Original Article
Pubblicato: 2023-01-26

Tobacco control in young people during COVID-19 pandemic: results from a pilot project

Psicologo Psicoterapeuta, Centro Antifumo di Copertino (LE), ASL Lecce Coordinatore della Società Italiana di Tabaccologia per Regione Puglia
Tobacco smoking COVID-19 remote anti-smoking treatment (RAT) in-presence anti-smoking treatment (IPT) integrated anti-smoking treatment (IAT)

Abstract

Introduction: Tobacco smoking, as a particular pandemic form, is likely to be an additional risk factor for infections during this period of healthcare emergency, especially for the development of severe COVID-19 forms. This paper presents the results of a project, titled “Smoke-free young students during Covid-19 pandemic and at all times” and aimed to contrast tobacco smoking during this pandemic. Specifically, the main purpose of this field study is to highlight the usefulness of integrated anti-smoking treatments (IATs), which are the integration of in-presence anti-smoking treatments (IPTs) and remote anti- smoking treatments (RATs), with the goal of using these treatments even after this health emergency.

Materials and methods: Methods used in this study come from a specific project designed to contrast smoking in young people, with particular attention to the definition of (1) objectives, (2) indica-tors of efficiency and effectiveness, (3) general intervention strategies, and (4) implementing modalities. This project arose from a preliminary survey conducted on a sample of 30 young students that consume cigarettes, which showed that smoking was perceived as an additional risk factor during the COVID-19 pandemic, and highlighted the need to integrate remote and in-person anti-smoking treatments. The objectives were measured with specific quantitative-qualitative indicators and with customer satisfaction analysis, using a purposely-constructed questionnaire. Recruitment of young smokers took place through voluntary accessions. Thirty-four smokers have been examined, divided into two groups with analogous characteristics composed of 17 subjects (10 males and 7 females). The first group was treated with both RAT and IPT while the second group was with IPT only. A preliminary assessment of nicotine dependence, craving, degree of efficacy and motivation to quit smoking was conducted in all subjects, using the Smoking Diary and the anti-smoking counseling according to the guidelines of the Italian National Institute of Health. Specifically, a particular method of smoking cessation, based on “planned smoking,” named COFUP, was used. This method is the result of many years of personal research and empirical findings.

Results: Generally, the goals set according to the planned indicators were achieved. In the preliminary investigation of the project, it was found that smoking was perceived by 60% of respondents as a risk factor for new coronavirus infections and, by 66% of subjects, as a behavior implemented to compensate for the loss of previous well-being, due to the pandemic. In addition, respondents perceive an increase in requests for intake at the Smoke Center (76.6 percent) and especially IATs (90 percent), regardless of the health emergency. Regarding treatment outcomes, results were better in the first group, as 47% of smokers treated with IAT stopped smoking, while 41.1% reduced the number of cigarettes up to 2/3. On the other hand, 29.4% of smokers treated only with IPT quit smoking, with a reduction of cigarettes up to 2/3 in 17.6% of smokers. The evaluation of “customer satisfaction” is positive in a large proportion of respondents (88.2%), who considered the project to contrast smoking in young students useful enough to suggest it to other smokers or health services and facilities (70.5%).

Conclusions: This study highlights a greater utility of integrated anti-smoking treatments, i.e., in-person and remote, than treatments conducted in-person only. In other words, the addition of RATs to IPTs tends to give greater efficacy than those performed in presence-only mode. Therefore, the preliminary results of this work encourage to consider integrated treatments (RATs + IPTs) as a viable additional option and opportunity to be used in smoking cessation.

Introduction

The title of the project, which is “Smoke-free young students during Covid-19 pandemic and at all times”, is meant to highlight the dual aspect of the initiative. On one hand, the importance of contrasting smoking during this pandemic emergency and, on the other hand, the usefulness of integrated anti-smoking treatments (IAT), i.e., the combination of in-person anti-smoking treatments (IPT) and remote anti-smoking treatments (RAT), to be used even after this health emergency.

Tobacco smoking is a pathological addiction that indicates that an individual persists in consuming tobacco, despite the social and health problems related to its use [1,2].

Smoking is “the leading cause of preventable death in the world,” as long highlighted by the World Health Organization. Specifically, it has been estimated that around 93,000 deaths due to cigarette smoking occur in Italy every year, resulting in enormous costs to the national healthcare system [3,4]. Moreover, in this pandemic period, the warning from the National Institute of Health is: “smoking seriously harms health, but it harms even more in times of COVID-19”. A careful analysis of the current literature by Zagà et al [5] highlighted how the mortality rate for COVID-19 is higher in men than in women (2.8 vs. 1.7) and suggest how tobacco smoking, as it is more prevalent in the male population, may partially explain this disproportion. This disparity was found not only for COVID-19 infection, but also in other forms of coronavirus infection, as men were found to be more affected during episodes of Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS).

In a specific survey, Gallus [6] points out that 23.3 percent of Italians were smokers before the lockdown while 21.9 percent were smokers during the lockdown. At the same time, he recorded an important increase in daily consumption, from an average of 10.9 to an average of 12.7 cigarettes per day.

Lupacchini et al [7] highlighted the harmful effects of nicotine in COVID-19 infection and progression based on post-mortem examinations that “strongly support a negative role of nicotine, as it can increase angiogenesis and coagulopathies”.

Palmi et al [8] examined the effects of lockdown on the use of tobacco products and electronic cigarette with a longitudinal study, aimed at analyzing tobacco and nicotine consumption during the pandemic period, in a representative sample of the Italian population (18-74 years). The results of this study show that, during the pandemic, the use of e-cigs (electronic cigarettes) and HTPs (heated tobacco products), contributed to the initiation and relapse of traditional cigarette consumption and hindered its cessation, thus fueling smoking. These data are even more remarkable considering that there are 11.6 million smokers in Italy, representing about 22% of the population older than 15 years.

The tobacco “pandemic,” which holds the sad record for the highest number of deaths among all pandemics, must be countered first and foremost with prevention interventions targeting the youth population. Early intervention, in fact, can prevent tobacco smoking addiction, which, being chronic and relapsing, very often becomes difficult to contrast in older ages. About a quarter of the Italian young population smokes traditional cigarettes, while 17.5 percent uses electronic cigarettes. The proportion of young dual (traditional and electronic cigarettes) smokers is also increasing, accounting for about 27.9% of e-cigarette smokers [4].

It turns out to be increasingly common in therapeutic smoking cessation programs to use distance intervention, which may be represented by the use of Internet, telephone advice or Short Message Service (SMS), with the aim of reinforcing the effectiveness of the treatment itself. Regarding the second aspect of this project, which is the continuation of integrated anti-smoking treatments, called IATs, even after this health emergency, it is necessary to consider some indications from the current literature. Taylor et al. [9] showed that interactive and personalized Internet-based interventions are moderately more effective than those that do not use such instruments. Matkin et al. [10], on the other hand, highlighted how telephone counseling facilitates smoking cessation, although they did not obtain specific findings. Lastly, Jugovac et al. [11] showed how the use of “SMS” can lead to further reinforcement of smoking cessation, even after many years, with greater chances of recovery contact in case of relapse. This is particularly important, because relapse in smoking cessation treatments is a rather frequent occurrence.

These few mentions are enough to highlight the actuality of the online tobacco treatments of the Smoking Centers, which have a crucial function in the prevention and treatment of smoking.

The “Smoke-Free Young Students in Covid-19 time and all times” project is part of a larger design to combat smoking, launched through two temporarily consecutive projects: 1) “Smoke-Free Social and Health District” (aimed at health workers and enriched with training projects) [12], 2) “The Smoke-Free Center in Coronavirus Era” [13].

It is necessary, given the contiguity of these project activities, to make a brief mention of the last project, which also involves the educational institution. “The Smoking Center in Coronavirus Era” was created to counteract smoking during the health emergency from COVID-19, particularly during the 2020 lockdown, through the inclusion of remote activities, with the intention of continuing it after the health emergency. The project was preceded by a survey on a sample of 90 smokers, with the aim of exploring the demand for RATs and IPTs. There were 47 (29 M, 18 F) smokers recruited in the six-month national lockdown, of whom 9 (7 M, 2 F) were treated only with RAT, and 38 (22 M, 16 F) with IAT [13]. The results, presented at the 16th SITAB Congress 2020 [13], showed that: a) 28.9% of smokers treated with IAT stopped smoking (partial remission according to DSM-5), b) 52.6% reduced the number of cigarettes by about half, c) 18.5% of smokers treated with IAT moved from the “pre-contemplation” to “contemplation” stage according to Prochaska’s model [14]. About 22% of smokers followed with RAT alone stopped smoking, 55.6% continued smoking the same number of cigarettes, and the remaining 22.4% showed a reduction of about half the number of cigarettes. The results inherent in the evaluation of the project through “customer satisfaction” appeared largely positive. This study reported the usefulness of RATs and especially IATs, especially during this public health emergency due to the new coronavirus, in line with the development of telemedicine. IATs have also been used by smokers treated jointly with General Practitioners through a special Protocol of Agreement [15]. The acronyms RAT, IPT and IAT (in Italian TAD, TIP e TAI) were coined in the above-mentioned field research work, which represents an observational study published in 2020 [13].

The design of the present study is noncontinuous with the previous field research experience, as the latter matured under extremely special conditions (lockdown of 2020). It is also intended to combine knowledge gathered from other personal research previously developed for smoking prevention and contrast [16-23]. This project, presented at the 17th SITAB Congress in 2021 [24], aims to contrast smoking through IATs. The methodology is the same used in the pilot projects, which on one hand introduces appropriate interventions in emergency areas, such as in the pandemic era, and on the other hand provides preparatory materials for clinical and experimental trials, in order to obtain new scientific evidence. The goals are seamless with smoking prevention and treatment of young tobacco users with incentive programs [21,22].

Specifically, the following objectives are planned in the project “Smoke-free young students in Covid-19 time and all times”:

  1. prevention, intake and treatment -remote, direct, or integrated- of student smokers,
  2. the continuation, after this pandemic health emergency, of remote anti-smoking activity as a supplementary or parallel service of the Smoke Control Center,
  3. the extension of part of the Smoke Control Center’s activity through “distance” activities with students from other schools in other districts,
  4. the implementation of an integrated online social-health network in the territory, considering the various educational institutions,
  5. the awareness of the population to tobacco control, as smoking is an additional risk factor for both COVID-19 infections and known smoking-related diseases, as reported in the scientific literature,
  6. psychological support for smokers who directly or indirectly have come across COVID-19, consequently developing stress.

A premise should be made regarding some techniques that have been incorporated into this project through a particular method, summarized in the acronym COFUP (Counseling-Assessment-Diary-Scheduled Smoking). This new method integrates counseling, according to national anti-smoking guidelines, together with smoking addiction assessment and the use of cognitive-behavioral strategies. It also adds some special anti-smoking techniques that have been previously tested, such as “programmed smoking” and the “three-breath prescription.” It is appropriate to mention the latter technique, which aims at:

  1. the finding of behavioral reactions in the execution of anti-smoking prescriptions, together with the assessment of the patient‘s degree of cooperation,
  2. the assessment of the stage of motivational change according to Prochaska‘s model,
  3. the modalities of facing craving,
  4. the reinforcement of therapeutic interventions given in session,
  5. increasing awareness in managing smoking addiction and related conditioning,
  6. the recognition of internal resources, especially those of which the smoker has no awareness to deal with smoking,
  7. the effective use of resources that the smoker knows to possess but does not know how to make the best use of to stop smoking,
  8. the monitoring of related interventions.

Regarding the project implementation methods, as previously mentioned, the interventions were carried out according to the users’ requests and taking into account the health emergency, in compliance with current national and regional regulations. The monthly hourly commitment was planned according to the available resources (staff, facilities, secretarial support, etc.) and adapted in relation to the organizational needs of the Smoke Control Center and the users. The duration of the project is one year with tacit renewal.

In particular, remote modalities have been used in compliance with privacy regulations and in relation to the concrete possibilities of adopting IT means. In this direction, video-consultation, consultations, interviews, questionnaires (interviews) and other telematic interventions are used in according to the terms of the “National Guidelines. Telemedicine of 2014” [25] and the “Interim Directions for Telemedicine Care Services during Health Emergency of the Italian National Institute of Health” of 2020 [26]. Telemedicine modalities (remote/online) are also used after the coronavirus emergency alongside the normal activities of the Smoke Center.

Methods

The study starts with a preliminary survey conducted through a specially constructed questionnaire on a group of 30 (15 M; 15 F) student volunteer smokers, with the aim of probing the usefulness of RATs and IPT. The questionnaire (Table 1), consists of six questions with a closed structure.

A sample consisting of 34 smokers, whose characteristics are described in Table 2, was then formed and divided into two student groups (with similar characteristics) consisting of 17 subjects (10 M, 7 W). The average age of smokers is between 18 and 19 years old. Regarding the initial age at which the first cigarettes were smoked, the minimum age reported was 12 years, and the maximum age 18 years. The minimum number of cigarettes smoked each day was 3 while the maximum number was 20, with an average of 9.6.

The first group was treated with RAT and IPT, while the second group was treated exclusively with IPT.

Inclusion criteria included:

  1. participation in an anti-smoking awareness activity with the collection of voluntary endorsements from students intent to quit smoking,
  2. age between 18 and 20 years,
  3. adherence to the previous “No Smoking at Schools” project, which included rewarding anti-smoking programs,
  4. self-experimentation of the smoking reduction method (scaling the number of cigarettes) that many young people use to quit smoking,
  5. the assessment: (a) of the degree of nicotine dependence with the Fagerstrom Test for Nicotine Dependence (FTND), (b) of the intensity of craving (desire to smoke), as an additional index of nicotine dependence, by the Visual Addiction Scale (VAS) test, (c) of the degree of motivation to quit smoking, with Marino’s test, which is crucial in the evolution of the antitabagic pathway, (d) of the level of self-efficacy of anti-smoking treatment, along with the possibility of quitting smoking, through the smoker’s diary [27-30].

Customer satisfaction assessment was carried out with a specific questionnaire consisting of six closed-ended questions (Table 3). Anti-smoking treatment was carried out according to national anti-smoking and telemedicine guidelines [25,30].

Another mode of qualitative evaluation of the project was carried out through a “Study Meeting,” held on 12-14-2021, at the IIS “V. Bachelet” in Copertino [31] in order to highlight the impact with similar experiences filtered by expert observers in the field. This particular evaluation generally recalls the “benchmarking” methodology.

Listed below are the quantitative and qualitative indicators that signal the positive results of the project:

  1. holding of at least one outreach event at a distance, with a group of at least 3 classes of students, open to teachers,
  2. 20% increase in distance outreach compared to that carried out in previous years referring to requests for treatment, counseling or information, etc., etc,
  3. 10 % increase in users taken care with remote mode,
  4. 20 % increase in therapeutic anti-smoking remote treatments,
  5. achievement of at least 60 % of perceived satisfaction (customer satisfaction) in users taken in charge,
  6. a study meeting to discuss the initial results achieved in comparison with other results of similar facilities (benchmarking).

Smoking cessation counseling has also been used, which takes into account the guidelines of the National Institute of Health, particularly the minimal clinical intervention [30] and the “planned smoking” method [32].

A brief mention of the tests used is appropriate. The FTND is a questionnaire consisting of six questions that allows for a gradation of nicotine dependence in 4 degrees (mild, medium, strong and very strong). It is based on a few indicators: 1) smoking the first cigarette in the morning and during the first hour of waking up, 2) use of smoking in prohibited places, 3) amount of cigarettes smoked per day, 4) most liked cigarette during the day, 5) presence or absence of smoking during illness [28,29].

Craving for smoking is measured with the VAS test, asking the smoker to draw a line between minimum and maximum (ten centimeters in all) in relation to the desire to smoke in the last week, thus obtaining a measure of craving, which is an important indicator of nicotine dependence [28].

Self-Efficacy (SE) is measured by asking the smoker to rate the possibility of quitting smoking, with a scale, from one to ten [28].

These tests are naturally interconnected, as they measure indicators of addiction from multiple perspectives. Craving, for example, is assessed in the smoker’s diary, VAS test, FTND, and SE.

Before exposing the method used to quit smoking, it is appropriate to analyze the minimal clinical intervention and the “planned smoking” technique.

Counseling, according to the guidelines of the National Institute of Health, has as its background Prochaska’s model of motivational stages (precontemplation, contemplation, determination, action, maintenance and relapse) and the minimal clinical intervention called “of the 5 A’s and 5 R’s” [29,30]. It is associated with the technique of “programmed smoking”, which, as pointed out by Kring et al [33], consists of tobacco smoking cessation through a graduated plan of the number of cigarettes until cessation. According to the same authors, “planned smoking,” which is a technique based on the time factor and not on the subject’s own instincts, situations or moods, achieves an abstinence rate, in one year, of about 44 percent [29]. This technique, in addition to its inclusion in anti-smoking counseling (2 to 7 sessions), has been used within a procedure that takes into account the assessment of the degree of nicotine dependence, motivational stage and degree, intensity of craving, level of self-efficacy, and indications from the smoker’s diary. It has been used by the undersigned, since 2012, in youth and adult anti-smoking treatments, published in 2013, in the variant smoking reduction and especially in works published in 2017 [20]. In the latter works, the technique of “planned smoking” is used more efficiently, as it is aligned with the “smoker’s diary” procedures. In this regard, the smoker records the cigarettes smoked in a day, before lighting them, indicating the location, activity performed, mood, and self-assessment of craving with a scale of 1 to 10 [26]. The “smoker’s diary” has a strategic function, as it can create a space between the intentionality of smoking and the act of smoking itself, which is manifested in the form of a ritual. This “space of reflection” that occurs between intention and act, characterized by momentary interruption of automatism, can trigger cure, through the reflection-decision to stop smoking [20]. The “smoker’s diary” includes cognitive-behavioral strategies. The smoking reduction technique has also been used in some longitudinal studies published in 2019 referring to young students [21].

The method for quitting smoking habit, developed by the undersigned, which is schematized in Figure 1, is then exposed. It is a circular model that includes anti-smoking counseling, smoker’s assessment, smoker’s diary and a specific technique for quitting smoking, namely “planned smoking.” This method is summarized in the acronym COFUP (Counseling-Assessment-Diary-Scheduled Smoking).

The first phase refers to counseling, according to the anti-smoking guidelines already mentioned, and specifically to the minimal clinical intervention of the so-called 5As and 5Rs.

The name of the first method (5As) refers to the initials of each phase, specifically: Ask, Advice, Assess, Assist and Arrange. In Ask, the focus is on the patient’s clinical condition; in Advice, the focus is on smoking cessation; in Assess, the call is directed at assessing motivation to quit smoking; in Assist, the priority is aimed at assessing smoking dependence; and finally in Arrange, the focus is directed at preventing relapse [27,28].

The second method (5Rs), similarly named after its initials, refers to: 1) Relevance, i.e., the importance of smoking cessation, 2) Risks i.e., the short-, medium- and long-term harms of smoking, including secondhand or third-hand smoke, 3) Rewards, in other words, the potential benefits of smoking cessation, 4) Roadblocks i.e., the identification of the obstacles of smoking cessation, 5) Repetition i.e., the reiteration of motivational reinforcement [27,28].

In the minimal clinical intervention (5As and 5Rs) the different moments, as can be observed, are seamless to each other and proceed in a circular perspective. It also interacts with the other phases of the COFUP model (Figure 1). For example, the clinical assessment of smoking (Ask) is related to the clinical assessment of smoking addiction (Assist) or smoking cessation (Advice), as well as the importance to quit smoking (Relevance) and the repetition of motivational reinforcement (Repetition). On the other hand, counseling cannot be done without the other phases, specifically the smoker’s in-depth assessment of both nicotine addiction and lifestyle which relates to phase 2. This stage is closely related to stage 3, that is, the indications of the smoker’s diary, which precisely gives a measure of the smoker’s lifestyle, but more importantly provides a quantitative-qualitative assessment of tobacco smoking addiction. This phase is also closely related to phase 4, the planned smoking phase, which is directly focused on smoking reduction and consequently smoking cessation. Phase 4 refers back to phase 1, in a circular view, and specifically to the follow-up of the 5As Arrangement, which in the case of relapse refers back to phase 2 and thus to a new assessment.

Phase 2 is mainly focused on motivational aspects, according to Prochaska’s stages of change model, which is used taking into account the actual situation of the smoking subject. Citing some examples, the smoker who continually proclaims to quit smoking while continuing to smoke is in the “precontemplation” stage, while the smoker who begins to think about quitting smoking but, for various reasons, fails to do so, refers to the “contemplation” stage. On the contrary, the one who has decided to quit smoking and asks for qualified help to implement this will refers to the “determination” stage. The “action” stage, on the other hand, relates to an active practice, thus resulting from the fact of having stopped smoking, even if only for a day, and is closely contiguous with the “maintenance” stage of action. Finally, the “relapse” stage brings the subject back to the initial stage in several ways: isolated relapse, temporary smoking use or restoration of the initial nicotine dependence situation. This model, used clinically, that is, taking into account the smoker’s time situation, helps the shift from one stage to the other. For example, from the stage of “precontemplation” to the stage of “contemplation” as well as from this to the state of “decision” and finally to the final result, i.e., consolidated action. Marino’s questionnaire [30], consisting of four questions regarding the importance, determination, motivation and likelihood of quitting smoking, provides a measure of the degree of motivation, but also of Prochaska’s stages of change, and thus of smoking cessation.

An auxiliary technique in smoking cessation is the three-breath prescription (t.b.p.), previously published in 2013 [20] following feedback with empirical evidence. This technique is derived from another technique, namely the hypnotic invariant prescription (h.i.p), which consists of self-hypnotic training, or relaxation self-training. T.b.p consists of taking three deep breaths, mentally counting them and focusing attention in the inhalation and exhalation phases. It involves self-experimentation and self-perception of smoke-free well-being, including self-stimulation of positive and rewarding experiences.

Results

A summary of the project experience was presented at the SITAB 2021 Congress and at a subsequent “Study Meeting,” held on 12-14-2021, at the IIS “V. Bachelet” in Copertino, where a positive impact was found [34].

Generally, the goals set according to the planned indicators were achieved (Table 4).

Specifically, the distance meeting, with classrooms and teachers, was particularly effective, allowing an increase in this activity by more than 20 percent.

In the propaedeutic survey (Table 5), smoking was perceived as a risk factor in COVID-19 infections in 60% of cases. Similarly, increased smoking was perceived in 60% of respondents during lockdown. Sixty-six percent of respondents said they smoked during the pandemic due to “loss of previous well-being,” perceiving an increase in requests for intake at the Smoking Center (76.6 percent). Respondents find IATs, which include RATs and IPTs, useful to the extent of 70%, and support the use of online treatments even after the end of the health emergency.

The increased demand for taking care of smokers, during lockdown, is in line with the results of the current literature, already highlighted in the introduction of this paper.

Regarding the clinical characteristics of the sample (Table 6), nicotine dependence is mild in most cases (63.4%) and is strong in only 6.6% of cases. Motivation is low in slightly more than half of the smokers (52.9%), while self-efficacy (SE) and craving (VAS) are in the average values in most cases.

As for the results of anti-smoking treatment (Table 7), they are better in the first group, especially in the aspect related to smoking reduction. In fact, 47.1% of smokers treated with RAT and IPT stopped smoking (DSM-5 partial remission) while 41.1% reduced cigarettes up to 2/3. In contrast, 29.4% of smokers in the second group, treated only with IPT anti-smoking pathways, stopped smoking, with a reduction of cigarettes up to 2/3, in 17.6% of smokers.

The evaluation of the project’s effectiveness, through “customer satisfaction” (Table 8), is generally positive (88.2% of respondents), to the point of being inclined to suggest it to other smokers or health services and facilities in 70.5% of respondents.

Responses were also mostly positive (73.5%) for integrated anti-smoking pathways (IATs). In addition, it is considered useful to associate psychological support in smoking cessation treatment (67.7%).

Discussion

The comment to the results is based on the assumptions of the project itself and the research work. This fieldwork, in fact, is based on a preparatory investigation for the implementation of the project “Smoke-free young students in Covid-19 time and in all times.” It was intended to test the general hypothesis that during this health emergency, a readjustment of the modes of daily living in the spheres of: family, work, school and social life has somehow been imposed. As is well known, every aspect of social life has been modulated according to the principle of physical distancing, with its related psycho-relational repercussions, along with other measures (quarantine, self-isolation, etc.) to prevent the contagion of the new coronavirus. As a result, smokers (like nonsmokers) have had to reshape their relationship with smoking. At the same rate, health services have also had to re-modulate how they deliver services by giving more space to telemedicine. The results find their significance in this framework, particularly in the evaluation of RATs and IATs.

The positivity of the project’s effectiveness-efficiency indicators indicates not only the usefulness of the project itself and its methodology, but also urges the implementation of research in the field through further projects themselves.

The propaedeutic survey confirmed the starting hypothesis of this study, namely the fact that the pandemic caused an increase in smoking use, probably related to psycho-social stress. In fact, most of the smokers interviewed considered the increase in smoking use during pandemic an expression of the loss of previous well-being, as observed in the quantitative data. It also emerges in the interview that smokers continue to smoke more, despite the knowledge that smoking, in COVID-19 infection, is an additional risk factor, as reported in the literature [4-6]. This is further confirmation of the criteria for establishing pathological dependence, as provided in DSM-5 [2], and in particular of how awareness of the harms of smoking, exacerbated by COVID-19, does not induce smoking cessation.

On the other hand, these data are in line with the studies, presented at the beginning of this paper, reporting an increase, in relation to COVID-19, not so in the number of smokers, but in the number of cigarettes smoked by the smokers themselves. This is an obvious compensatory, albeit inappropriate, response to social frustration with the effects of the pandemic. This fact is, all things considered, in line as the answers of the respondents to the questionnaire, who justify the increase in smoking in the pandemic by the “loss of previous well-being.”

The other element that emerges in the survey is the use of IATs even after the pandemic.

In particular, the outcomes of this study are in line with the current literature that emphasizes how the addition to traditional anti-smoking programs of remote intervention, including the use of the Internet, telephone counseling, and text messaging, can reinforce [9-11] the effectiveness of the treatment itself. On the other hand, the Italian National Institute of Health has long offered help to quit smoking through a special platform called “smettodifumare” using a multidisciplinary team [35]. This means that online, i.e., remote, intervention actually offers help to those who want to quit smoking.

How can we explain the better results of integrated treatments compared to those carried out only in presence? The most likely hypothesis is related to the fact that tobacco treatment requires continued support over time, in the interval between two sessions or even between two health interventions. In fact, craving, which is one of the major causes of relapse in anti-smoking treatments, can be better addressed with repeated supports that reinforce the action of therapeutic treatment in attendance.

Another note of comment deserves the reduction in the number of cigarettes smoked, which is greater in smokers treated with integrated programs, i.e., with IAT, as it aligns with what has just been mentioned. Reduction in cigarettes smoked, moreover, can be used strategically to achieve complete smoking cessation, which is the real goal of antitabagic treatment.

In addition, the results are positive for the method used, COFUP, which uses anti-smoking techniques and procedures that have been tried in the past with empirical evidence (such as scheduled smoking), and their combination can only enhance the effects of the interventions. The smoker’s diary, for example, uses cognitive-behavioral strategies that are important in smoking cessation [28]. The t.b.p., to take another example, allows for the prevention of relapses, as it acts in the earliest stages in which craving (or compulsivity to smoke) and related consequences leading to tobacco use are about to occur [17,18,20]. This technique is important because it is incorporated within other, more general procedures, such as a thorough assessment of the young smoker’s characteristics.

The “Customer satisfaction” questionnaire proved to be a significant tool, as it is a subjective evaluation of the project itself by users. The evaluation of perceived satisfaction, by the users, is important, as it allows us to understand the impact of the project itself on the individual subjects. This evaluation is necessary to complement the objective one and simultaneously allows for an adaptation of the project itself.

The major limitation of this study is the small sample size, as the sample including the two groups does not exceed 34. The results should be considered keeping this limitation in mind. However, it is necessary to consider the fact that this is a pilot project, the results of which may initiate large-scale experimentation. In addition, the small numerical quantity is offset by qualitative and methodological factors. The subjects comprising the sample underwent an in-depth evaluation including assessment of addiction and motivational level, degree of craving, and self-efficacy with counseling according to anti-smoking guidelines. The full picture of these assessments allows prediction of the course of anti-smoking treatment. High levels of motivation and self-efficacy are indicators of good outcomes compared with low motivation and reduced self-efficacy. In the same vein, craving (indicator of addiction) should be considered, the very high level of which predicts a more complex anti-smoking course, especially when accompanied by low motivation [27,28]. In other words, the indicator of addiction severity is not sufficient to predict the progress of the treatment pathway, but other factors, such as motivation, craving intensity and self-efficacy, are also needed.

This study has many characteristics of clinical studies and can be preparatory, precisely because of the methodological rigor used, to clinical evidence studies and, in some aspects, even to experimental studies. However, this study retains the genuineness of field studies and consequently of empirical evidence.

It turns out, however, that further studies are needed, not only to confirm what has been pointed out in this paper about the greater effectiveness of IATs compared to IPTs, but also to research the positive and negative factors, in remote treatments, in relation to the smoker’s personality and his or her clinical and social situation.

Conclusions

In conclusion, the present field study, which retains many characteristics of observational experimental research, highlights the usefulness of IATs, compared with IPTs. This suggests prospectively using IATs even after this health emergency. RATs specifically tend to give continuity to treatments given in the presence, most likely increasing their effectiveness.

IATs highlight that antitabagic treatment needs constant support, which complements the reinforcement of individual therapeutic interventions as well, increasing the effectiveness of nicotine dependence treatment compared to treatments done only in presence.

RATs could also be used to more effectively engage the family and social context with which the smoker interacts, and more generally the territorial social-health interaction. In this perspective, new scenarios would open up not only on the therapeutic level but also on the prevention level.

Further researches are appropriate, as in today’s post-modern society, the development of telemedicine is an increasingly current reality, to be used independently of pandemic emergencies.

Looking forward, distance interventions, of course structured with appropriate settings and rigorous methodologies, as proposed in this field study, can bring undoubted benefits to patients and overcome some difficulties such as, for example, remoteness or inability to access health facilities or centers at times other than those established in presence.

Remote interventions can also be used for supervisory consultations on the same treatments or to facilitate “network” integration among the various facilities and practitioners involved in taking care of the same patient.

Ultimately, these results encourage further clinical and experimental studies to develop integrated, i.e., in-presence and distance, anti-smoking treatments, that are increasingly tailored to the clinical needs of smokers.

Figures and tables

Figure 1.Steps of the anti-smoking method COFUP (Counseling-Assessment-Diary-Scheduled Smoking).

Table 1.Questionnaire used in the preliminary project survey.

Total n 34 smokers 1st group 2nd group
Minimum Maximum Mean Minimum Maximum Mean
Age 18 19.6 18.6 18 19.7 18.7
Age at starting smoking 12 18 14.7 12 18 14.2
Number of cigarettes (daily) 3 20 9.6 3 20 9.1
Table 2.Age and number of daily cigarettes in the two groups of student smokers.

Table 3.Questionnaire used for customer satisfaction evaluation.

Project outcome indicators Expected outcome % Achieved outcome %
Conducting at least one outreach event at a distance 12 16
Increased remote activity (counseling, information, etc.) 20 >20
Increase in users taken care with distance modalities 10 15.3
Increase in remotely processed therapeutic anti-smoking treatments 20 23
Table 4.Results according to the expected indicators.
Questions Percentage responses In reference to COVID-19
N. 1 YES = 60% NO = 6,7% DON’T KNOW = 33,3% Smoking as a risk factor (SI = 60%)
N. 2 more = 60% less = 3,3% the same = 33,4% quit smoking = 3,3% Increase in smoking (60%)
N. 3 isolation of social relationships = 20% economic crisis = 3.3% uncertainty of the future = 6.6% loss of previous well-being = 66%. school closure = 3.3% Prevalent stress, sadness, worries, fear and boredom (66%)
N. 4 YES = 76,6% NO = 23,4% DON’T KNOW = 0 Increased attendance at the smoke-free center (76.6%)
N. 5 YES = 70% NO = 0 DON’T KNOW = 30% Importance of online programs (YES = 70%)
N. 6 YES = 90% NO = 6,6% DON’T KNOW = 3,4% Online programs even after health emergency (SI =90%)
Table 5.Results of the preparatory survey for the project. Legend: Questions numbered 1 to 6 correspond to those described in the methods in Table 1.
Tests Strong % Mild % Low % Total %
Fagerström Test Nicotine Dependence - FTND 6.6 30 63.4 100
Marino’s motivational test 17.6 29.5 52.9 100
Self-Efficacy (SE) 11.2 58.8 30 100
Visual Addiction Scale - VAS 35.3 58.8 5.9 100
Table 6.Clinical characteristics of the sample. Legend: FTND = nicotine dependence assessment; Marino test = measure of motivation; SE = self-efficacy assessment; VAS = measure of craving.
Anti-smoking treatment Group 1 - Treated with IAT Group 2 - Treated with IPT
Result N % N %
Reduction 1/3 1 5.9 8 47.1
Reduction 2/3 7 41.1 3 17.6
Smoking cessation 8 47.1 5 29.4
Unchanged 1 5.9 1 5.9
Total 17 100 17 100
Table 7.Results of anti-smoking treatments. Legend: IAT = Integrated Anti-smoking Treatment, IPT = in-Presence anti-smoking treatment.
Questions Percentage responses In reference to the project
N.1 YES = 88.2% NO = 0 Partially = 11.8% Positive evaluation (YES = 88.2%)
N.2 YES = 67.6% NO = 14.7% Partially = 17.6% Importance of anti-smoking psychological support (YES = 67.6%)
N.3 YES = 47.1% NO = 11.8% Partially = 41.1% Cultural change (YES = 47.1%)
N. 4 YES = 82.4% Partially = 17.6 Importance of IAT (YES = 82.4%)
N. 5 YES = 76.4 NO = 0 Partially = 23.6 Extension of the project to other users (YES = 76.4)
N. 6 YES = 70.5 NO = 0 Partially= 29.5% Extension of the project to other institutions (YES = 70.5)
Table 8.Results of “customer satisfaction”. Legend: Questions numbered 1 to 6 correspond to those described in the methods of Tab 3.

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Affiliazioni

Francesco Tarantino

Psicologo Psicoterapeuta, Centro Antifumo di Copertino (LE), ASL Lecce Coordinatore della Società Italiana di Tabaccologia per Regione Puglia

Copyright

© SITAB , 2022

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