BACKGROUND: The aim of nicotine replacement therapy (NRT) is to replace nicotine from cigarettes. This reduces withdrawal symptoms associated with smoking cessation thus helping resist the urge to smoke cigarettes. OBJECTIVES: The aims of this review were to determine the effectiveness of the different forms of nicotine replacement therapy (chewing gum, transdermal patches, nasal spray, inhalers and tablets) in achieving abstinence from cigarettes, or a sustained reduction in amount smoked; to determine whether the effect is influenced by the clinical setting in which the smoker is recruited and treated, the dosage and form of the NRT used, or the intensity of additional advice and support offered to the smoker; to determine whether combinations of NRT are more effective than one type alone; and to determine its effectiveness compared to other pharmacotherapies. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group trials register in July 2002. SELECTION CRITERIA: Randomized trials in which NRT was compared to placebo or no treatment, or where different doses of NRT were compared. We excluded trials which did not report cessation rates, and those with follow-up of less than six months. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate on the type of subjects, the dose and duration and form of nicotine therapy, the outcome measures, method of randomization, and completeness of follow-up. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed effects model (Peto). MAIN RESULTS: We identified 110 trials; 96 with a non NRT control group. The odds ratio for abstinence with NRT compared to control was 1.74 (95% confidence interval 1.64 - 1.86), The odds ratios for the different forms of NRT were 1.66 for gum, 1.74 for patches, 2.27 for nasal spray, 2.08 for inhaled nicotine and 2.08 for nicotine sublingual tablet/lozenge. These odds were largely independent of the duration of therapy, the intensity of additional support provided or the setting in which the NRT was offered. In highly dependent smokers there was a significant benefit of 4 mg gum compared with 2mg gum (odds ratio 2.67, 95% confidence interval 1.69 - 4.22). There was weak evidence that combinations of forms of NRT are more effective. Higher doses of nicotine patch may produce small increases in quit rates. Only one study directly compared NRT to another pharmacotherapy, in which bupropion was significantly more effective than nicotine patch or placebo. REVIEWER'S CONCLUSIONS: All of the commercially available forms of NRT (nicotine gum, transdermal patch, the nicotine nasal spray, nicotine inhaler and nicotine sublingual tablets/lozenges) are effective as part of a strategy to promote smoking cessation. They increase quit rates approximately 1.5 to 2 fold regardless of setting. The effectiveness of NRT appears to be largely independent of the intensity of additional support provided to the smoker. Provision of more intense levels of support, although beneficial in facilitating the likelihood of quitting, is not essential to the success of NRT. There is promising evidence that bupropion may be more effective than NRT (either alone or in combination). However, its most appropriate place in the therapeutic armamentarium requires further study and consideration.

Nicotine replacement therapy for smoking cessation.

Socioeconomic status (SES) underlies three major determinants of health: health care, environmental exposure, and health behavior. In addition, chronic stress associated with lower SES may also increase morbidity and mortality. Reducing SES disparities in health will require policy initiatives addressing the components of socioeconomic status (income, education, and occupation) as well as the pathways by which these affect health. Lessons for U.S. policy approaches are taken from the Acheson Commission in England, which was charged with reducing health disparities in that country.

Socioeconomic Disparities In Health: Pathways And Policies

Introduction PART ONE: COGNITION Ideas and Beliefs Social Beliefs Structures and Strategies Structures of Ideologies Values Mental Models Consistency Consciousness Common Sense Knowledge and Truth Identity Social Cognition PART TWO: SOCIETY Ideology and Society Groups Group Relations Elites Dominant Ideologies? Institutions PART THREE: DISCOURSE The Relevance of Discourse Discourse Structures Context Reproduction From Cognition to Discourse Persuasion Legitimation Ideological Discourse Structures The Ideology and Discourse of Modern Racism Conclusions

Ideology: A Multidisciplinary Approach

Cost Effectiveness in Health and Medicine.

Program integrity in primary and early secondary prevention: are implementation effects out of control?

This paper examines whether the relationship between parenting style and adolescent depressive symptoms, smoking, and academic grades varies according to ethnicity, gender, and socioeconomic status. Four parenting styles are distinguished, based on patterns of parent-adolescent decision making: autocratic (parents decide), authoritative (joint process but parents decide), permissive (joint process but adolescent decides), and unengaged (adolescent decides). The sample included 3993 15-year-old White, Hispanic, African-American, and Asian adolescents. Results are generally consistent with previous findings: adolescents with authoritative parents had the best outcomes and those with unengaged parents were least well adjusted, while the permissive and the autocratic styles produced intermediate results. For the most part, this pattern held across ethnic and sociodemographic subgroups. There was one exception, suggesting that the relationship between parenting styles, especially the unengaged style, and depressive symptoms may vary according to gender and ethnicity. More research is needed to replicate and explain this pattern in terms of ecological factors, cultural norms, and socialization goals and practices.

Parenting Style and Adolescent Depressive Symptoms, Smoking, and Academic Achievement: Ethnic, Gender, and SES Differences

OBJECTIVE To assess the impact of televised alcohol commercials on adolescents' alcohol use. METHODS Adolescents completed questionnaires about alcohol commercials and alcohol use in a prospective study. RESULTS A one standard deviation increase in viewing television programs containing alcohol commercials in seventh grade was associated with an excess risk of beer use (44%), wine/liquor use (34%), and 3-drink episodes (26%) in eighth grade. The strength of associations varied across exposure measures and was most consistent for beer. CONCLUSIONS Although replication is warranted, results showed that exposure was associated with an increased risk of subsequent beer consumption and possibly other consumption variables.

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Exposure to televised alcohol ads and subsequent adolescent alcohol use.

Foreword - C Anderson Johnson PART ONE: FOUNDATIONS OF SCHOOL-BASED ADOLESCENT TOBACCO USE PREVENTION AND CESSATION PROGRAMS Beginnings Tobacco Use Prevalence and Consequences Focus and Content of Prevention and Cessation Programs Phases in the History of School-Based Prevention Programs PART TWO: THEORETICAL BASIS AND METHODOLOGICAL CONSIDERATIONS OF THE PREVENTION COMPONENT OF PROJECT TOWARDS NO TOBACCO USE (PROJECT TNT) Social Influence in Etiology and Prevention of Tobacco Use Sampling, Design and Tracking Issues Alternative Methods of Assessment of Tobacco-Use-Related Variables PART THREE: CURRICULUM DEVELOPMENT, IMPLEMENTATION AND FOLLOW-UP IN PREVENTION Curriculum Development Applied to Prevention in Project TNT Lesson Contents and Implementation Prevention Program Evaluation PART FOUR: CESSATION COMPONENT OF PROJECT TOWARDS NO TOBACCO USE (TNT) History, Theoretical Basis and Program Development of Adolescent Tobacco Use Cessation Research Cessation Clinic Evaluation PART FIVE: CONCLUSIONS AND FUTURE DIRECTIONS IN TOBACCO USE PREVENTION AND CESSATION PROGRAMS Discussion of Prevention and Cessation Results Remaining General Issues in Adolescent Tobacco Use Research

Developing School-Based Tobacco Use Prevention and Cessation Programs

Objective: This article presents a meta-analysis of 48 teen cigarette smoking cessation studies, the 1st meta-analysis of its kind. The authors conducted searches of electronic databases and unpublished manuscripts from 1970 to 2003. Fifty contextual elements were coded from each article. A weighted least squares random effects method was used to pool results from individual study net effects estimates. Multilevel random coefficients modeling was applied to control for the intrastudy variation. Main Outcome Measures: The primary outcome for the present analysis was quit rate. Data were entered as intent-to-treat (ITT) quit rates (not compliance sample rates). Overall treatment effect size and treatment effect sizes as a function of program content, modality, number of sessions, and length of follow-up were examined. Results: Across studies, program conditions, compared with control conditions, appeared to give smokers a 2.90% (95% confidence interval 1.47–4.35%) absolute advantage in quitting, increasing the probability of quitting by approximately 46% (9.14% vs. 6.24%). Relatively higher quit rates were found in programs that included a motivation enhancement component, cognitive–behavioral techniques, and social influence approaches. Also, relatively higher quit rates were found in school-based clinic and classroom modalities. Furthermore, relatively higher quit rates were found for programs consisting of at least 5 quit sessions. Data also indicated that the effects were maintained at short-term (1 year or less) and longer term (longer than 1 year) follow-ups. Conclusion: Much more teen smoking cessation research is needed, but teen smoking cessation programming is effective, and the present study provides a framework to move forward.

A meta-analysis of teen cigarette smoking cessation.

Understanding the psychosocial factors that predict cigarette smoking onset in young people is of crucial importance for prevention efforts. The present study examined prospective psychosocial predictors of smoking in a three-wave longitudinal data set. Similar in design to an earlier study by Chassin, Presson, Sherman, Corty, and Olshavsky (1984), the present study replicated their work, and extended it by (a) using composite predictors derived from exploratory factor analysis, (b) including prior behavior as a predictor, (c) using a design extended over three waves of data collection, and (d) using a sample composed primarily of urban teenagers. Subjects were 3295 7th-grade students at the beginning of the study. The subjects completed a questionnaire containing items tapping cigarette smoking behavior and psychosocial items that have previously been shown to predict smoking behavior. Forty-one psychosocial items on the Wave 1 (initial) questionnaire were factor analyzed, and five factors were retained. Subscale scores were constructed based on these factors and were used as predictors. Regression analyses were performed using the subscales and pretest smoking frequency to predict a continuous measure of smoking, and discriminant analyses were performed to predict transitions between qualitative levels of smoking. Prior smoking behavior was the most important predictor of future smoking. Four of the subscales, Social Disapproval, Risk Taking/Rebelliousness, Perceived Smoking Prevalence, and Motivation to Comply, were significant predictors. One subscale, Physical Consequences from Smoking, was not predictive of smoking in any of the analyses. The effect sizes cross-validated well. It is suggested that an integrative model of smoking initiation developed by Flay, d'Avernas, Best, Kersell, and Ryan (1983) best summarizes the results of the present study.

Clyde W. Dent

Papers

Parenting Style and Adolescent Depressive Symptoms, Smoking, and Academic Achievement: Ethnic, Gender, and SES Differences

Exposure to televised alcohol ads and subsequent adolescent alcohol use.

Developing School-Based Tobacco Use Prevention and Cessation Programs

A meta-analysis of teen cigarette smoking cessation.

Psychosocial Predictors of Young Adolescent Cigarette Smoking: A Sixteen‐Month, Three‐Wave Longitudinal Study