Background: Approximately 70% of current (past 30-day) adult marijuana users are current tobacco users, which may complicate tobacco cessation. We assessed prevalence and trends in tobacco cessation among adult ever tobacco users, by marijuana use status.Methods: Data came from the National Survey on Drug Use and Health, a cross-sectional, nationally representative, household survey of U.S. civilians. Analyses included current, former, and never marijuana users aged >= 18 reporting ever tobacco use (cigarette, cigar, chew/snuff). We computed weighted estimates (2013-2014) of current tobacco use, recent tobacco cessation (quit 30 days to 12 months), and sustained tobacco cessation (quit > 12 months) and adjusted trends in tobacco use and cessation (2005-2014) by marijuana use status. We also assessed the association between marijuana and tobacco use status.Results: In 2013-2014, among current adult marijuana users reporting ever tobacco use, 69.1% were current tobacco users (vs. 38.5% of former marijuana users, p < 0.0001, and 28.2% of never marijuana users, p < 0.0001); 9.1% reported recent tobacco cessation (vs. 8.4% of former marijuana users, p < 0.01, and 6.3% of never marijuana users, p < 0.001), and 21.8% reported sustained tobacco cessation (vs. 53.1% of former marijuana users, p < 0.01, and 65.5% of never marijuana users, p < 0.0001). Between 2005 and 2014, current tobacco use declined and sustained tobacco cessation increased among all marijuana use groups.Conclusions: Current marijuana users who ever used tobacco had double the prevalence (vs. never-marijuana users) of current tobacco use, and significantly lower sustained abstinence. Interventions addressing tobacco cessation in the context of use of marijuana and other substances may be warranted.

To quantify the prevalence of 10 quit methods commonly used by adult cigarette smokers, we used data from a nationally representative longitudinal (2014-2016) online survey of US adult cigarette smokers (n = 15,943). Overall, 74.7% of adult current cigarette smokers used multiple quit methods during their most recent quit attempt. Giving up cigarettes all at once (65.3%) and reducing the number of cigarettes smoked (62.0%) were the most prevalent methods. Substituting some cigarettes with e-cigarettes was used by a greater percentage of smokers than the nicotine patch, nicotine gum, or other cessation aids approved by the US Food and Drug Administration. Further research into the effectiveness of e-cigarettes as a cessation aid is warranted.

The purpose of this study was to examine the patterns of marijuana and tobacco use and their associations with suboptimal self-rated health (SRH) among US adults who reported “ever, even once, using marijuana or hashish.” Data came from the 2009–2012 National Health and Nutrition Examination Survey, restricting to respondents aged 20 years and older who reported using marijuana at least once in their lifetime (n = 3,210). We assessed the age-adjusted prevalence of mutually exclusive groups of regular (at least once a month for more than one year) and non-regular marijuana smoking by current (serum cotinine ≥3.08 ng/mL) and not current use of tobacco. Suboptimal SRH status was defined as “fair” or “poor” in response to the question “Would you say that in general your health is excellent, very good, good, fair, or poor?” We produced prevalence ratios with multivariable log-linear regression models. Among ever users of marijuana, the age-adjusted prevalence of regular marijuana smoking with current tobacco use, non-regular marijuana smoking with current tobacco use, and regular marijuana smoking without current tobacco use was 24.7%, 15.2%, and 21.1%, respectively. When compared to non-regular marijuana smokers without current tobacco use, the adjusted prevalence ratio for reporting suboptimal SRH was 1.98 (95% CI: 1.50–2.61), 1.82 (95% CI: 1.40–2.37), and 1.34 (95% CI: 1.05–1.69), respectively. In conclusion, among adult ever users of marijuana, current tobacco use is high and strongly associated with suboptimal SRH; regular marijuana smoking with or without current tobacco use is significantly associated with suboptimal SRH.

Introduction: Policies legalizing marijuana for medical and recreational use have been increasing in the U.S. Considering the potential impact of these policies, important knowledge gaps exist, including information about the prevalence of various modes of marijuana use (e.g., smoked in joints, bowls, bongs; consumed in edibles or drinks) and about medical versus recreational use. Accordingly, this study assessed (1) prevalence and correlates of modes of current and ever marijuana use and (2) prevalence of medicinal and recreational marijuana use in U.S. adults.Methods: Data came from Summer Styles (n=4,269), a nationally representative consumer panel survey of adults aged >= 18 years, collected in 2014. The survey asked about past 30-day (current) and ever mode of marijuana use and current reason for use (medicinal, recreational, both). Weighted prevalence estimates were computed and correlates were assessed in 2014 using logistic regression.Results: Overall, 7.2% of respondents reported current marijuana use; 34.5% reported ever use. Among current users, 10.5% reported medicinal-only use, 53.4% reported recreational-only use, and 36.1% reported both. Use of bowl or pipe (49.5%) and joint (49.2%) predominated among current marijuana users, with lesser use of bong, water pipe, or hookah (21.7%); blunts (20.3%); edibles/drinks (16.1%); and vaporizers (7.6%); 92.1% of the sample reported combusted-only marijuana use.Conclusion: Combusted modes of marijuana use are most prevalent among U.S. adults, with a majority using marijuana for recreation. In light of changing policies and patterns of use, improved marijuana surveillance is critical for public health planning. (C) 2016 American Journal of Preventive Medicine. All rights reserved.

Lung cancer is the leading cause of cancer death and the second most commonly diagnosed cancer (excluding skin cancer) among men and women in the United States. Although lung cancer can be caused by environmental exposures, most efforts to prevent lung cancer emphasize tobacco control because 80%-90% of lung cancers are attributed to cigarette smoking and secondhand smoke. One sentinel health consequence of tobacco use is lung cancer, and one way to measure the impact of tobacco control is by examining trends in lung cancer incidence rates, particularly among younger adults. Changes in lung cancer rates among younger adults likely reflect recent changes in risk exposure. To assess lung cancer incidence and trends among men and women by age group, CDC used data from the National Program of Cancer Registries (NPCR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program for the period 2005-2009, the most recent data available. During the study period, lung cancer incidence decreased among men in all age groups except <35 years and decreased among women aged 35-44 years and 54-64 years. Lung cancer incidence decreased more rapidly among men than among women and more rapidly among adults aged 35-44 years than among other age groups. To further reduce lung cancer incidence in the United States, proven population-based tobacco prevention and control strategies should receive sustained attention and support.

Electronic nicotine delivery systems (ENDS), including electronic cigarettes (e-cigarettes) and other devices such as electronic hookahs, electronic cigars, and vape pens, are battery-powered devices capable of delivering aerosolized nicotine and additives to the user. Experimentation with and current use of e-cigarettes has risen sharply among youths and adults in the United States. Youth access to and use of ENDS is of particular concern given the potential adverse effects of nicotine on adolescent brain development. Additionally, ENDS use in public indoor areas might passively expose bystanders (e.g., children, pregnant women, and other nontobacco users) to nicotine and other potentially harmful constituents. ENDS use could have the potential to renormalize tobacco use and complicate enforcement of smoke-free policies. State governments can regulate the sales of ENDS and their use in indoor areas where nonusers might be involuntarily exposed to secondhand aerosol. To learn the current status of state laws regulating the sales and use of ENDS, CDC assessed state laws that prohibit ENDS sales to minors and laws that include ENDS use in conventional smoking prohibitions in indoor areas of private worksites, restaurants, and bars. Findings indicate that as of November 30, 2014, 40 states prohibited ENDS sales to minors, but only three states prohibited ENDS use in private worksites, restaurants, and bars. Of the 40 states that prohibited ENDS sales to minors, 21 did not prohibit ENDS use or conventional smoking in private worksites, restaurants, and bars. Three states had no statewide laws prohibiting ENDS sales to minors and no statewide laws prohibiting ENDS use or conventional smoking in private worksites, restaurants, and bars. According to the Surgeon General, ENDS have the potential for public health harm or public health benefit. The possibility of public health benefit from ENDS could arise only if 1) current smokers use these devices to switch completely from combustible tobacco products and 2) the availability and use of combustible tobacco products are rapidly reduced. Therefore, when addressing potential public health harms associated with ENDS, it is important to simultaneously uphold and accelerate strategies found by the Surgeon General to prevent and reduce combustible tobacco use, including tobacco price increases, comprehensive smoke-free laws, high-impact media campaigns, barrier-free cessation treatment and services, and comprehensive statewide tobacco control programs.

Background Cigarette smoking remains the leading cause of preventable morbidity and mortality in the United States. Despite overall declines in cigarette smoking, a high prevalence of smoking persists among certain subpopulations, including persons with mental illness. Methods Combined data from the 2009–2011 National Survey on Drug Use and Health (NSDUH) were used to calculate national and state estimates of cigarette smoking among adults aged ≥18 years who had any mental illness (AMI), defined as having a mental, behavioral, or emotional disorder, excluding developmental and substance use disorders, in the past 12 months. Results During 2009–2011, an annual average of 19.9% of adults aged ≥18 years had AMI; among these persons, 36.1% were current smokers, compared with 21.4 % among adults with no mental illness. Smoking prevalence among those with AMI was highest among men, adults aged <45 years, and those living below the poverty level; smoking prevalence was lowest among college graduates. During 2009–2011, adults with AMI smoked 30.9% of all cigarettes smoked by adults. By U.S. region, smoking prevalence among those with AMI was lowest in the West (31.5%) and Northeast (34.7%) and highest in the Midwest (39.1%) and South (37.8%), with state prevalence ranging from 18.2% (Utah) to 48.7% (West Virginia). Conclusions The prevalence of cigarette smoking is high among adults with AMI, especially for younger adults, those with low levels of education, and those living below the poverty level; the prevalence varies by U.S. region. Implications for Public Health Practice Increased awareness about the high prevalence of cigarette smoking among persons with mental illness is needed to enhance efforts to reduce smoking in this population. Proven population-based prevention strategies should be extended to persons with mental illness, including implementing tobacco-free campus policies in mental health facilities. Primary care and mental health-care providers should routinely screen patients for tobacco use and offer evidence-based cessation treatments. Given that persons with mental illness are at risk for multiple adverse behavioral and health outcomes, tobacco cessation will have substantial benefits, including a reduction in excess morbidity and mortality attributed to tobacco use.

Objective. To determine the prevalence and characteristics of current cigarette smokers who report receiving health care provider interventions ('5A's': ask, advise, assess, assist, arrange) for smoking cessation.Methods. Data came from the 2009-2010 National Adult Tobacco Survey, a telephone survey of United States adults aged >= 18 years. Among current cigarette smokers who reported visiting a health professional in the past year (n = 16,542), estimates were calculated overall and by sex, age, race/ethnicity, education, income, health insurance coverage, and sexual orientation.Results. Among smokers who visited a health professional (75.2%), 87.9% were asked if they used tobacco, 65.8% were advised to quit, and 42.6% were asked if they wanted to quit. Among those wanting to quit, 78.2% were offered assistance and 17.5% had follow-up arranged. Receipt of the 'ask' component was lower among males and uninsured individuals. Receipt of the 'advise' and 'assess' components was lower among those aged 18-24 and uninsured individuals. Receipt of the 'assist' component was lower among non-Hispanic blacks. No differences were observed for the 'arrange' component.Conclusions. Many current smokers report receiving health care provider interventions for smoking cessation. Continued efforts to educate, encourage, and support all health professionals to provide effective, comprehensive tobacco cessation interventions to their patients may be beneficial. Published by Elsevier Inc.

During March 4-June 23, 2013, CDC conducted its second annual national paid-media tobacco education campaign encouraging adult smokers to quit. These campaigns, called Tips from Former Smokers (Tips), feature true stories of former smokers living with serious smoking-related diseases. To assess the immediate impact of the 2013 Tips campaign, CDC analyzed the weekly numbers of calls to the national telephone quitline portal (1-800-QUIT-NOW) and the weekly numbers of unique visitors to the Tips website (http://www.cdc.gov/tips)* during the 16-week campaign and during the 4 weeks before and after the campaign. During the campaign, the average weekly numbers of calls and website visitors increased by 75% and almost 38-fold, respectively, compared with the 4 weeks before the campaign, and quickly decreased almost to pre-campaign levels once the campaign ended. This suggests that the campaign led to 151,536 additional quitline calls and nearly 2.8 million additional unique Tips website visitors above pre-campaign levels. During the first 12 weeks of the campaign,† when the national television ads were on and off air on alternate weeks, average weekly call volume fell by 38% during the 6 weeks when the national television ads were off air compared with the 6 weeks when these ads were running. These results suggest that emotionally evocative tobacco education media campaigns featuring graphic images of the health effects of smoking can increase quitline calls and website visits and that these campaigns' effects decrease rapidly once they are discontinued.

Background: Fax referral programs quickly and economically can link smokers' visiting primary care clinics to state-based telephone quitlines. Yet, it is unclear how to optimize use of this strategy.Purpose: To evaluate the potential of enhanced academic detailing in clinics (i.e., on-site training, technical assistance, and performance feedback) to boost utilization of a fax referral program called Fax to Quit.Design: Participants were randomized to one of two intervention conditions.Setting/participants: Participants were drawn from 49 primary care clinics in southeastern Wisconsin. The sample size was based on a power analysis in which the control intervention condition was estimated to generate 0.5 referrals/clinic/month and the experimental condition 2.0 referrals/clinic/month.Interventions: One of two fax referral program interventions was administered: the control condition Fax to Quit-Only (F2Q-Only) or the experimental condition Fax to Quit plus Enhanced Academic Detailing (F2Q+EAD).Main outcome measures: Clinic- and clinician-specific referral and quality referral rates (those resulting in quitline enrollment) were measured for 13 months post-intervention, starting in March 2009.Results: Mean number of post-intervention referrals/clinician to the Wisconsin Tobacco Quitline was 5.6 times greater for F2Q+EAD (8.5, SD=7.0) compared to F2Q-Only (1.6, SD=3.6, p<0.001). The F2Q+EAD (4.8, SD=4.1) condition produced a greater mean number of quality referrals/clinician than did the F2Q-Only (0.86, SD=1.8, p<0.001) condition. Data were analyzed in 2010.Conclusions: Enhanced academic detailing, which included on-site training, technical assistance, and performance feedback, increased the number of referrals more than fivefold over a fax referral program implemented without such enhanced academic detailing.

INTRODUCTION Telephone tobacco quitlines are effective and are widely used, with more than 500,000 U.S. callers in 2010. This study investigated the clinical effectiveness and cost-effectiveness of 3 different quitline enhancements: combination nicotine replacement therapy (NRT), longer duration of NRT, and counseling to increase NRT adherence. METHODS In this study, 987 quitline callers were randomized to a combination of quitline treatments in a 2 × 2 × 2 factorial design: NRT duration (2 vs. 6 weeks), NRT type (nicotine patch only vs. patch plus nicotine gum), and standard 4-call counseling (SC) versus SC plus medication adherence counseling (MAC). The primary outcome was 7-day point-prevalence abstinence (PPA) at 6 months postquit in intention-to-treat (ITT) analyses. RESULTS Combination NRT for 6 weeks yielded the highest 6-month PPA rate (51.6%) compared with 2 weeks of nicotine patch (38.4%), odds ratios [OR] = 1.71 (95% confidence interval [CI]:1.20-2.45). A similar result was found for 2 weeks of combination NRT (48.2%), OR = 1.49 (95% CI: 1.04-2.14) but not for 6 weeks of nicotine patch alone (46.2%), OR = 1.38 (95% CI: 0.96-1.97). The MAC intervention effect was nonsignificant. Cost analyses showed that the 2-week combination NRT group had the lowest cost per quit ($442 vs. $464 for 2-week patch only, $505 for 6-week patch only, and $675 for 6-week combination NRT). CONCLUSIONS Combination NRT for 2 or 6 weeks increased 6-month abstinence rates by 10% and 13%, respectively, over rates produced by 2 weeks of nicotine patch when offered with quitline counseling. A 10% improvement would potentially yield an additional 50,000 quitters annually, assuming 500,000 callers to U.S. quitlines per year.

The use of combustible tobacco products (e.g., cigarettes, cigars, pipe, bidis, kreteks, and hookah) among adults remains widespread around the world. Unless dramatic progress is made diminishing the initiation and increasing cessation of combustible tobacco product use, a billion preventable deaths will occur in the 21st century [1]. These deaths will be accompanied by unimaginable human suffering and unaffordable economic loss from both preventable healthcare expenditures and loss of productivity from early death and disease. Health risks not only impact the smoker, but also hundreds of millions of individuals who inhale secondhand smoke from combustible tobacco products. In addition to the risks associated with smoking tobacco products, there are important concerns associated with the use of noncombustible tobacco products (e.g., chew, dip, snus, Gutka, and Ikmik). Concerns include both direct health effects from high-toxicant products, particularly in Southern Asia that account for the majority of global noncombustible use and the impact of dual use of noncombustible products with smoked tobacco products [2, 3]. This is a pattern being seen in youth, young adults [4, 5], and adults in the United States (as in the paper of R. McMillen et al. “Use of emerging tobacco products in the United States”), potentially increasing initiation and prolonging smoking. In order to successfully tackle the immense challenges ahead, it is critical that public health workers and others committed to eradicating the harm caused by the tobacco epidemic have a full understanding of what is actually happening. Questions need to be answered such as: How are tobacco use patterns evolving? How are changes in the design of tobacco products impacting health outcomes? How are emerging tobacco products being marketed? and, How is their use impacting the use of combustible tobacco products? Which tobacco control policies and interventions work for different populations and use patterns? Few health risks have received as much attention from researchers and policy makers as the use of tobacco products. Articles recently published in the Journal of Environmental and Public Health can inform health policy decisions in several ways: by providing information on specific populations who use these products, by targeting interventions to products and users, and by identifying and characterizing emerging products developed and marketed by the tobacco industry. Scientific research, surveillance, and evaluation are valuable tools for informing health policy decisions because they can identify the introduction of new products, offer insight as to the prevalence of use of those products, and provide information on the effectiveness of specific interventions and tobacco control policy. In the United States, 15.8% of high school students [6] and 19.3% of adults smoke cigarettes [7]. Attention to the marketing of new tobacco products and combinations of use of these products is essential to ending the tobacco epidemic. Current tobacco use trend indicators may provide insufficient information as the tobacco industry innovates its products and strategies. For example, a primary indicator of progress in the tobacco epidemic has been the prevalence of cigarette smoking and cigarette consumption. However, because of differences in taxation between cigarettes and other combustible products and lack of FDA authority to regulate flavoring and other product characteristics of cigars and pipe tobacco, consumption and prevalence of use of cigars and pipe tobacco (used in roll-your-own cigarettes) is increasing dramatically [8, 9]. An over-estimation of progress in tobacco control, particularly among youth and young adults, would result if we do not pay appropriate attention to increases in use of these other tobacco products. Another example highlighted in this issue in the paper by R. Sacks et al. “Exploring the next frontier for tobacco control: nondaily smoking among New York city adults” is a trend towards decreased consumption of cigarettes among smokers, resulting from both an increase in nondaily smoking and a decrease in the average number of cigarettes smoked per day. How is this trend evolving? What population groups are most affected? Have risk perceptions altered, including the perception of being a smoker? Conversely, there is concern that the percent of the smoking population with significant mental health or substance abuse disorders is increasing [10], but this information is less routinely collected in surveys. What are the implications of these trends for clinical interventions, media and education campaigns, and public policy approaches that were designed and tested in a time when most people who smoked did so daily, smoked a pack of cigarettes or more a day, and where people who had mental health and substance abuse disorders were often excluded from studies? Federal and state tobacco control efforts will benefit greatly from the information provided by studies such as those found within this special issue, especially given the new potential of regulatory action to profoundly diminish the death, disease, and suffering caused by tobacco use. With the authority to regulate toxicant exposure, including potentially requiring the lowering of nicotine content to nonaddictive levels, major alterations in the tobacco product marketplace are possible, especially if combined with proven nonregulatory tobacco control interventions such as raising the price of tobacco products, eliminating secondhand smoke exposure, fully funding tobacco control programs (including high-impact tobacco control mass media campaigns), and barrier-free access to quit help for those who want it. However, while this new path presents opportunity, it is also fraught with challenges and even peril. The role of broad-spectrum research ranging from surveillance, to laboratory studies, to market research is essential to help evaluate the impact, as well as monitor for unanticipated consequences of these interventions, which will help guide policy evolution and provide needed support for the regulatory process. The goal of this special issue is to educate the readership of the Journal of Environmental and Public Health about emerging tobacco products and their patterns of use and to stimulate research in tobacco control. Through these and other papers, we hope to provide information that will eventually have an impact on reducing the number of tobacco users and help those who use it to quit. The list of topics is broad and impressive; the studies cover a wide range of areas: prevalence; secondhand smoke exposure; dual use; smoking cessation efforts; and product design.

Introduction: One in 5 young adults in the United States currently smoke, and young adults are less likely than other smokers to make aided quit attempts. Telephone quitlines may be a useful tool for treating this population. This study tested a quitline-based smoking cessation intervention versus mailed self-help materials in smokers 18-24 years old.Methods: This was a 2-group randomized clinical trial. The quitline-based counseling intervention (CI) included up to 4 proactive telephone counseling sessions; participants in the self-help (SH) group received only mailed cessation materials. Participants included 410 young adults who had smoked at least 1 cigarette in the past 30 days and who called the Wisconsin Tobacco Quit Line (WTQL) for help with quitting. Primary study outcomes included whether or not a quit date was set, whether or not a serious quit attempt was undertaken, and self-reported 7-day point-prevalence abstinence at 1-, 3-, and 6-month postenrollment.Results: The CI and SH groups did not differ in the intent-to-treat abstinence analyses at any of the follow-ups. However, the CI group was significantly more likely to set a quit date at 1-month postenrollment. Follow-up response rates were low (67.8% at 1 month; 53.4% at 3 months; and 48.3% at 6 months) reflecting lower motivation to participate in this kind of research.Conclusions: Relative to self-help, quitline counseling motivated young adults to set a quit date but abstinence rates were not improved. Research is needed on how to motivate young adult smokers to seek cessation treatment including quitline services.

There is a lack of evidence of the relative cost-effectiveness of proactive telephone counseling (PTC) and Web-based delivery of smoking cessation services in conjunction with pharmacotherapy. We calculated the differential cost-effectiveness of three behavioral smoking cessation modalities with varenicline treatment in a randomized trial of current smokers from a large health system. Eligible participants were randomized to one of three smoking cessation interventions: Web-based counseling ( n = 401), PTC ( n = 402), or combined PTC-Web counseling ( n = 399). All participants received a standard 12-week course of varenicline. The primary outcome was a 7-day point prevalent nonsmoking at the 6 month follow-up. The Web intervention was the least expensive followed by the PTC and PTC-Web groups. Costs per additional 6-month nonsmoker and per additional lifetime quitter were $1,278 and $2,601 for Web, $1,472 and $2,995 for PTC, and $1,617 and $3,291 for PTC-Web. Cost per life-year (LY) and quality-adjusted life-year (QALY) saved were $1,148 and $1,136 for Web, $1,320 and $1,308 for PTC, and $1,450 and $1,437 for PTC-Web. Based on the cost per LY and QALY saved, these interventions are among the most cost-effective life-saving medical treatments. Web, PTC, and combined PTC-Web treatments were all highly cost-effective, with the Web treatment being marginally more cost-effective than the PTC or combined PTC-Web treatments.

INTRODUCTION:Phone counseling has become standard for behavioral smoking cessation treatment. Newer options include Web and integrated phone-Web treatment. No prior research, to our knowledge, has systematically compared the effectiveness of these three treatment modalities in a randomized trial. Understanding how utilization varies by mode, the impact of utilization on outcomes, and predictors of utilization across each mode could lead to improved treatments.METHODS:One thousand two hundred and two participants were randomized to phone, Web, or combined phone-Web cessation treatment. Services varied by modality and were tracked using automated systems. All participants received 12 weeks of varenicline, printed guides, an orientation call, and access to a phone supportline. Self-report data were collected at baseline and 6-month follow-up.RESULTS:Overall, participants utilized phone services more often than the Web-based services. Among treatment groups with Web access, a significant proportion logged in only once (37% phone-Web, 41% Web), and those in the phone-Web group logged in less often than those in the Web group (mean = 2.4 vs. 3.7, p = .0001). Use of the phone also was correlated with increased use of the Web. In multivariate analyses, greater use of the phone- or Web-based services was associated with higher cessation rates. Finally, older age and the belief that certain treatments could improve success were consistent predictors of greater utilization across groups. Other predictors varied by treatment group.CONCLUSIONS:Opportunities for enhancing treatment utilization exist, particularly for Web-based programs. Increasing utilization more broadly could result in better overall treatment effectiveness for all intervention modalities.

This article examines reported symptoms, nonsmoking rates, and medication use among 1,018 smokers using varenicline in a randomized trial comparing three forms of behavioral support for smoking cessation (phone, Web, or phone + Web). One month after beginning varenicline, 168 people (17%) had discontinued the medication. Most (53%) quit due to side effects and other symptoms. The most common side effect among all users was nausea (reported by 57% of users). At 1 month post medication initiation, those not taking varenicline were more likely to report smoking than those who continued the medication (57% vs. 16%, p < .001). Women reported more symptoms but did not discontinue medication at higher rates. Participants who received any telephone counseling (n = 681) were less likely to discontinue their medication than those with Web support only (15% vs. 21%, p < .01). Counseling may improve tolerance of this medication and reduce the rate of discontinuation due to side effects.

BACKGROUND:State-level tobacco quitlines are integrating nicotine replacement therapy (NRT) into service. Because of funding limitations some provide short courses of NRT. No randomized trial has evaluated the relative benefit of short versus standard treatment.DESIGN:A two-cell randomized trial comparing 2 weeks of NRT to 8 weeks.SETTING/PARTICIPANTS:Uninsured callers to the Oregon Quit Line during a free-patch initiative from October 18, 2004, to May 5, 2005, who were 18 years or older, smoked five or more cigarettes per day, did not have a medical contraindication to NRT use, and were interested in quitting in 30 days. Data were collected from April to November 2005, and analyzed in 2006--2007.INTERVENTION:Participants were eligible for two phone counseling sessions. 1154 participants were randomized to receive via the mail either 2 or 8 weeks of nicotine patches.MEASURES:Primary outcome was self-reported complete abstinence from tobacco for 30 or more days at the 6-month phone survey. Secondary outcomes were 7-day point prevalence and 90-day abstinence, satisfaction, and patch use. ORs and CIs were computed. Cost per quit and incremental cost per additional quit were computed based on program costs.RESULTS:Intent-to-treat 30-day abstinence was 14.3% in the 2-week group, and 19.6% in the 8-week group (OR 1.45 [CI=1.01, 2.12]). Average cost per quit was $1156 for 2 weeks and $1405 for 8 weeks, with an incremental cost effectiveness of $2068. Satisfaction increased from 90% to 97% with 8 weeks. Those receiving 8 weeks of NRT took more calls (2.0 vs 1.6) and used more patches (6.3 weeks vs 4.3 weeks), but were less likely to purchase patches (16.2% vs 39.3%).CONCLUSIONS:Eight weeks of patches improved quit rates compared with 2 weeks, and was cost effective.

Objectives: State and national tobacco quitlines have expanded rapidly and offer a range of services. We examined the effectiveness and cost effectiveness of offering callers single session versus multisession counselling, with or without free nicotine patches.Methods: This 3 x 2 randomised trial included 4614 Oregon tobacco quitline callers and compared brief (one 15-minute call), moderate (one 30-minute call and a follow-up call) and intensive (five proactive calls) intervention protocols, with or without offers of free nicotine patches (nicotine replacement therapy, NRT). Blinded staff assessed tobacco use by phone at 12 months.Results: Abstinence odds ratios were significant for moderate (OR = 1.22, CI = 1.01 to 1.48) and intensive (OR = 1.29, CI = 1.07 to 1.56) intervention, and for NRT (OR = 1.58, CI = 1.35 to 1.85). Intent to treat quit rates were as follows: brief no NRT (12%); brief NRT (17%); moderate no NRT (14%); moderate NRT (20%); intensive no NRT (14%); and intensive NRT (21%). Relative to brief no NRT, the added costs for each additional quit was $2467 for brief NRT, $1912 for moderate no NRT, $2109 for moderate NRT, $2641 for intensive no NRT, and $2112 for intensive NRT.Conclusion: Offering free NRT and multisession telephone support within a state tobacco quitline led to higher quit rates, and similar costs per incremental quit, than less intensive protocols.

Quitlines in the United States have grown dramatically over the past 15 years, from one state and a handful of health plans to all 50 states and over 200 health plans and employers. Over half a million tobacco users received help from state quitlines alone in 2005. Research to confirm and improve quitline effectiveness also has burgeoned, with multiple meta-analyses confirming a dose-related treatment effect. Quitlines are increasing the depth and breadth of services offered, including the integration of medication support and other electronic communication mediums such as web and e-mail. Quitlines have the capacity to serve a larger fraction of the population than they currently serve. Accomplishing this is dependent on creating ambitious, multi-institution funding and delivery mechanisms, as well as further research and development to improve reach, effectiveness, and efficiency.