This article outlines a theoretical framework for research concerning secondhand smoke exposure (SHSe) prevention as a means to curtail the tobacco industry.
The Behavioral Ecological Model (BEM) assumes interlocking social contingencies of reinforcement (i.e., rewards or punishments) from the highest level of society (e.g., taxing cigarette sales) to physiological reactions to nicotine that influence smoking and SHSe. We review selected research concerning both policy and clinical efforts to restrict smoking and/or SHSe.
Research to date has focused on smoking cessation with modest to weak effects. The BEM and empirical evidence suggest that cultural contingencies of reinforcement should be emphasized to protect people from SHSe, especially vulnerable children, pregnant women, the ill, the elderly, and low-income adults who have not "elected" to smoke. Doing so will protect vulnerable populations from industry-produced SHSe and may yield more and longer-lasting cessation.
Interventions that reduce SHSe may serve as a Trojan horse to counter the tobacco industry. Future studies should: (a) guide policies to restrict SHSe; (b) develop powerful community and clinical interventions to reduce SHSe; (c) test the degree to which policies and other contexts enhance the effects of clinical interventions (e.g., media programs disclosing the disingenuous marketing by the industry); and (d) investigate the effects of all health care providers’ ability to reduce SHSe and generate an antitobacco culture, by advising all clients to avoid starting to smoke, to protect their children from SHSe, and to quit smoking.
Given the substantial health risks of smoking during pregnancy, and the potential of pharmacotherapy to enhance quit rates, a need exists to examine the utility of pharmacotherapy for smoking cessation during pregnancy.
We briefly review the first-line medications that are recommended for smoking cessation in nonpregnant adults. Additionally, we review the toxicity of tobacco smoke and the potential risks of pharmacotherapy as evidenced by animal studies. We review in more detail studies conducted in pregnant women, including (a) observational studies, (b) short-term safety and longer term uncontrolled studies, and (c) randomized controlled clinical trials (both effectiveness and efficacy studies).
Because the safety and efficacy of pharmacotherapy for smoking cessation during pregnancy have not been established, no definitive recommendations can be made on the topic. Effectiveness trials have shown that nicotine replacement therapy (NRT) enhances smoking cessation during pregnancy, but efficacy trials have not shown an advantage for NRT compared with placebo treatment. Small sample size or poor medication compliance (with either the dose or the duration of treatment) may contribute to lack of efficacy in placebo-controlled NRT trials. However, these trials showed that NRT did not adversely affect birth outcomes and increased birth weight. Based on these findings and the fact that all medications have some risk, psychosocial interventions should be the first treatment option for pregnant smokers. Additional research is needed to determine fully the risks and benefits of the various pharmacotherapies for smoking cessation during pregnancy.
Current smoking cessation treatments largely address pharmacological dependence on nicotine. New approaches are needed that address both nicotine dependence and psychological dependence on cigarettes as the source of nicotine. One such approach is the use of cigarettes with reduced nicotine content.
We reviewed the available literature on the use of reduced–nicotine content cigarettes as a cessation aid.
One case series study and trial data indicate that reduction in the level of nicotine in cigarette tobacco can reduce the level of nicotine dependence in smokers and do so without adverse effects on cardiovascular biomarkers or significant compensatory smoking. We identified three clinical trials (total n = 489) that suggest that smokers can dissociate nicotine delivery from the act of smoking if they use reduced–nicotine content cigarettes in combination with nicotine replacement therapy.
The identified studies point to a benefit but involved only a small number of participants and provide only limited data on long-term abstinence. More definitive evidence from larger trials with longer follow-up is needed to clarify the role of reduced nicotine cigarettes as an aid to smoking cessation.
Much of the existing research on smoking outcome expectancies has been guided by the Smoking Consequences Questionnaire (SCQ ). Although the original version of the SCQ has been modified over time for use in different populations, none of the existing versions have been evaluated for use among Spanish-speaking Latino smokers in the United States.
The present study evaluated the factor structure and predictive validity of the 3 previously validated versions of the SCQ—the original, the SCQ-Adult, and the SCQ-Spanish, which was developed with Spanish-speaking smokers in Spain—among Spanish-speaking Latino smokers in Texas.
The SCQ-Spanish represented the least complex solution. Each of the SCQ-Spanish scales had good internal consistency, and the predictive validity of the SCQ-Spanish was partially supported. Nearly all the SCQ-Spanish scales predicted withdrawal severity even after controlling for demographics and dependence. Boredom Reduction predicted smoking relapse across the 5- and 12-week follow-up assessments in a multivariate model that also controlled for demographics and dependence.
Our results support use of the SCQ-Spanish with Spanish-speaking Latino smokers in the United States.
This study examined whether children with cancer are exposed to measurable levels of passive smoke as assessed by parent report and laboratory measures of urine cotinine, an established biomarker of passive smoke exposure (PSE). It also determined whether parents/caretakers of young cancer patients can provide valid reports of their child's PSE during the child's treatment, by examining their association with urine cotinine measures.
Participants included 124 parents of a child with cancer who lived with at least one adult smoker in the home and was exposed to tobacco smoke in the home and/or car. Eligible patients were younger than 18 years of age, were receiving active treatment for cancer at a large pediatric oncology institution, were at least 30 days postdiagnosis, and did not smoke. Parents provided information about smoking and their child's PSE by responding to a series of questionnaires. Patients provided urine samples for cotinine analyses.
Findings showed that parents provided valid short-term accounts of their child's PSE in the context of their child's cancer treatment. Parent reports of PSE showed moderately strong positive relationships with urine cotinine levels which were stronger for reports provided by parents who smoked compared with nonsmoking parents.
Parent reports of PSE were validated by positive and significant associations with urine cotinine. Reports provided in the context of possible verification by biomarker assays can provide sufficiently accurate estimates of PSE to serve as outcome measures for clinical research and clinical care in a pediatric cancer setting.
Empirical work has demonstrated a linkage between smoking rate and anxious arousal symptoms. However, there is little understanding of the mechanisms underlying this association.
The present investigation examined the role of coping-based smoking motives in terms of mediating the relations between smoking rate and anxious arousal symptoms and anxious arousal symptoms and smoking rate among a sample of treatment-seeking adult smokers (N = 123; 84 women; Mage = 45.93, SD = 10.34).
Results indicated that coping motives mediated the relations between smoking rate and anxious arousal symptoms and anxious arousal symptoms and smoking rate.
These results suggest that coping motives play a key role in terms of better understanding the association between smoking rate and anxious arousal symptoms.
Tobacco and alcohol are frequently co-abused, but the mechanism underlying this interaction is not well understood. Experimental data on the influence of nicotine upon alcohol consumption are not conclusive.
To elucidate the role of nicotine in alcohol consumption, alcohol-experienced rats were submitted to consecutive phases of forced abstinence from alcohol, followed by relapses, in which their alcohol consumption was measured in a 2-bottle choice test. Rats were assigned to one of 4 groups: (a) "Control," which received daily saline injections during both the abstinence and relapse phases, (b) "Nic. All," which received nicotine injections during both phases, (c) "Nic. Abst.," which received nicotine during the abstinence phase only, and (d) "Nic. Rel.," which received nicotine during the relapse phase only. The nicotine doses (0.4, 0.6, and 0.8 mg/kg) were administered in an escalating fashion. Alcohol consumption was measured 3 times per day.
Overall, the rats treated daily with nicotine during both the abstinence and relapse phases (Nic. All) significantly increased their alcohol intake compared with the rats treated daily with vehicle alone (Control). Similarly, rats treated with nicotine during the alcohol abstinence phase only (Nic. Abst.) also increased their alcohol consumption. However, rats treated with nicotine during the alcohol relapse phase only (Nic. Rel.) decreased their alcohol intake. In addition, a more exhaustive analysis showed critical differences in patterns of alcohol consumption during the first hour and the first day of alcohol access.
Taken together, we provide evidence that depending on the timing of exposure, the same dose of nicotine can have opposite effects on alcohol consumption.
Smoking is highly prevalent among lesbian, gay men, bisexual, and transgender (LGBT) persons and contributes to health disparities. Guided by the theory of planned behavior (TPB), we identified beliefs related to attitudes, perceived behavioral control, and subjective norms, as well as LGBT-specific variables, to explain variance in intention to quit smoking in the next 6 months in LGBT smokers.
Individual interviews (n = 19) identified beliefs about quitting smoking and LGBT-salient variables and aided in survey development. Surveys were sent to a random sample from an LGBT community center's mailing list and center attendees, with a 25.4% response rate. Bivariate and multivariate analyses were conducted with the final sample of 101 smokers.
No sociodemographic or LGBT-specific variables beyond the TPB constructs were related to intention to quit smoking. A multivariate TPB model explained 33.9% of the variance in quitting intention. More positive attitudes and specific beliefs that cessation would make smokers feel more like their ideal selves and improve health and longevity were related to greater intention to quit (p values < .05). Subjective norm and perceived behavioral control were marginally significant, with perceived approval of partners and others and beliefs that life goal achievement would make it easier to quit positively related to intention. Depression and stress levels were high.
This is among the first studies to examine theoretically grounded variables related to intention to quit smoking in LGBT smokers. We identified specific behavioral, normative, and control beliefs that can serve as intervention targets to reduce smoking in the LGBT community.
TaqIA polymorphism, a genetic variant associated with the expression level of dopamine D2 receptors in the brain, has been linked to various aspects of smoking behavior, including smoking prevalence, affective withdrawal symptoms, and smoking cessation outcome. However, its involvement in motivation to smoke cigarettes has not been elucidated.
The present study examined the possible differences in self-reported reasons to smoke and craving for smoking in 160 smokers participating in a clinical trial.
Individuals with at least one A1 allele of the TaqIA polymorphism were more likely to report smoking for stimulating effects and to reduce negative affect compared with those lacking an A1 allele. The association of the A1 genotype with a higher probability and stronger motive to smoker to enhance cognitive functioning was evident in female but not in male smokers. Female A1 carriers also expected a greater likelihood of smoking for pleasure than those without an A1 allele. A1 subjects reported stronger craving for cigarettes during early days and the last phase of a 6-week abstinence period.
These results support the idea that dopaminergic transmission plays an important role in the neurobiological basis of reasons for smoking and that the TaqIA variant is one of the genetic factors underlying individual differences in these aspects. These findings also have implications for improving treatment strategies to help individuals quit smoking by controlling their motivation to continue cigarette consumption.
Smoking cessation counseling by health professionals is an effective approach to increase cessation rates among smokers. To guide the development of training and educational interventions, we surveyed six health professional groups including general practitioners (GPs), pharmacists, dentists, dental hygienists, nurses, and respiratory therapists, in order to describe current practices and identify the correlates of smoking cessation counseling.
Self-administered questionnaires were mailed to 500 persons randomly selected from the membership lists of active licensed professionals in each health professional group in Québec.
Response proportions ranged from 52% (nurses) to 70% (dental hygienists). Compared with other groups, GPs and pharmacists undertook more counseling with patients ready to quit. GPs and respiratory therapists undertook more counseling with patients not ready to quit. Three factors emerged consistently across most groups as positively associated with counseling, including the belief that counseling is the role of health professionals, perceived self-efficacy to engage in effective counseling, and knowledge of community cessation resources.
The correlates of cessation counseling are similar across health professional groups. Interventions that address beliefs that cessation counseling is the role of health professionals, self-efficacy to provide effective counseling, and knowledge of community resources may result in improved cessation counseling practices among health professionals.
This study examined cognitive barriers that might prevent cigarette smokers who are interested in quitting from calling a smoking quitline.
Using qualitative and quantitative methods, we developed a 53-item inventory of possible cognitive barriers to quitline access. A total of 641 daily smokers who reported high intentions to stop smoking in the next 30 days completed this inventory and were then prompted to call a toll-free smoking quitline (800-QUIT NOW) on 3 occasions. Two months later, they completed a follow-up phone interview to assess use of the quitline, quit attempts, and smoking status.
Exploratory and confirmatory factor analysis of the barrier items revealed a 5-factor solution: stigma, low appraisal of the service, no need for assistance, poor fit with the service, and privacy concerns. Endorsements of barrier factors were generally low. Although several barrier factor scores predicted concurrent intentions to call a quitline in the near future, none prospectively predicted calling the quitline by 2-month follow-up.
Cognitive barriers to use of quitlines remain elusive.
Smoking is associated with a systemic inflammatory response. However, the role of genetic predisposition is not well known. We assessed whether circulatory acute phase reactants were associated with smoking and whether or not the association was modified by the major cytokine gene of the acute phase reaction, interleukin-6 (IL-6).
In total, 1,003 postmyocardial infarction patients were recruited in six European cities and six repeated clinical examinations performed. C-reactive protein (CRP), interleukin 6 (IL-6), and fibrinogen levels were assayed at 5,659 subject visits. Genotyping of single nucleotide polymorphisms was performed in the IL-6 gene.
Cumulative smoking (pack-years) and time since smoking cessation were strongly associated with blood levels of all three inflammatory markers. Among subjects without any respiratory disorder, these associations remained statistically significant for CRP and IL-6. A polymorphism in the IL-6 gene (rs2069840) showed an interaction with smoking on CRP (p < .001) and IL-6 (p = .049) peripheral levels.
These results indicate a potential role of the IL-6 gene in the inflammatory response associated with smoking and suggest rs2069840 polymorphism deserves attention.
Clinical trials that do not collect data on tobacco use/exposure may not adequately assess the efficacy and effectiveness of experimental treatments.
A cross-sectional study of interventional trials cited on
Only 3 trials (7%) reported routine collection of tobacco use information at baseline and no trial reported monitoring tobacco use during treatment follow-up. None of the 3 trials collecting tobacco data reported using exposure information in analysis of treatment effects. Survey respondents suggested that uncertainty about the relevance of tobacco exposure to therapeutic efficacy, ambivalence about how to incorporate such data into analyses, insufficient resources for collecting such information, and uncertainty about the validity of assessment methods might be reasons why tobacco use is not routinely assessed.
Additional studies that address a fuller range of cancers, therapies, disease states, and clinical environments are needed to fully define the extent of this data lapse. Providing clinicians and trialists with appropriate tools for tobacco use assessment and encouraging them to collect such information about patients during treatment and follow-up may offer a simple cost-effective way to improve the quality and consequences of cancer care for every patient.
Research on effective teen smoking cessation interventions is critical to reducing the tobacco-related disease burden and risk of lifetime negative health outcomes for youth. However, informed consent procedures requiring active parental consent may restrict or influence teen participation in critical teen cessation programs.
Not On Tobacco (N-O-T) is a teen smoking cessation intervention that has been implemented under both active parental consent and passive parental consent conditions. The present study determined if there are differences in characteristics of youth enrolled under each condition. Data were available for active consent (n = 968) and passive consent (n = 4,924) participants aged 14–18 who completed the N-O-T program between 1998 and 2006 across several states.
Participants enrolled under active consent conditions were more likely to be older, White/non-Hispanic, live in father-only or grandparent-headed household, start smoking at an earlier age, smoke more on weekdays, have previous unsuccessful quit attempts, and have siblings and friends who smoke. Additional differences were found between active and passive consent conditions in motivation to quit smoking, confidence in quitting, and stage of change.
Results highlight important differences between youth who enroll in a smoking cessation program under active and passive consent conditions, often a distinguishing feature of research and non-research implementation.
Uncertainty exists about how best to measure daily cigarette consumption. Two common measures are timeline followback (TLFB), which involves structured, prompted recall, and ecological momentary assessment (EMA), which involves recording consumption, as it occurs, on a handheld electronic device.
We evaluated the agreement between TLFB and EMA measures collected for 14 days prior to the target quit date from 236 smokers in a smoking cessation program. We performed a Bland–Altman analysis to assess agreement of TLFB and EMA using a regression-based model that allows for a nonuniform difference between methods and limits of agreement that can vary with the number of cigarettes smoked.
For pairs of measurements taken on the same smoker, TLFB counts were on average 3.2 cigarettes higher than EMA counts; this difference increased for larger numbers of cigarettes. Using a model that allows for variable limits of agreement, the width of the 95% interval ranged from 8.7 to 61.8 cigarettes, with an average of 26.4 cigarettes. Variation between the methods increased substantially for larger cigarette counts, leading to wider limits and poorer agreement for heavy smokers.
Throughout the measurement range, the estimated limits of agreement were far wider than the limits of clinical significance, defined a priori to be 20% of the number of cigarettes smoked. We conclude that TLFB and EMA cannot be considered equivalent for the assessment of daily cigarette consumption, especially for heavy smokers.
Smoking rates are higher among lesbian/gay/bisexual (LGB) than heterosexual (HT) individuals. However, there is scant information regarding smoking cessation treatments and outcomes in LGB populations. This study examined abstinence outcome in response to a high intensity smoking cessation program not specifically tailored to LGB smokers.
A total of 54 gay/bisexual (GB) and 243 HT male smokers received 8-week open treatment with nicotine patch, bupropion, and counseling. Participants reported biologically verified abstinence at multiple time points during the study.
Demographic, smoking, and psychological characteristics at baseline were similar according to sexual orientation. During the first 2 weeks after quit day, abstinence rates were higher among GB smokers (Week 1: GB = 89%, HT = 82%; Week 2: GB = 77%, HT = 68%; ps < .05); abstinence rates converged subsequently, becoming nearly identical at the end of treatment (Week 8, GB = 59% vs. HT = 57%). In mixed effects longitudinal analysis of end-of-treatment outcome, sexual orientation (b = 1.40, SEM = 0.73, p = .056) and the Sexual Orientation x Time interaction (b = –0.146; SEM = 0.08, p = .058) approached statistical significance, reflecting the higher initial abstinence rates among GB smokers and the later convergence in abstinence rates by sexual orientation.
This first report comparing smoking cessation treatment response by sexual orientation found higher initial and similar end-of-treatment abstinence rates in GB and HT smokers. Further work is needed to determine whether these observations from GB smokers who displayed a willingness to attend a non-tailored program and broad similarity with their HT counterparts in many baseline characteristics will replicate in other groups of GB smokers.