Background: Internet-based interventions can help smokers to quit compared with brief written materials or no intervention. However, they are not widely used, particularly by more disadvantaged smokers, and there is significant variation in their effectiveness. A new smoking cessation website (‘StopAdvisor’) has been systematically developed on the basis of PRIME theory, empirical evidence, web-design expertise and user-testing with socio-economically disadvantaged smokers. This paper reports the protocol of a randomised controlled trial to evaluate the efficacy of StopAdvisor and determine whether it translates across the social spectrum.

Methods: The trial has two arms with participants randomised to the offer of the interactive ‘StopAdvisor’ website (intervention condition) or a non-interactive, static website (control condition). Participants are adults from the UK, who smoke every day and are willing to make a serious quit attempt within a month of enrolment. At least 4260 participants will be recruited with a minimum of 2130 in each of two socio-economic sub-groups. The intervention comprises a structured quit plan and a variety of theory- and evidence-based behaviour change techniques for smoking cessation. Tailored support is offered in the form of a series of tunnelled sessions and a variety of interactive menus for use up to a month before, and then for one month after quitting (http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The control is a static website that presents brief and standard advice on smoking cessation. Assessments are at baseline and 2-, 4- and 7-months post-enrolment. The primary outcome measure will be Russell Standard 6-months sustained abstinence, defined as self-reported continuous abstinence verified by saliva cotinine or anabasine at 7-month follow-up. Secondary outcome measures will include 7-day point-prevalence abstinence at 7-month follow-up, self-reported abstinence at 2- and 4-month follow-ups, satisfaction ratings of the website and quantitative indices of website interaction. All analyses will be by intention to treat and the main analysis will compare the two conditions on the primary outcome measure using a logistic regression model, adjusted for baseline characteristics. The efficacy of the intervention across the social spectrum will be assessed by a logistic regression focusing on the interaction between condition and socio-economic disadvantage.

Trial registration: ISRCTN99820519.

Smoking cessation has been the primary goal for those of us working in tobacco treatment for many decades. However, we have all noticed that in countries where there is a strong anti-smoking climate, there seems to be an increasing percentage of smokers, willing and motivated to quit, who, despite all efforts on our part, find it very difficult to achieve this. ‘Harm reduction’ or ‘harm minimisation’ strategies have become part of our agenda and is now offered routinely to smokers in these circumstances. As these strategies invariably incorporate concurrent smoking with nicotine-containing products, there is the dilemma of on-going nicotine usage, or ‘therapeutic/medicinal nicotine’ for extended periods of time (though evidently better and safer than smoking alone).

Tobacco dependence is characterised as a chronic, relapsing disorder that typically requires multiple quit attempts before successful, long-term abstinence is achieved (Steinberg, Foulds, Richardson, Burke, & Shah, 2006). Best practice, evidence-based treatment includes multiple-session counselling and pharmacotherapy, or the combination of both (Fiore et al., 2008). The field has moved past the notion that tobacco dependence is simply a bad habit, a vice, or a moral deficiency that can be overcome by willpower or education alone (Mars & Ling, 2008). However, the language used in discussing treatment has not always been consistent with this evidence. Some words and phrases used lend themselves to varied meanings, and could lead to significant misunderstanding not only among professionals in the field, but also among the general public (O'Brien, 2010; Davis, 1992; Perkins, 1999; Hughes, 2013). In this paper, we discuss some commonly used, problematic terminology, and suggest more appropriate terms (Table 1).

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.

Since its launch as a smoking cessation aid, varenicline use has been linked to a number of serious adverse events, notably the exacerbation of pre-existing psychiatric illness, depressed mood and suicidal ideation. Regulators’ fears have been somewhat allayed by varenicline's status as a prescription only medication. The purpose of this study was to examine the care provided by physicians – or general practitioners – and pharmacists to varenicline users under real-world conditions. Participants were 141 patients who had filled a prescription for varenicline at a participating pharmacy within the previous six-months. Identified patients were mailed a survey to complete that included items on interactions with their physician and pharmacy staff, and knowledge of treatment side-effects. Most participants reported that their physician encouraged them to set a quit date (82.5%) and provided additional cessation materials (57.2%). While most (79.0%) physicians discussed whether varenicline was appropriate for the patient, fewer asked about psychiatric illness (40.1%), or asked to be informed about mood or behaviour change during treatment (48.1%). Participants (78.4%) reported that their physician had discussed a follow-up consultation, but only 59.4% of patients who had finished treatment at the time of the survey reported having one. Most reported discussing potential drug side-effects with their physician (71.0%) and or pharmacist (52.9%); when probed, knowledge was variable. These results suggest that many patients do not receive the level of support that physicians and pharmacists are assumed to provide.

Smoking cessation interventions during routine clinical encounters by health professionals have the potential to reach smokers and facilitate cessation. Although psychologists might appear to be ideal providers of such interventions, international research suggests that their provision is limited. This paper reports the results of a survey conducted in NSW, Australia, of psychologists’ (n = 72) smoking intervention practices, attitudes, and barriers to providing such care. Less than half of the respondents reported assessing smoking status for ‘all or nearly all’ of their clients. Across a range of smoking cessation intervention types, the most frequent response given indicated provision to ‘none or almost none’ of clients who smoked. Only 13% of respondents indicated even ‘advising cessation’ to ‘all or nearly all’ of their smoking clients. Barriers included concern about negative influence on the therapeutic relationship, inadequacy of training and lack of confidence to intervene. Respondents were less likely to provide intervention for smoking than for cannabis, methamphetamine ‘ice’, and alcohol. The study suggests that the potential of Australian psychologists to assist smokers to quit is not being realised, and that there is a need to address the barriers to care provision.

Objectives: To assess the smoking cessation counselling practices of family physicians in Jordan and assess their perception about the availability of smoking cessation resources and about the barriers to effective smoking cessation practices. Methods: A pre-structured questionnaire was distributed to 124 family physicians practicing in teaching and Ministry of Health medical centres in Jordan. All participants were asked about their smoking cessation practices and about the barriers to effective smoking cessation practices. Results: Only 39.8% reported that they assess the willingness of the patients to quit smoking and 28.2% reported that they discuss counselling options with smokers. Considerably fewer percentages of physicians reported that they prepare their patients for withdrawal symptoms (11.6%), discuss pharmacotherapies (4.9%), describe a nicotine patch (5.0%), and provide patients with self-help materials (6.7%). The two factors cited most often by physicians as significant barriers to smoking cessation counselling were lack or too few available cessation programmes (90.3%) and limited training for physicians on tobacco and cessation interventions (90.3%). Conclusion: While a high proportion of Jordanian family physicians reported that they usually ask patients about smoking status and advise them to stop smoking, they do not regularly provide extensive assistance to help their patients to quit smoking. Lack or too few available cessation programmes and limited training for physicians on smoking cessation interventions were identified as the two major barriers to effective smoking cessation counselling.

This study sought to obtain a preliminary assessment of whether a new model of behaviour change (SNAP) could provide a useful conceptual framework for classifying smokers’ reports of their beliefs and feelings about the process of stopping smoking. Eight smokers’ clinic attendees in Malaysia underwent semi-structured interviews before and four weeks after the start of their quit attempt. A variant of Template Analysis found support for the view that smokers’ inferred identities could be reliably classified in the terms Smoker, Non-smoker, Attempter or Planner (SNAP) using self-statements about their motivation and behaviour as well as identity. There was evidence for wide variation in the coherence of smokers’ beliefs and feelings defined in terms of the proportion that fitted their modal SNAP category. As would be expected there was a shift in SNAP categories pre- to post-quit in those who were not smoking but only so far as ‘attempter’. An important next step is to assess how far lack of coherence in a given identity predicts transitions to other categories.

Background: The issue of tobacco control had almost unanimous support among public health professionals. It is therefore apparent that the dental care system should be involved in tobacco prevention and tobacco cessation. Objective: To assess dental students’ and practicing dentists’ perceptions of tobacco cessation content in curriculum and attitudes concerning their professional responsibility to help users quit tobacco. Methods: The study was conducted with Bachelor of Dental Surgery (BDS) 3rd year students, Interns and practicing dentists of Moradabad city (India). A 17-item questionnaire focused on attitudes of dental fraternity, professional responsibilities, effectiveness and scope of Tobacco Use Cessation (TUC) practice in dental setting. Results: Statically significant difference is seen among responses of dental fraternities, with students having less positive attitudes than practicing dentists (p < 0.001). Conclusion: Attitudes of the participants appear to be positive and encouraging, but they feel unprepared and needed further training in TUC.

Introduction: While numerous barriers to smoking cessation in pregnancy have been identified, less is known about the role of pregnant smokers’ beliefs in promoting and inhibiting abstinence. This study explored these beliefs and how they might interact with psychosocial factors related to pregnancy and antenatal care.

Methods: In-depth face-to-face semi-structured interviews were conducted with 20 women with experience of prenatal smoking. Grounded theory and the constant comparative approach guided the analysis towards a theoretical explanation of the women's experiences.

Results: Cognitive dissonance generated by the discrepancy between smoking-related prenatal harm beliefs and continued smoking was a strong motivator to quit. However, difficulty in quitting led many to resolve this dissonance by endorsing disengagement beliefs which downplayed the threat of smoking. Four main types of disengagement belief were identified. The tendency to endorse disengagement beliefs appeared to be influenced by two factors: uncertainty about how smoking caused foetal harm and reassurance from health professionals and others that reduced smoking was sufficient for harm minimisation.

Conclusions: Disengagement belief endorsement is common among pregnant smokers and enables the justification of continued smoking, potentially hindering efforts to quit. Increased promotion of complete abstinence by antenatal care professionals and health education interventions targeting risk comprehension and disengagement belief endorsement should be considered to promote greater efforts to quit among pregnant smokers.

Introduction: Nondaily smoking is a growing public health concern, particularly among young adults. Given the lack of existing measures for assessing factors associated with this smoking pattern, the present study aims to develop a measure of motivation to quit among young adult nondaily smokers. Specifically, we developed a scale assessing motivation for nondaily smoking cessation, and examined its reliability, factor structure, and concurrent validity.

Methods: We administered an online survey to 2,000 students at six colleges in the Southeastern US, and 718 (35.9%) returned a completed survey. The current analyses focused on the 95 participants who reported nondaily smoking (i.e., smoking between 1 and 29 days of the past 30 days). In addition to the items created for scale development, measures included sociodemographics, other measures of motivation and confidence/self-efficacy, past smoking/quitting history, readiness to quit, and perceived harm.

Results: The 13-item Nondaily Smoking Cessation Motivation Questionnaire (NSCM) had an average score of 56.95 (SD = 24.33) and high internal consistency (Cronbach's alpha of 0.94). Factor analysis using principal components extraction with varimax rotation extracted three factors accounting for 76.8% of the variance: Controlled motivation, Autonomous motivation, and Amotivation. Concurrent and discriminant validity were documented.

Conclusions: This study provided information about the development and validation of the Nondaily Smoking Cessation Motivation Questionnaire for young adult nondaily smokers. Given the lack of validated measures to assess factors associated with nondaily smoking, this assessment may be critical in informing our intervention strategies and potentially for predicting cessation among nondaily smokers in the young adult population.

Introduction: The ability of Swedish snus to serve as a smoking cessation aid has been documented in several observational, population surveys from Scandinavia, but randomised clinical trials provide more reliable information on efficacy. Aims: To perform a systematic review and meta-analysis of randomised clinical trials of Swedish snus as an aid to smoking cessation. Methods: Literature searches were conducted in MedLine, Cochrane Library, and Embase to identify relevant clinical trials. The primary outcome was defined as biologically confirmed smoking cessation during around six months. Meta-analyses based on primary subject data tested for effect of allocated treatment as well as selected baseline characteristics. Results: There were two relevant clinical trials, one conducted at five sites in the US (n = 250), the other at two sites in Serbia (n = 319). Based on the primary outcome, success was higher in the treated group in both Serbia (5.7% vs 1.9%) and the US (4.0% vs 1.6%). Meta-analysis estimated the relative success rate at 2.83 (95% CI 1.03–7.75), which was of borderline significance (exact p = 0.06, chi-squared p = 0.03). For smoking cessation in the last 4 weeks of each study, rates were 12.4% for snus and 6.6% for placebo (RR 1.86, 95% CI 1.09-3.18). Efficacy of snus was not clearly related to any baseline characteristic. Conclusions: Swedish snus increased quit rates similarly in US and Serbia. These results confirm and extend previous information based on observational population surveys.

Introduction – The potential impact of electronic health records (EHR) in driving tobacco treatment behaviours within healthcare settings has been established. However, little is known about the administrative variables that may undermine effectiveness in real world settings.

Aims – Assist healthcare planners interested in implementing tobacco-EHR systems by identifying an EHR framework that is consistent with published treatment guidelines, and the important organisational variables that can undermine the effectiveness of tobacco-EHR.

Methods – This paper considers the established literature on EHR implementation and physician behaviour change, and integrates this understanding with the observations of an expert workgroup tasked with facilitating tobacco-EHR implementation in Southeastern Pennsylvania.

Results/ Findings – System change in this topic area will continue to be problematic unless attention is paid to several important lessons regarding: 1) the evolving healthcare regulatory environment, 2) the integration of tobacco use treatment into primary care, and 3) the existing social and organisational barriers to uptake of evidence-based recommendations.

Conclusion – Healthcare organisations seeking to reduce the impact of tobacco use on their patients are well served by tobacco-EHR systems that improve care. Managers can avoid sub-optimal implementation by considering several threats to effectiveness before proceeding to systems change.

Aims: To review population surveys to assess (a) prevalence of the use of NRT for smoking reduction (SR) and temporary abstinence (TA) and (b) how far this is associated with attempts to stop smoking, smoking cessation and reduction in cigarette consumption.

Methods: An electronic search was undertaken of EMBASE, MEDLINE, Web of Science and PsycINFO. Articles were selected if they (1) assessed whether smokers had used or were currently using NRT for SR and/or TA; (2) involved smokers who had not taken part in a harm reduction programme; and (3) assessed prevalence and/or association of SR and/or TA with reductions in cigarette consumption and/or attempts to stop smoking and/or with smoking cessation. Twelve studies met the inclusion criteria and results were extracted independently by two researchers.

Results: Data were available from five countries (US, UK, Canada, Switzerland and Australia). Between 1% and 23% of smokers reported having ever used NRT for smoking reduction and between 2% and 14% during periods of temporary abstinence. Use of NRT for SR and/or TA was associated with little or no reduction in cigarette consumption. There was some evidence that it was positively associated with attempts to stop smoking and smoking cessation.

Conclusion: In smoking populations use of NRT to aid SR and in situations where smoking is not permitted appears to be having little effect on achieving a reduction in cigarette consumption but does not undermine cessation and may promote it.

It is not uncommon for staff of mental health facilities to have diverging opinions regarding the tobacco use of their patients. Surveys have shown that a significant proportion of staff believe that the smoke free policies are harsh and difficult to implement in health facilities where patient compliance is a matter of serious concern (Lawn, 2004, Wye et al., 2010). Intra-staff disputes and arguments with patients as to how to implement these policies, if at all, occur frequently. This protocol was developed at the request of staff at a mental health facility for HIV AIDS patients afflicted with dementia. Staff were concerned about imminent smoke-free regulations that would impact on their unit.

Background: The mechanism of action of varenicline as a partial agonist may make it useful for cigarette reduction as smokers experience reduced craving and withdrawal at the same time their cigarettes provide reduced reinforcement value.

Case Description: The current case report describes a 51-year-old African American woman using varenicline to reduce her cigarette use. After making a substantial reduction in cigarettes per day (from 25 to 8), the patient unexpectedly began smoking considerably more (from 8 to 20) after 11 days treatment with varenicline.

Conclusions: The temporary increase in smoking while taking varenicline was likely the result of an ‘extinction burst’ where the extinction of a reward (e.g., nicotine's rewarding effects after smoking a cigarette) was temporarily associated with an increase in the behaviour usually associated with the reward (e.g., smoking a cigarette). Once explaining to her that no amount of cigarettes would overcome the feeling of reduced reward she likely felt while taking varenicline, she was able to reduce her smoking again.

Carbon monoxide-validated four-week smoking abstinence from 167,487 treatment episodes among patients from 42 UK National Health Service Stop Smoking Services (1 April 2009, to 30 June 2011) showed smoking abstinence rates were higher with varenicline than combination nicotine replacement therapy (43.5% vs. 36.9%) but systematic variation in medication effect across clinical services and differences in predictors of outcome between medications resulted in a small mean advantage for varenicline (odds ratio, 1.080; 95% CI, 1.003–1.163; difference, 1.86%; 95% CI, 0.07%–3.67%; P = .04).