8. Question:
I was given a newspaper cutting last year about "third hand smoke" breathed in by babies from clothing or furniture. Nicotine and cotinine were found in urine and hair of 49 babies, even when the parents smoked outside. Has any more recent research been done on this - or where can more information be found?

‘Third-hand’ smoke exposure

The paper you refer to is:

Matt GE, Quintana PJ, Hovell MF, Bernert JT, Song S, Novianti N, Juarez T, Floro J, Gehrman C, Garcia M, Larson S. (2004) Households contaminated by environmental tobacco smoke: sources of infant exposures.
Tobacco Control, 3(1):29-37.

The major finding that I took from the paper was that infants of parents who reported having a ‘no smoking policy’ in their homes had significantly reduced exposure to environmental tobacco smoke (ETS) than those infants who were directly exposed to cigarette smoke.

The study does not establish a causal link between surface, dust and finger nicotine levels and the nicotine found in infants’ hair and urine (i.e. we cannot say that infants received [‘breathed in’] the nicotine from this source). One of the main reasons why such a conclusion could not be reached is that there was no way of ensuring that those parents that reported having a no smoking policy actually complied with their own policy; in other words their children could have been exposed to direct tobacco exposure (second hand smoke) either in or out of the home.

For further information on this topic see: Royal College of Physicians (2005) Going smoke-free: The medical case for clean air in the home, at work and in public places. London: Royal College of Physicians; or visit the ASH website and view the ‘second hand smoke’ page in the ‘information’ section: http://www.newash.org.uk/

7. Question:
Can I have the validity and reliability of the questionnaires listed on the research resources section?
They are:
1. Dependence questionnaire (Fagerstrom Test for Nicotine Dependency [FTND])
2. Past quit attempts questionnaire
3. Smoking motives questionnaire
4. Motivation to stop smoking questionnaire
5. Health questionnaire
6. Research consent form
7. Mood and Physical symptoms questionnaire
8. Physical activity questionnaire
9. Social support questionnaire
I will be using this for my research proposal and would be grateful if you can help!

Validity and reliability of research questionnaires
Clearly some of the questionnaires listed as research resources on the SCSRN website do not require formal testing for validity (the degree to which a questionnaire accurately reflects or assesses the specific concept that the researcher is attempting to measure) or reliability (the extent to which a questionnaire yields the same result on repeated trials). Such questionnaires (e.g. the health questionnaire and physical activity questionnaire) are asking clients for factual answers to specific questions (i.e. they have face validity) and are as reliable as peoples’ memories.

1. Dependence questionnaire (Fagerstrom Test for Nicotine Dependency [FTND])
Although the FTND as an index of dependence has been criticized for lack of comprehensiveness and validity (Heatherton et al. 1991, Etter et al. 1999) it is still the most widely used and the most reliable (West 2006).

Etter JF, Duc TV & Perneger TV (1999) Validity of the Fagerstrom test for nicotine dependence and of the Heaviness of Smoking Index among relatively light smokers. Addiction 94: 269-81.
Heatherton T, Kozlowski L, Frecker R & Fagerstrom K (1991) The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction 86(9): 1119 - 27.
West R (2006) Theory of Addiction. Oxford, Blackwell Publishing.

There is a fairly extensive literature on this subject which can be checked via PubMed (http://www.ncbi.nlm.nih.gov/sites/entrez). The following search terms produced a number of papers: “FTND” (129); “FTND reliability” (10); “FTND validity” (17) and “FTND reliability Validity” (6).

2. Past quit attempts questionnaire
Tests of validity and reliability not required. However, it is worth noting that we know that a recall bias exists in regard to recalling quit attempts. See: West, R. (2006) Feasibility of a national longitudinal study (‘The Smoking Toolkit Study’) to monitor smoking cessation and attempts at harm reduction in the UK. http://www.aspsilverbackwebsites.co.uk/smokinginengland/Ref/stp001.pdf

3. Smoking motives questionnaire
See: McEwen, A., West, R. & McRobbie, H. (In press) Self-reported smoking motives and their correlates in clients attending stop smoking treatment services. Nicotine & Tobacco Research.

4. Motivation to stop smoking questionnaire
See: McEwen, A., West, R. & McRobbie, H. (2006) Effectiveness of specialist group treatment for smoking cessation vs one-to-one treatment in primary care. Addictive Behaviors, 31(9):1650-60.

5. Health questionnaire
Tests of validity and reliability not really required.

6. Research consent form
Tests of validity and reliability clearly not required.

7. Mood and Physical symptoms questionnaire
See: West, R. & Hajek, P. (2004) Evaluation of the Mood and Physical Symptoms Scale (MPSS) to assess cigarette withdrawal. Psychopharmacology, 177, 195-199.

8. Physical activity questionnaire
See: Blair, S.N., Haskell, W.L., Ho, P., Paffenbarger, P., Vranizan, K.M., Farquhar, J.W. & Wood, P.D. (1985) Assessment of habitual physical activity by seven-day recall in a community survey and controlled experiments. American Journal of Epidemiology,122:794-804.

9. Social support questionnaire
The support questionnaire in its entirety has not been tested for reliability and validity. The first page of items are taken from the Shortened Partner Interaction Questionnaire (PIQ-20) (Coppotelli et al, 1985). However, it was adapted to include support from all sources (not just partners) and 5 items were removed and 4 were added. So it is loosely derived from that. The PIQ-20 was derived from the PIQ (Mermelstein et al, 1983) for which tests for reliability and validity were conducted. The others items appear to have face validity in that they appear to make sensible enquiries about social support.

Coppotelli HC, Orleans CT. Partner support and other determinants of smoking cessation maintenance among women. Journal of Consulting and Clinical Psychology 1985; 53(4):455-460.

Mermelstein RJ, Lichtenstein E, McIntyre KO. Partner support and relapse in smoking cessation programs. Journal of Consulting and Clinical Psychology 1983;51:456-466.

6. Question:
We are changing the way that we deliver smoking cessation to pregnant women. The service has always been provided by smoking cessation advisors, not midwives, using a home visit. This has proved costly, not very effective and difficult to manage.
We are starting to work with Childrens Centres and Sure Start venues.
Is there another service that has experience of providing smoking cessation for pregnant women from these venues?

This request for assistance was emailed direct to every SCSRN member service with a request for them to respond directly to the Isle of Wight SSS.

5. Question:
The new service monitoring guidance refers to the updated Russell Standard. I note that the one on the SCSRN website (which we currently use) is dated 2005 - is this the most up to date or is there another one?

Russell Standard (clinical)
The new Department of Health monitoring guidance (NHS STOP SMOKING SERVICES. Service and Monitoring Guidance – October 2007/08) refers to an adapted Russell Standard and not an updated one. There is only a very slight variation in wording but the criteria are essentially identical. The copy of the Russell Standard we have on the SCSRN website is the most current version.

4. Question:
Page 17 of the new Department of Health monitoring guidance (NHS STOP SMOKING SERVICES. Service and Monitoring Guidance – October 2007/08): "Smokers who participate in an assessment session but fail to attend for treatment should not be counted but those who have consented to a programme of treatment, attended their first session and have set a quit date should be included".

Does this therefore mean that any clients who attend only the assessment session (one session) and no treatment sessions (maybe because they are unable or do not wish to), but consent to treatment and have set a quit date are to be counted?

Monitoring guidance clarification
The important factor here is whether a quit date has been agreed between the client and the service. If this is the case, regardless of whether the client attends for this quit appointment/group, then they are to be ‘counted’. It might be useful to make a distinction between an ‘assessment’ appointment (where the client is assessed for suitability for treatment and/or to be informed about what treatment is offered) and a ‘pre-quit’ appointment (where a quit date is set and preparations for this quit date are made). Attendance at the former ‘assessment’ appointment would mean the client would not be included in return figures; attendance at the latter ‘pre-quit’ appointment would be included.

If further clarification is required contact Nicky Willis in the Tobacco Programme at the Department of Health: nicola.willis@dh.gsi.gov.uk

3. Question:
At Walsall Stop Smoking Service we would like to subscribe to Addiction and Tobacco Control journals so that we can keep up-to-date with current research. However we can't afford the subscriptions. I am wondering if there may be some way for several services to share the subscription cost and for several of us to access the journals.

If you join the Society for the Study of Addiction (SSA) as an individual member, which costs £85 per year, you receive Addiction for free. A hard copy of Addiction will then be mailed to your home address monthly. For more details of the SSA see their website: http://www.addiction-ssa.org/

We have had some discussions with the Managing Editor of BMJ Journals, who are the publishers for Tobacco Control, around the possibility of an SCSRN group subscription to the journal. We are awaiting a decision and will post the response when we get it.

2. Question:
I am looking for the most up to date paper that recommends and approves combination use of Nicotine replacement therapy. Can you help me?

Combination use of nicotine replacement therapy (NRT)
There are a relatively small number of studies comparing the efficacy of combining different forms of nicotine replacement therapy (NRT) versus use of a single product or placebo; the evidence that exists is not overwhelming, but does suggest that combination therapy provides smokers’ with an increased chance of stopping long term. What also appears clear is that there are no real safety concerns with combining NRT products.

The Manual of Smoking Cessation states that:
“Combining two NRT products to gain better control of withdrawal symptoms is a logical approach. An example would be to use a patch to provide a steady delivery of nicotine combined with nicotine gum to provide relief of breakthrough urges. However, some current product licensing still warns that NRT products should not be used together. This not only acts as a barrier for combination use, but also contributes to fear of medicinal nicotine among smokers and healthcare professionals. The current evidence suggests that combination treatment can provide a small, but significant increase in abstinence rates compared to a single product (OR= 1.42; 95% CI: 1.14-1.76) and, above all else, is safe (Silagy et al, 2004; NICE, 2002).”

[McEwen, A., McRobbie, H., West, R. & Hajek, P. (2006) Manual for Smoking Cessation: a guide for counsellors and practitioners. Oxford, Blackwell.]

The most reliable source is the Cochrane review (Nicotine replacement therapy for smoking cessation) which states that: “There was weak evidence that combinations of forms of NRT are more effective.” For the full Cochrane review see the link (number 26: Nicotine replacement therapy for smoking cessation) on the ‘Research reviews’ page of the SCSRN website (www.scsrn.org): http://www.scsrn.org/research_reviews.html

[Silagy C, Lancaster T, Stead L, Mant D, Fowler G. 2006. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews(2).]

The recently published New Zealand Smoking Cessation Guidelines say: “There is a moderate advantage to using a combination of NRT products over just a single product. There are no safety concerns with combining NRT products.”

[Ministry of Health. 2007. New Zealand Smoking Cessation Guidelines. Wellington: Ministry of Health.]

Similarly, an update to the Smoking Cessation Guidelines for Scotland concludes that: “Concurrent use of more than one form of NRT in smokers quitting abruptly
Warnings on NRT products not to use more than one product at a time are to be removed. This would permit users to identify and use the combination that was most appropriate for them. Reference must always be made to the product information details.”

[Health Scotland and ASH Scotland (2007) Smoking Cessation Update 2007: Supplement to the 2004 Smoking Cessation Guidelines for Scotland. Health Scotland and ASH Scotland.]

1. Question:
I have recently got a query on chewing tobacco. Are there any papers on this topic?
And what is the effective treatment for it?

There are a great number of published papers on oral tobacco use, although much of it is of course culturally specific and not necessarily relevant to the use of oral tobacco in the UK (e.g. the use of ‘spit’ tobacco by US baseball players, use of Swedish snus etc). The best review of the patterns and prevalence of oral tobacco use in the UK, and of treatment options, is:

West, R., McNeill, A. & Raw, M. (2004) Smokeless tobacco cessation guidelines for health professionals in England. British Dental Journal, 196(10): 611-8.

The following is the abstract from this review and I have attached a PDF of the paper:

Download PDF

“Smokeless tobacco is used in the UK predominantly by members of the Indian, Pakistani and especially Bangladeshi communities. The most commonly used form is tobacco mixed with lime and additional psychoactive compounds, most notably areca nut. The resulting "quid" is chewed or held in the mouth. Studies from Asia indicate that use of this kind of product is linked with an increased risk of oral cancers and possibly low birth-weight infants. There is little high quality research evaluating interventions to promote cessation of smokeless tobacco use, especially of the forms used in the UK. However, what evidence there is suggests that advice to stop coupled with behavioural support and counselling may increase long-term abstinence rates by some 5-10%. It seems appropriate therefore to recommend that dentists, GPs and other relevant health professionals should routinely assess and record smokeless tobacco use in patients belonging to relatively high prevalence groups, that they ensure that smokeless tobacco users know the potential health risks (as well as the health risks of smoking) and that they advise them to stop and keep a record of the outcome. Dental professionals should also examine the oral cavity of smokeless tobacco users for lesions when the opportunity arises. Patients expressing an interest in stopping should be referred to specialist smoking cessation services for behavioural support and specialists in areas of high smokeless tobacco use will need to ensure that they are sufficiently knowledgeable and their services sufficiently accessible to these users. There is insufficient evidence to recommend the use of nicotine replacement therapy or bupropion to aid smokeless tobacco cessation. Research is needed in the UK to quantify the personal and population health risks from smokeless tobacco, the benefits of stopping, the effectiveness of interventions aimed at promoting cessation and patterns of use, knowledge and attitudes of users.”

The evidence on treatment is not particularly strong. A Cochrane review of eight trials investigating behavioural interventions did show that such interventions had a significant positive effect upon long term (six month) abstinence. However, the same review concluded that pharmacotherapies (including one trial investigating bupropion, three the nicotine patch and two nicotine gum) have not been shown to affect long-term abstinence. For the full Cochrane review see the link (number 18: Interventions for smokeless tobacco use cessation) on the ‘Research reviews’ page of the SCSRN website (www.scsrn.org).

Your best bet for getting some practical advice on treating users of smokeless tobacco is to contact the stop smoking service at Tower Hamlets (0800 169 1943). I know that Cancer Research UK has funded a pilot project in the area and that they have a team dedicated to working with the Bangladeshi community. Shamsia Begum & Dipul Ghosh from the Bengali Tobacco Cessation project can be contacted on: 020 377 8481.