration centre in the world and has licenses to administer a wide variety of drugs, including cannabis, cocaine and heroin. This means that much of the research conducted here is cutting edge. The aim of the study that I would be working on was to shed light on how and why drug abusers repeatedly make decisions to take drugs despite substantial negative consequences. The study used brain imaging (fMRI) to examine the neural and behavioural processes involved in decisions to self-administer cannabis, compared to decisions to eat food, in regular cannabis users. We also examined the influence of drug and food cues on the processes underlying these decisions. To do this, participants were recruited as inpatients and stayed with us in the lab for a week. Data collection for this study is still ongoing, but I will be sure to write another blog post with what we found when the results are available.

coney_2I found this research fascinating and it was a pleasure to be involved in the work carried out in this department. The experience was made even more enjoyable by the people I was working with. There were many office conversations about the British and American slang that was being used, many lunchtime trips to Chipotle (an American fast food restaurant that I am definitely missing since my return to the UK), and several Friday evening trips to the local Irish bar. One office memory that will always stick in my mind was meeting a very accomplished researcher in the field of my PhD, a researcher that was definitely someone I should be impressing. Upon entering this individuals office on an extreme
ly hot New York day, the fan was turned to the meeting area and the smell of cannabis filled the room as the flow of air reached me (I had been administered the drug to a participant earlier that afternoon). Probably not the best first impression I have ever made!

milkshakeI did, of course, take every opportunity to explore New York. I was lucky enough to get tickets to watch the New York Yankees beat the Boston Red Sox at the Yankee Stadium, which was also one of the last games played by baseball-legend Derek Jeter. I made several trips to the American Natural History Museum (my favourite type of museum, and this one cannot be done in a day), and while there saw a live spider show, a 3D film about Great White Sharks and a full T-Rex skeleton. The glorious weather allowed for several leisurely strolls around Central Park. And, of course, the American food definitely needs a mention. If anyone reading this takes a trip over the Atlantic, I would definitely recommend visiting Big Daddy’s Diner for what could be the best milkshake on the planet. And don’t be shy about trying a hotdog from one of the carts that can be found on nearly every street corner. The reason there are so many of them is that they’re delicious! I would also recommend a trip to the Russian Tea Rooms for caviar afternoon tea, an evening at the New York Metropolitan Opera (if that’s your cup of tea), and a trip to Coney Island.

t_rexAlthough it was daunting going abroad for that length of time to begin with, I don’t think I would be having those feelings again and I would definitely jump at any opportunity to work in a different environment in the future. I am very grateful that I am a PhD student in a large working group like TARG, as without this I probably would not have come across opportunities such as this one. This experience has taught me the importance of inter-disciplinary research, and the need for several fields contributing evidence to a much larger research question. Since this trip, I have been successful in a fellowship application allowing me 9 months in a different department at the University of Bristol, an application that I probably would not have made if it wasn’t for my experience at the Columbia University. I am an epidemiologist and do not have any plans to change that; however I do plan to conduct more interdisciplinary research in the future. I would like to that Gill (and everyone in her lab group) for welcoming me and making this trip possible. I look forward to hopefully working with you again in the future…

E-cigarettes and teenagers: cause for concern?

By Marcus Munafo @MarcusMunafo 

This blog originally appeared on the Mental Elf site on 20th April 2015

shutterstock_208797175

Electronic cigarettes (e-cigarettes) are a range of products that deliver vapour which typically contains nicotine (although zero-nicotine solutions are available). The name is misleading because some products are mechanical rather than electronic, and because they are not cigarettes. While first-generation products were designed to be visually similar to cigarettes, second- and third-generation products are visually distinctive and come in a variety of shapes and sizes. Critically, these products do not contain tobacco, and are therefore intended to deliver nicotine without the harmful constituents of tobacco smoke.

There has been rapid growth in the popularity and use of e-cigarettes in recent years, accompanied by growth in their marketing. At present they are relatively unregulated in many countries, although countries are introducing various restrictions on their availability and marketing. For example, a ban on sales to under-18s will be introduced in England and Wales in 2015.

These products have stimulated considerable (and often highly polarized) debate in the public health community. On the one hand, if they can support smokers in moving away from smoking they have enormous potential to reduce the harms associated with smoking. On the other hand, the quality and efficacy of these products remains largely unknown and is likely to be highly variable, and data on the long-term consequences of their use (e.g., the inhalation of propylene glycol vapour and flavourings) is lacking. There is also a concern that these products may re-normalise smoking, or act as a gateway into smoking.

E-cigarettes and teenagers: a gateway

Methods

This study reports the results of a survey conducted by Trading Standards in the North-West of England on 14 to 17 year-old students. The survey focuses on tobacco-related behaviours, and a question on access to e-cigarettes was introduced in 2013. This enabled identification of factors associated with e-cigarette use among people under 18 years old.

The study used data from the 5th Trading Standards North West Alcohol and Tobacco Survey among 14 to 17 year-olds in North-West England, conducted in 2013. The questionnaire was made available to secondary schools across the region through local authority Trading Standards departments, and delivered by teachers during normal school lessons. Compliance was not recorded, and the sample was not intended to be representative but to provide a sample from a range of communities.

The survey consisted of closed, self-completed questions covering sociodemographic variables, alcohol consumption and tobacco use. There were also questions on methods of access to alcohol and tobacco, as well as involvements in violence when drunk. E-cigarette access was assessed by the question “Have you ever tried or purchased e-cigarettes?”.

The study used data from the North West Alcohol and Tobacco Survey, which asked 14 to 17 year-olds lots of questions about their substance use behaviour.

Results

A total of 114 schools participated, and the total dataset included 18,233 participants, of which some were removed for missing data or spoiled questionnaires (e.g., unrealistic answers), so that the final sample for analysis was 16,193. Some of the main findings of the survey included:

  • In total, 19.2% of respondents reported having accessed e-cigarettes, with this being higher in males than females, and increasing with age and socioeconomic deprivation.
  • Level of e-cigarette access was higher among those who had smoked, ranging from 4.9% of never smokers, through 50.7% of ex-smokers, 67.2% of light smokers and 75.8% of heavy smokers.
  • E-cigarette use was associated with alcohol use, with those who drank alcohol more likely to have accessed e-cigarettes than non-drinkers, as well as with smoking by parents/guardians.

Nearly 1 in 5 of the young people surveyed

Conclusion

The authors conclude that their results raise concerns around the access to e-cigarettes by children, particularly among those who have never smoked cigarettes. They argue that their findings suggest that the children who access e-cigarettes are also those most vulnerable to other forms of substance use and risk-taking behavior, and conclude with a call for the “urgent need for controls on e-cigarette sales to children”. The study has some important strengths, most notably its relatively large size, and ability to determine which respondents were living in rich and poor areas.

Understanding the determinants of e-cigarette use, and patterns of use across different sections of society, is important to inform the ongoing debate around their potential benefits and harms. However, it is also not clear what this study tells us that was not already known. The results are consistent with previous, larger surveys, which show that young people (mostly smokers) are trying e-cigarettes. Critically, these previous surveys have shown that while some young non-smokers are experimenting with electronic cigarettes, progression to regular use among this group is rare. Product labels already indicate that electronic cigarettes are not for sale to under-18s, and in 2014 the UK government indicated that legislation will be brought forward to prohibit the sale of electronic cigarettes to under-18s in England and Wales (although at present no such commitment has been made in Scotland).

This study does not add anything significant to our knowledge about e-cigarettes.

Limitations

There are a number of important limitations to this study:

  • As the authors acknowledge, this was not meant to be a representative survey, and the results can therefore not be generalized to the rest of the north-west of England, let alone the wider UK.
  • As a cross-sectional survey it was not able to follow up individual respondents, for example to determine whether never smokers using e-cigarettes progress to smoking. This problem is common to most e-cigarette surveys to date.
  • The question asked does not tell us whether the participants actually used the e-cigarette they accessed, or what liquid was purchased with the e-cigarette (e.g., the concentration of nicotine). Zero-nicotine solutions are available, and there is evidence that these solutions are widely used by young people.
  • The results are presented confusingly, with numerous percentages (and percentages of percentages) reported. For example, 4.9% of never smokers reported having accessed e-cigarettes, but this is less than 3% of the overall sample (fewer than 500 out of 16,193 respondents). This is potentially an important number to know, but is not reported directly in the article.

Summary

This study does not add much to what is already known. Young people experiment with substances like tobacco and alcohol, and as e-cigarettes have become widely available they have begun to experiment with these too. However, to describe electronic cigarette use as “a new drug use option” and part of “at-risk teenagers’ substance using repertoires” is probably unnecessarily alarmist, given that:

  1. There is evidence that regular use of e-cigarettes among never smokers is negligible
  2. There is little evidence of e-cigarette use acting as a gateway to tobacco use
  3. The likelihood that e-cigarette use will be associated with very low levels of harm

It's alarmist to suggest

Links

Primary reference

Huges K, Bellis MA, Hardcastle KA, McHale P, Bennett A, Ireland R, Pike K. Associations between e-cigarette access and smoking and drinking behaviours in teenagers. BMC Public Health 2015; 15: 244. doi: 10.1186/s12889-015-1618-4

Other references

Young Persons Alcohol and Tobacco Survey 2013. Lancashire County Council’s Trading Standards.