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Oral nicotine pouches for cessation or reduction of use of other tobacco or nicotine products.
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: Primary objectives To evaluate the benefits and harms of oral nicotine pouches when used to help people transition away from combustible tobacco use (smoking) To evaluate the impact of oral nicotine products on the prevalence of combustible tobacco use Secondary objectives To evaluate the benefits and harms of oral nicotine pouches when used to help people transition away from other non-combustible tobacco/commercial nicotine product use To evaluate the impact of oral nicotine products on the prevalence of use of other non-combustible tobacco/commercial nicotine products.
The impacts of e-cigarette flavours: An overview of systematic reviews.
BACKGROUND AND AIMS: E-cigarette flavours have the potential to impact the appeal, harms and use of e-cigarettes and combustible tobacco. Systematic reviews have synthesised evidence on their impacts but have always focused on specific outcomes or populations. This overview aimed to draw together syntheses from past systematic reviews of e-cigarette flavours to provide a holistic, population-wide view. METHODS: Overview of systematic reviews investigating the impacts of e-cigarette flavours on any outcome. We searched six databases to February 2024, and appraised reviews using AMSTAR2. We used association direction plots and narratively synthesised results. RESULTS: We included 32 reviews (11 higher quality; 21 lower). Reviews reported impacts of e-cigarette flavours on: appeal/perceptions of vaping (13 reviews); harms (12); smoking (7); and vaping (13) behaviours. Availability of non-tobacco e-cigarette flavours may increase the appeal of (8 reviews) and motivation to try/continue using e-cigarettes (5) and decrease harm perceptions (5). There were no clear differences in impacts based on age or history of combustible tobacco use, and little difference in findings between higher and lower quality reviews. Two reviews indicated that among adolescents, experimenting with different flavours increased e-cigarette appeal. Twelve reviews indicated that a range of specific flavours (including cinnamon, menthol and various sweet/fruity flavours) may be harmful; this often came from in vitro experiments and chemical analyses. Findings were inconclusive on the impact of e-cigarette flavours on smoking cessation (six reviews not showing clear impact), smoking initiation (two reviews not showing clear impact) and vaping initiation (two reviews showing increased initiation and two not showing clear impact). CONCLUSIONS: Non-tobacco flavourings for e-cigarettes may increase e-cigarette appeal and harms; this increase may vary by flavour and apply across different population groups. The impacts of e-cigarette flavours on e-cigarette and cigarette use are inconclusive.
Factors associated with link workers considering leaving their role: a cross-sectional survey.
BACKGROUND: Social prescribing (SP) link workers (LWs) listen to patients' concerns and difficulties, and connect them to relevant community assets (groups/organisations/charities) that can help with their non-medical issues (eg, loneliness, debt, housing). LW retention is key to sustaining SP within primary care. AIM: To examine occupational self-efficacy, job discrepancy and other factors as potential predictors of LWs' intentions to leave or remain in their post. DESIGN & SETTING: Cross-sectional survey involving LWs from the United Kingdom. METHOD: An online questionnaire was distributed via SP-related organisations. Questions were on: a) intention to leave the role, b) demographics, and c) role experience, including occupational self-efficacy and discrepancy between expectations and reality of the job. Questions were mainly closed, although some allowed LWs to provide a written response. Logistic regression models were fitted to identify predictors, and content analysis used to categorise open ended responses. RESULTS: 342 questionnaire responses were included in the analysis. Higher job discrepancy was associated with past (odds ratio [OR] per 30 unit increase=6.86; 95% CI: 3.91 to 12.0; P=0.003) and future (OR=4.86; 95% CI: 2.70 to 8.72; P<0.001) intentions to leave, whilst lower occupational self-efficacy was associated only with past intentions to leave (OR per 10 unit decrease=1.91; 95% CI: 1.24 to 2.93; P=0.003). CONCLUSION: Findings highlight factors influencing LW retention, offering a foundation for targeted interventions, which could include clearer communication about the role during recruitment, and adjusting job descriptions and support when required.
Incentives for smoking cessation
Background: Financial incentives (money, vouchers, or self-deposits) can be used to positively reinforce smoking cessation. They may be used as one-off rewards, or in various schedules to reward steps towards sustained smoking abstinence (known as contingency management). They have been used in workplaces, clinics, hospitals, and community settings, and to target particular populations. This is a review update. The previous version was published in 2019. Objectives: Primary. To assess the long-term effects of incentives and contingency management programmes for smoking cessation in mixed and pregnant populations. Secondary. To assess the long-term effects of incentives and contingency management programmes for smoking cessation in mixed populations, considering whether incentives were offered at the final follow-up point. To assess the difference in outcomes for pregnant populations, considering whether rewards were contingent on abstinence or guaranteed. Search methods: For this update, we searched CENTRAL, MEDLINE, Embase, PsycINFO, and two trials registers on 2 November 2023, and the Cochrane Tobacco Addiction Group Specialised Register on March 2023, together with reference checking, citation searching, and contact with study authors to identify additional studies. Selection criteria: We considered only randomised controlled trials (RCTs), allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community-, work-, clinic- or institution-based), studies with specific populations (e.g. those with diagnosed mental health conditions), and studies in pregnant people who smoke. Data collection and analysis: We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant people, we used abstinence from smoking measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenszel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations. Main results: Forty-eight mixed-population studies met our inclusion criteria, recruiting more than 21,924 participants; 15 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 16 to be at high risk of bias, with the remaining 24 studies at unclear risk. Thirty-three of the trials were run in the USA, two in Thailand, one in the Philippines, one in Hong Kong, and one in South Africa. The rest were European. Incentives offered included cash payments, self-deposits, or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.52 (95% CI 1.33 to 1.74; I2 = 23%; 39 studies, 18,303 participants; high-certainty evidence). Results were not sensitive to the exclusion of seven studies that offered an incentive for cessation at long-term follow-up (result excluding those studies: RR 1.46, 95% CI 1.23 to 1.73; I2 = 26%; 32 studies, 15,082 participants), suggesting the impact of incentives continues for at least some time after incentives cease (at least six months). For this update, we included an adjusted analysis incorporating three cluster-RCTs. The pooled odds ratio was 1.57 (95% CI 1.37 to 1.79; I2 = 30%; 43 studies, 23,960 participants; high-certainty evidence). Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between 45 US dollars (USD) and USD 1185. There was no clear difference in effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits. We ran an updated exploratory meta-regression and found no significant association between the outcome and the total value of the financial incentive (P = 0.963). Any such indirect comparison is particularly crude in this context, due to differences in the cultural significance of financial amounts (e.g. USD 50 might have different significance in different contexts). We included 14 studies of 4314 pregnant people (11 conducted in the USA, one in France, and two in the UK). We judged four studies to be at low risk of bias, two at high risk of bias, and eight at unclear risk. When pooled, the 13 trials with usable data delivered a risk ratio at longest follow-up (up to 48 weeks postpartum) of 2.13 (95% CI 1.58 to 2.86; I2 = 31%; 13 studies, 3942 participants; high-certainty evidence), in favour of incentives. Authors' conclusions: Overall, our conclusion from this latest review update remains that there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The evidence demonstrates that the effectiveness of incentives is sustained even when the last follow-up occurs after the withdrawal of incentives. There is also now high-certainty evidence that incentive schemes conducted amongst pregnant people who smoke improve smoking cessation rates, both at the end of pregnancy and postpartum. This represents a change from the previous update in which we rated this evidence as moderate certainty. Current and future research might more precisely explore differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations, focusing on low- and middle-income countries where the burden of tobacco use remains high.
Experiences of social prescribing in the UK: a qualitative systematic review.
BACKGROUND: Social prescribing connects patients to resources or activities to meet their non-medical needs. In the UK, it is often implemented in primary care. In the social prescribing pathway, patients are directed to link workers to identify suitable solutions for their needs such as art workshops or welfare benefit guidance. Social prescribing marks a notable transition from traditional medical treatments to more comprehensive strategies focusing on holistic health and wellbeing. Insights from patient experiences can improve the development of social prescribing to better meet their needs. This understanding can aid in improving the delivery and outcomes of social prescribing. AIM: To synthesise qualitative research on the experiences of social prescribing among patients in the UK. DESIGN AND SETTING: Qualitative systematic review using thematic synthesis for peer-reviewed studies that focused on experiences of users of social prescribing in the UK. METHOD: An exhaustive search was performed in six databases: ASSIA, CINAHL, Embase, MEDLINE, PsycINFO, and Social Sciences Citation Index via Web of Science. The Critical Appraisal Skills Programme tool for qualitative research was used for quality assessment and the PRISMA 2020 checklist was used to ensure the report transparency. RESULTS: Titles and abstracts of 1269 studies were screened. In total, 85 studies were full-text screened, and 19 studies were included in the review. Five analytical themes were developed from these studies: a) searching for hope in times of adversity; b) variability in temporal responsiveness; c) sustained change from a positive response; d) feeling supported and empowered by the social prescribing pathway; and e) misalignment producing no response. CONCLUSION: Patients might experience lasting advantages from social prescribing if it aligns with their needs and expectations. Results highlighted the importance of matching social prescribing referral with patients' readiness to engage. Therefore, it is recommended that healthcare professionals evaluate patient suitability before beginning a social prescribing referral.
plaTform fOr Urinary tract infection diagnostiC evAluatioN (TOUCAN): a protocol for a prospective diagnostic accuracy study of point-of-care testing in patients suspected of acute uncomplicated urinary tract infection in primary care clinics in England.
INTRODUCTION: Acute uncomplicated urinary tract infection (UTI) is a common condition with potentially serious sequelae that is mostly diagnosed and managed in primary care settings. Around half of all women have a UTI in their lifetime, and a quarter experience an infection caused by organisms resistant to more than one antibiotic. Reducing inappropriate prescribing of antibiotics is a core tenet of antimicrobial stewardship. However, current diagnostics for UTI are unfit for purpose in acute (highest prescribing) settings, being too slow to inform the required immediate decision-making and often confounded by sample contamination.Rapid point-of-care diagnostic tests (POCTs) that facilitate timely decision-making are potential solutions to this problem. Several such tests have reached advanced stages of technology readiness, but their diagnostic performance has not been evaluated in primary care with clinical users. To progress novel tests towards implementation, a diagnostic field study is required, to allow for parallel and sequential evaluation of multiple tests in a primary care population. METHODS AND ANALYSIS: We will recruit participants assigned female at birth from primary care clinics in England who contact their clinic with symptoms of acute uncomplicated UTI. Eligible participants will complete a short questionnaire to capture symptoms and symptom severity and will provide a urine sample. Samples will be split and initially tested using novel index tests (POCTs) and conventional urinalysis 'dipstick' at the primary care clinic. The second part of the sample will be processed at a National Health Service-based reference laboratory using a modified reference standard including microscopy, microbiological culture, pathogen speciation and antimicrobial susceptibility testing. The UTI reference standard culture, although based on the national methods, is modified to provide accurate bacterial counts, better to define a microbiological diagnosis of UTI. Susceptibility testing will be performed using 'gold-standard' methods, not usually performed in diagnostic laboratories. The primary outcome will be the diagnostic performance (sensitivity, specificity, positive and negative predictive values) of POCTs for detection of UTI and antimicrobial susceptibility for POCTs that include antimicrobial susceptibility testing. Secondary outcomes will include the symptom profile of patients presenting with uncomplicated UTI, a theoretical determination of how use of POCT results might change prescribing, an understanding of POCT failure rate and qualitative capture of the experiences of those using the POCT to deliver the study in primary care clinics. ETHICS AND DISSEMINATION: Ethical approval was received from the London Central Research Ethics Committee (23/LO/0371) and the UK Health Research Authority. We will publish the findings of The plaTform fOr Urinary tract infection diagnostiC evAluatioN evaluations in peer-reviewed medical journals and more broadly following a dissemination plan formulated by a communications specialist in consultation with patients and the public. TRIAL REGISTRATION NUMBER: ISRCTN80937472.
Electronic cigarettes for smoking cessation: a Cochrane review
BACKGROUND Electronic cigarettes (ECs) are handheld electronic vaping devices which produce an aerosol by heating an e-liquid. People who smoke, healthcare providers and regulators want to know if ECs can help people quit smoking, and if they are safe to use for this purpose. This is a review update conducted as part of a living systematic review. OBJECTIVES To examine the safety, tolerability and effectiveness of using electronic cigarettes (ECs) to help people who smoke tobacco achieve long-term smoking abstinence, in comparison to non-nicotine EC, other smoking cessation treatments and no treatment. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group’s Specialized Register to 1 February 2023, and Cochrane Central Register of Controlled Trials (Central), Medline, Embase, and PsycINFO to 1 July 2023, and reference-checked and contacted study authors. SELECTION CRITERIA We included trials in which people who smoke were randomized to an EC or control condition. We also included uncontrolled intervention studies in which all participants received an EC intervention as these studies have the potential to provide further information on harms and longer-term use. Studies had to report an eligible outcome. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods for screening and data extraction. Critical outcomes were abstinence from smoking after at least six months, adverse events (AEs), and serious adverse events (SAEs). We used a fixed-effect Mantel-Haenszel model to calculate risk ratios (RRs) with a 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, we calculated mean differences. Where appropriate, we pooled data in pairwise and network meta-analyses (NMA). MAIN RESULTS We included 88 completed studies (10 new to this update), representing 27,235 participants, of which 47 were randomized controlled trials (RCTs). Of the included studies, we rated ten (all but one contributing to our main comparisons) at low risk of bias overall, 58 at high risk overall (including all non-randomized studies), and the remainder at unclear risk. There is high certainty that nicotine EC increases quit rates compared to nicotine replacement therapy (NRT). In absolute terms, this might translate to an additional four quitters per 100. There is moderate-certainty evidence that the rate of occurrence of AEs is similar between groups. SAEs were rare, and there is insufficient evidence to determine whether rates differ between groups due to very serious imprecision. There is moderate-certainty evidence, limited by imprecision, that nicotine EC increases quit rates compared to non-nicotine EC. In absolute terms, this might lead to an additional three quitters per 100. There is moderate-certainty evidence of no difference in the rate of AEs between these groups. There is insufficient evidence to determine whether rates of SAEs differ between groups, due to very serious imprecision. Due to issues with risk of bias, there is low-certainty evidence that, compared to behavioral support only/no support, quit rates may be higher for participants randomized to nicotine EC. In absolute terms, this represents an additional four quitters per 100. There was some evidence that (non-serious) AEs may be more common in people randomized to nicotine EC and, again, insufficient evidence to determine whether rates of SAEs differed between groups. Results from the NMA were consistent with those from pairwise meta-analyses for all critical outcomes, and there was no indication of inconsistency within the networks. Data from non-randomized studies were consistent with RCT data. The unwanted effects (at medium and short term) reported most often with nicotine EC were throat or mouth irritation, headache, cough and feeling sick. These appeared similar to those people experience when using NRT. These effects were reduced over time as people continued using nicotine EC. AUTHORS’ CONCLUSIONS There is high-certainty evidence that ECs with nicotine increase quit rates compared to NRT and moderate-certainty evidence that they increase quit rates compared to ECs without nicotine. Evidence comparing nicotine EC with usual care/no treatment also suggests benefit, but is less certain due to risk of bias inherent in the study design. Confidence intervals were for the most part wide for data on AEs, SAEs and other safety markers, with no difference in AEs between nicotine and non-nicotine ECs nor between nicotine ECs and NRT. Overall incidence of SAEs was low across all study arms. We did not detect evidence of serious harm from nicotine EC, but the longest follow-up was two years and the number of studies was small. The main limitation of the evidence base remains imprecision due to the small number of RCTs, often with low event rates. Further RCTs are underway. To ensure the review continues to provide up-todate information to decision-makers, this review is a living systematic review. We run searches monthly, with the review updated when relevant new evidence becomes available.