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.
Smoke-free homes are known to reduce exposure to harmful secondhand smoke. Recent studies suggest that they may also positively affect smoking behavior among smokers themselves.
We review the literature on the effect of smoke-free homes on adult smoking behavior. The literature search included database (PubMed) and manual searches of related articles and reference lists for English-language studies published from 1 January 1990 to 16 November 2008.
We identified 16 cross-sectional and 7 longitudinal studies of the population-level association of smoke-free homes with adult smoking behavior. Additional studies provided population estimates of trends in and correlates of smoke-free homes. Prevalence of smoke-free homes varies but has been increasing over time in the countries studied and was greater among smokers who were younger, of higher income or educational attainment, smoked fewer cigarettes per day, or lived with a nonsmoking adult or child. Both longitudinal and cross-sectional studies showed that smokers who had or who newly implemented a smoke-free home were significantly more likely to make a quit attempt and to be abstinent, after controlling for confounding factors. In longitudinal studies, those who continued to smoke had a modest, but significant, decrease in cigarette consumption at follow-up.
There is strong and consistent population-level evidence that a smoke-free home is associated with increased smoking cessation and decreased cigarette consumption in adult smokers. As they not only reduce exposure to secondhand smoke but also increase cessation rates, promotion of smoke-free homes should be a key element in tobacco control programs.
Bupropion and cognitive–behavioral treatment (CBT) for depression have been used as components of treatments designed to alleviate affective disturbance during smoking cessation. Studies of treatment-related changes in precessation affect or urges to smoke are needed to evaluate the proposed mechanisms of these treatments.
The present report examines affective trajectories and urges to smoke prior to, on quit day, and after quitting in a sample of 524 smokers randomized to receive bupropion versus placebo and CBT versus standard smoking cessation CBT.
Bupropion and/or CBT did not affect the observed decreases in positive affect and increases in negative affect prior to cessation. However, on quit day, observed levels of negative affect and urges to smoke were diminished significantly among individuals receiving bupropion. Decreases in positive affect prior to quitting, lower levels of positive affect, and increased levels of negative affect and urges to smoke on quit day were each related to higher risk of smoking lapse. Depression proneness was an independent predictor of lower positive affect and higher negative affect but did not moderate the effects of bupropion on outcomes. In mediational analyses, the effect of bupropion was accounted for in part by lower negative affect and urges to smoke on quit day.
Results support the efficacy of bupropion in reducing relapse risk associated with urges to smoke and negative affect and suggest the need to better understand the role of low positive affect as a risk factor for early lapse.
The two largest U.S. cigarette manufacturers introduced Swedish-style low-nitrosamine smokeless tobacco (snus) to several U.S. test markets in summer 2006. Since then, snus brands and test markets have proliferated.
This article assesses consumer response by analyzing data from the 2006 and 2007 Indiana Adult Tobacco Survey (IATS), a statewide telephone survey of 3,544 adults. During those years, the IATS included questions on awareness and trial of Camel Snus and Taboka. Analyses examined rates and predictors of awareness and trial statewide, and within the central Indiana test market.
Nineteen percent of Indiana adults were aware of either Taboka or Camel Snus in 2006 and 2007. Estimates are larger (29%) for central Indiana and larger still (70%) for central Indiana smokers. Trial of snus, however, was very low (1.5% statewide), except among male smokers in central Indiana, 20% of whom are estimated to have tried it. Multivariate analyses showed that trial was more likely among men than women (odds ratio [OR] 13.85), residents of central Indiana than those farther from Indianapolis (OR 2.96), recipients than nonrecipients of tobacco promotions (OR 6.08), and those believing that smokeless tobacco is less harmful than cigarettes compared with those who believe it is equally or more harmful (OR 3.86).
Results from this study suggest substantial initial interest in the new products among male smokers in this test market, especially those who receive promotional mailings from tobacco companies, which often include coupons for free or discounted products.
This study examined the psychometric properties of the Brazilian versions of the Fagerström Test for Nicotine Dependence (FTND) and the Heaviness of Smoking Index (HSI).
The test–retest reliability of the FTND was assessed in a sample of 61 smoking university students, with a 15-day interval between assessments. The interrater reliability was examined in 30 smoking patients of a psychosocial care center for alcohol and drug users (PCC-AD). The reliability coefficient was estimated by the kappa and intraclass correlation coefficients. The predictive validity, internal consistency, and factor structure of the FTND and the HSI were evaluated by factor analysis in 271 smokers treated at an emergency unit and at the PCC-AD. The gold standard was the nicotine dependence criteria of DSM-IV, as assessed by the Structured Clinical Interview for DSM-IV.
The FTND showed high reliability, with correlation coefficients of .92 for test–retest reliability and .99 for interrater reliability. Both the FTND and the HSI presented high levels of sensitivity and specificity. The internal consistency evaluation yielded a Cronbach’s alpha coefficient of .83 for the FTND and of .56 for the HSI. An exploratory factor analysis found 2 factors in the FTND, which were validated by a confirmatory factor analysis.
The results obtained in this study confirm the validity and reliability of the Brazilian versions of the FTND and the HSI.
Retrospective recall of smoking during pregnancy is assumed to be substantially biased, but this has rarely been tested empirically.
We examined the validity of an interview-based retrospective recall more than a decade after pregnancy, in a cohort with repeated, multimethod characterization of pregnancy smoking (N = 245). Retrospective smoking patterns were examined in relation to prospective reported and biological estimates of overall and trimester-specific smoking status and intensity. We also compared characteristics of women whose smoking status was misclassified by either prospective or retrospective measures with women whose status was congruent for nonsmoking across timepoints.
In general, sensitivity and specificity of recalled smoking were excellent relative to both prospective self-reported and cotinine-validated smoking status and trimester-specific intensity. However, measures were less congruent for amount smoked for women who recalled being heavy smokers. Further, retrospective measures captured some smokers not identified prospectively due to smoking that occurred prior to assessments. Women who would have been misclassified as nonsmokers based on either prospective or retrospective assessment differed significantly from congruently classified nonsmokers in a number of maternal, family, and neighborhood, but not child behavior, characteristics.
When epidemiological studies of the impact of smoking in pregnancy use retrospective methods, misclassification may not be a significant problem if prenatal smoking is assessed in terms of the pattern across pregnancy. This type of interview-based recall of pregnancy smoking may be relatively accurate, although optimal measurement should combine retrospective and prospective self-report and biological assays, as each provide unique information and sources of error.
Snus is an oral snuff consisting of moist finely ground tobacco which is available in a loose form or with portions of the tobacco sealed in small sachets termed "pouches." The product has a long history of use in Sweden. Currently, there is very little published information on levels of consumption and usage behaviors for snus in Sweden. The objective of this study was to obtain data on the frequency and duration of loose and pouched snus consumption in Sweden and investigate usage behaviors.
Telephone surveys of snus users randomly selected from telephone directories in all regions of Sweden were conducted in 2007 and 2008. In total, 2,914 respondents answered questions on snus usage, including the types of products used and the quantity and frequency of use.
The majority of respondents (96%) used either pouched or loose snus alone. A minority (12.6%) reported dual use of smokeless and combustible tobacco products. Average daily consumption was 11–12 g for pouched snus and 29–32 g for loose snus. The typical duration of use of each pouch/portion was 60–70 min.
This survey has provided new insights into contemporary snus use in Sweden, such as the marked differences in daily consumption between loose and pouched snus, length of time that snus users typically keep pouches in the mouth, differential patterns of use in males and females, and the simultaneous use of multiple pouches in a small proportion of users.
Understanding motivation to continue smoking may help the development of smoking cessation interventions. However, little information exists on the prevalence of specific motives for smoking in representative samples of smokers. This study examined smokers’ reports of their motives for continued smoking in an English general population sample.
A total of 2,133 smokers participating in monthly cross-sectional surveys (the Smoking Toolkit Study) identified which, if any, of the following motives they believed were important in keeping them smoking: enjoyment, stress relief, weight control, boredom relief, aid to concentration, aid to socializing, pain relief, liking being a smoker, and feeling bad when not smoking. Associations between these motives and gender, age, social grade, Fagerström Test for Nicotine Dependence, and quit attempts in the last year were examined using logistic regression.
Enjoyment and stress relief were the most commonly reported motives (51% and 47%, respectively). Women reported stress relief and weight control more often than men, whereas men were more likely to report enjoyment and liking being a smoker. Older smokers reported enjoying smoking and liking being a smoker more than younger smokers but were less likely to report socializing and stress relief as important motives. Not having made a quit attempt in the last year was associated with enjoying smoking and liking being a smoker. Higher dependence was associated with a greater number of reported motives.
While smoking for stress relief is common, perceptions of enjoyment of smoking and positive smoker identity may be the key motives that inhibit attempts at cessation.
Despite the strong association between smoking and posttraumatic stress disorder (PTSD), mechanisms influencing smoking in this population remain unclear. Previous smoking research has largely examined PTSD as a homogenous syndrome despite the fact that PTSD is composed of four distinct symptom clusters (i.e., reexperiencing, effortful avoidance, emotional numbing, and hyperarousal). Examination of the relationship between smoking and PTSD symptom clusters may increase understanding of mechanisms influencing comorbidity between smoking and PTSD. The goals of the present study were to (a) examine the influence of overall PTSD symptom severity on likelihood of smoking and smoking heaviness and (b) examine the influence of each PTSD symptom cluster on smoking.
Participants (N = 439) were Operation Iraqi Freedom/Operation Enduring Freedom combat veterans referred to VA mental health services.
Multinomial logistic regression was chosen to accommodate a three-level outcome, in which the likelihood of being a nonsmoker was compared with (a) light smoking (1–9 cigarettes/day), (b) moderate smoking (10–19 cigarettes/day), and (c) heavy smoking (≥20 cigarettes/day). Results showed that veterans with higher levels of overall PTSD symptomatology were more likely to endorse heavy smoking (Wald = 4.56, p = .03, odds ratio [OR] = 1.65). Veterans endorsing high levels of emotional numbing were also more likely to endorse heavy smoking (Wald = 6.49, p = .01, OR = 1.81); all other PTSD symptom clusters were unrelated to smoking.
The association between emotional numbing and heavy daily smoking suggests that veterans with PTSD may smoke to overcome emotional blunting following trauma exposure.
No previous studies document the effects of both comprehensive tobacco control and its defunding on youth smoking. This study tests the effect of the youth-focused Minnesota Youth Tobacco Prevention Initiative (MYTPI) and its shutdown on youth smoking and determines whether these effects differed by age.
The Minnesota Adolescent Community Cohort is a population-based, observational study designed to evaluate the MYTPI. The sample included cohorts of youth aged 12–16 years at baseline in Minnesota (N = 3,636) and a comparison group in six other Midwestern states (n = 605). Biannual surveys assessed youth smoking from October 2000, 5 months after the MYTPI launch, through October 2005, 2 years postshutdown. Adjusted piecewise linear trajectories predicted smoking stage (measured on a 1–6 continuum) comparing Minnesota with a comparison group during the MYTPI (Slope 1) and postshutdown (Slope 2) for each baseline age cohort. Analysis then compared baseline age cohorts with each other by centering their intercepts on age 16.
Neither slope of smoking stage differed between Minnesota and comparison groups, showing no period effects for the MYTPI or shutdown. However, younger cohorts, with early teen experience of MYTPI, smoked less than older cohorts by the same age. Mean smoking stage at age 16 differed by almost a half stage from the youngest (2.04) to the oldest (2.46) age cohort.
The study offers no evidence of period effects for the MYTPI or its shutdown. Design limitations, national or continued post-MYTPI statewide tobacco control efforts, or program flaws could explain the findings.
Passive recruitment strategies relying on smoker-initiated contact probably contribute to particular groups of smokers using quitlines. Compared with the smoking population, smokers who call quitlines are more likely to be female, younger, higher educated, more addicted, quit previously, and motivated to quit. Quitlines could adopt new recruitment approaches such as active telephone recruitment involving recruiter-initiated contact, since this may enroll a broader representation of smokers. This study explored acceptability of active telephone recruitment to quitline support, smokers’ use, and acceptability of assistance and predictors of acceptability.
Smokers (N = 1,562) randomly selected from the New South Wales telephone directory were actively recruited by telephone into a randomized controlled trial that offered proactive telephone counseling (n = 769) or self-help materials (control: n = 793). Overall, 1,369 completed the 4-month postrecruitment interview, which examined acceptability.
More than 90% of 4-month interview respondents found active telephone recruitment to cessation assistance acceptable. Of smokers allocated to proactive telephone counseling (n = 769), 90% accepted at least one and 65% three or more counseling calls. Of control participants who completed the 4-month interview, 84% read at least some self-help materials. Proactive telephone counseling recipients were significantly more likely than self-help material users to find the advice useful. Few characteristics predicted acceptability of proactive telephone counseling or self-help materials, suggesting that many types of smokers actively recruited by telephone are receptive to support.
Active telephone recruitment could potentially enroll a broader representation of smokers to quitline services. Given these smokers are receptive to cessation assistance, quitlines should consider active telephone recruitment.
There are about 4,800 different chemical constituents in cigarette smoke. Therefore, the total systemic exposure evaluation of the population of smokers to cigarette smoke is challenging. Measurement of biomarkers as surrogates of cigarette smoke constituents is a realistic approach to assess exposure.
To estimate cigarette smoke exposure of the U.S. smoker population.
Stratified, cross-sectional, multicenter design (39 sites in 31 states); 3,585 adult cigarette smokers and 1,077 nonsmokers. Biomarkers were determined from 24-hr urine collections or blood samples. Population estimates were generated by weighting sample data with weights from a large U.S. probability sample (Behavioral Risk Factor Surveillance System).
The adult smoker population estimates for tobacco-specific biomarkers were nicotine equivalents 13.3 mg/24 hr (SE 0.14), serum cotinine 184 ng/ml (1.8), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol 439 ng/24 hr (5.5). The population estimates for smokers and nonsmokers for nontobacco-specific biomarkers were 1-hydroxypyrene 317 (6.8) and 110 (7.1) ng/24 hr, 4-aminobiphenyl Hb adducts 43.1 (1.04) and 11.4 (1.5) pg/g Hb, carboxyhemoglobin 5.26(0.04) in percent of hemoglobin saturation and 1.45(0.02), 3-hydroxypropylmercapturic acid 2,030 (24) and 458 (17) µg/24 hr, monohydroxy-butenyl-mercapturic acid 3.61 (0.1) and 0.30 (0.02) µg/24 hr, and dihydroxy-butyl-mercapturic acid 556 (4.9) and 391 (5.5) µg/24 hr. On average, young adult smokers had lower exposure than older smokers; female smokers had lower exposure than males, and Black smokers had lower exposure than Whites.
This study estimated the population exposure to cigarette smoke constituents in adult U.S. smokers and identified significant differences between subpopulations. The data may serve as a reference for monitoring the impact of changes in cigarette consumption and the introduction of potentially reduced exposure cigarettes.
Adolescents’ relationships can play an influential role in adopting, maintaining, or changing health behaviors. Previous research has suggested that adolescent dating is a risk factor for both concurrent and prospective tobacco use. This study extends previous research by examining whether a partner's smoking status moderated the relationship between dating and adolescent smoking.
Participants were 1,263 9th and 10th grade students who took part in a longitudinal study investigating the social and emotional contexts of adolescent smoking patterns. Adolescents were recruited into the longitudinal study based on prior smoking history. The presence of a romantic partner, the partner's smoking status, and the adolescents’ smoking behavior were assessed at baseline and at 15 months.
Our findings indicated that a change in dating status from not dating to having a partner significantly increased the odds of the adolescent smoking at 15 months but significantly only for those who dated a smoker. This effect was especially pronounced among boys. All boys who dated a smoker smoked themselves. Among adolescents who smoked at 15 months, there was also a strong protective effect among boys for dating a nonsmoker, compared with either those who did not have partners or those with smoking partners; boys with nonsmoking partners smoked significantly less than those with partners who smoked or those without partners.
These results highlight the importance of considering the smoking status of the romantic partner in the smoking–dating relationship in adolescents.
There are 1.1 billion smokers worldwide. Traditional smoking cessation methods, such as nicotine replacement therapy and smoking cessation groups, yield between 14% and 27% abstinence rates at 6 months. Evidence-based Internet interventions with comparable abstinence rates could be a powerful global tool to reduce tobacco-related morbidity and mortality.
We report a randomized control trial in which 500 Spanish-speaking and 500 English-speaking adult Internet users, smoking at least 5 cigarettes/day and intending to quit in the next month, were recruited online from 68 countries. Consenting participants who completed baseline measures, logged cigarettes smoked on 3 days within a week, and set a quit date were randomized to four conditions. Each condition added new elements: Condition 1 was the "Guía Para Dejar de Fumar," a static National Cancer Institute evidence-based stop smoking guide; Condition 2 consisted of Condition 1 plus E-mail reminders to return to the site; Condition 3 consisted of Condition 2 plus mood management lessons; and Condition 4 consisted of Condition 3 plus a "virtual group" (an asynchronous bulletin board). Main outcome measures were 7-day point prevalence abstinence at 1, 3, 6, and 12 months after initial quit date.
There were no significant differences among the four conditions. The overall 12-month 7-day abstinence rates were 20.2% for Spanish speakers and 21.0% for English speakers when those with missing data were assumed to be smoking.
Internet smoking cessation interventions with such abstinence rates provided globally in additional languages could contribute substantially to tobacco control efforts.
The present study expands previous research on early experiences with tobacco by using a Multiple Indicator Multiple Causes (MIMIC) model, which permits combining indicators tapping into pleasant experiences into one latent construct and those indicators of unpleasant experiences into another latent construct.
A sample of 458 participants was recruited via newspaper advertisements. Response to early experimentation with cigarettes was assessed using the Early Smoking Experiences questionnaire, in which participants were asked the following question: "The first time you tried cigarettes, did you experience any of the following? (pleasurable and displeasurable sensations [overall], pleasurable rush or buzz, dizziness, relaxation, nausea, cough, difficulty inhaling)." These experiences were rated on a scale ranging from 1 = none to 4 = intense.
The MIMIC model revealed that current smoking status and age of initial experimentation with cigarettes were significantly associated with both early pleasant and unpleasant experiences (p < .05). African Americans were less likely than Whites to have early unpleasant experiences (p < .05). No association was found between race and early pleasant experiences.
Our findings are consistent with the inferences that pleasant experiences in response to early experimentation with smoking lead to regular smoking and that positive experiences play a stronger role than negative experiences in the transition to regular smoking. Our study also demonstrates that the MIMIC model is pertinent and practicable in nicotine and smoking research. We recommend it as a useful tool for identifying endophenotypes related to nicotine dependence and tobacco use latent constructs.
Few studies have assessed the association between exposure to movie smoking and urge to smoke under real-world conditions.
We conducted exit interviews with 4,073 movie patrons, of whom 2,817 were aged 18 years or older. Some 536 were smokers and had complete data. Subjects had exited 26 movies, of which 12 contained smoking. We used least squares regression to assess the association between exposure to movie smoking and urge to smoke (scale range 0–10), controlling for movie rating, age, sex, heaviness of smoking index (HSI, range 0–6), and time since last cigarette smoked.
Median age was 27 years and 52% were female. Median urge to smoke level at movie exit was 7. The dose–response between higher categories of movie smoking and median urge to smoke was one point for two lower categories (1–11 and 11–54 s) and two for the highest category (≥55 s), but these differences were not statistically significant. In the multivariate analysis, attendance of a movie with smoking was associated with a 0.81-point increase (95% CI = 0.46–1.16) in urge to smoke. For comparison, an HSI score of 3 (vs. 0) was associated with a 2-point increase in urge to smoke.
In this sample of adult smokers, exposure to movie smoking was associated with higher urge to smoke after the movie, independent of movie rating. The effect size was consistent with responses seen in cue reactivity experiments. Exposure to movie smoking may affect urge to smoke among adult smokers.
A growing literature suggests that anhedonia—an affective dimension related to the inability to experience pleasure—is associated with poor smoking cessation outcomes. Despite these findings, research of the motivational mechanisms linking anhedonia and smoking has been limited. Accordingly, the present study examined (a) relationships between anhedonia and motivationally relevant smoking characteristics and (b) whether anhedonia moderated the effects of tobacco deprivation on appetitive and aversive aspects of smoking urges.
Smokers (N = 212; ≥5 cigarettes/day) first attended a baseline session during which measures of anhedonia and smoking characteristics were completed. Prior to a subsequent experimental session, a portion of participants were randomized to one of two groups: (a) 12-hr tobacco deprivation before the session (n = 51) and (b) ad libitum smoking (n = 69).
Smokers with higher levels of anhedonia reported a greater number of past failed quit attempts and a higher proportion of quit attempts that ended in rapid relapse within 24 hr, rs > .20, ps < .05. Anhedonia did not consistently correlate with smoking heaviness, chronicity, and dependence motives. Anhedonia significantly moderated the influence of tobacco deprivation on appetitive smoking urges, such that deprivation effects on appetitive urges were stronger in high anhedonia smokers (β = .64) than in low anhedonia smokers (β = .23). Anhedonia did not moderate deprivation effects on aversive smoking urges. This pattern of results remained robust when controlling for baseline negative affect.
These findings elucidate anhedonia’s link with smoking relapse and could be useful for developing cessation interventions for anhedonic smokers.
Male and female never-smokers stratified on parental history of smoking were tested for possible differences in susceptibility to the hedonic effects of nicotine.
We recruited nicotine-exposed never-smokers with two never-smoking biological parents (PH–) or two ever-smoking biological parents (PH+). After completing a baseline assessment battery focusing on conditions or behaviors associated with smoking, participants were tested for subjective and hedonic effects in response to administration of three different nicotine doses (0.0, 0.5, and 1.0 mg) via nasal spray. Physiological and biochemical reactivity also was monitored.
PH+ were significantly more likely to report having experienced a "buzz" upon early smoking experimentation and to have histories of alcohol abuse and alcoholism; they also scored higher on disordered eating. In response to nicotine dosing, PH+ reported an increase in depressed mood, compared with a minimal response in PH–, in keeping with our expectation that nicotine would have more pronounced effects in PH+. Regardless of parental history, women reported experiencing greater anxiety in response to the highest nicotine dose, compared with men.
Further exploration in larger samples, using more stringent selection criteria, a wider range of measures, and a less aversive dosing method, may provide a full test of the possible utility of the parental history model for illuminating biobehavioral mechanisms underlying response to nicotine. Also important would be broadening the scope of inquiry to include comparisons with ever-smokers to determine what protected PH+ from becoming smokers, despite the presence of factors that might be expected to decrease resilience and increase susceptibility.
Previous studies have reported that smoking abstinence rates are increased when nicotine skin patch treatment is initiated prior to the target quit smoking date, as compared with conventional treatment beginning on the quit date. We hypothesized that smoking in the presence of continuous levels of nicotine would attenuate the reinforcing effects of cigarette smoking and lead to a decline in dependence on inhaled nicotine, thus facilitating cessation.
This study involved four groups of smokers (n = 100 per group) who received either nicotine patch (21 mg/24 hr) or placebo patch treatment for 2 weeks before the quit smoking date, and during this period, smoked their usual brands of cigarettes or switched to low-tar and nicotine cigarettes: a 2 (nicotine patch) x 2 (cigarette type) factorial design. From the quit date on, all groups received standard nicotine patch treatment, consisting of 6 weeks of 21 mg/24 hr, 2 weeks of 14 mg/24 hr, and 2 weeks of 7 mg/24 hr. Abstinence was defined as self-report of no smoking from the quit date on, confirmed by expired-air carbon monoxide.
Continuous abstinence rates were approximately doubled by precessation nicotine patch treatment. The treatment mainly benefited smokers with lower levels of dependence, based on Fagerström Test for Nicotine Dependence score. All treatments were well tolerated.
In view of these findings and similar results from previous studies, current labeling of the nicotine patch, which recommends using nicotine replacement therapy only after the quit date, should be reexamined.
Recent genetic evidence has implicated nicotine as a possible cause of cancer, suggesting the need to examine the potential contributions of nicotine itself to cancer versus the confounding effects of addiction and thus exposures to known carcinogens. The objective of this study was to examine the relationship between nicotine replacement therapy, smoking, and cancer outcomes.
The Lung Health Study enrolled 5,887 participants in a randomized trial to prevent chronic obstructive pulmonary disease. The present study used surveillance data on 3,320 intervention participants who enrolled in the Lung Health Study for 5 years and who were then followed by the Lung Cancer Substudy for 7.5 years. Nicotine replacement therapy use and smoking exposure were recorded during the 5-year Lung Health Study trial. Surveillance for lung cancer, gastrointestinal cancer (including oral cancers), and all cancers began following the Lung Health Study.
Adjusted Cox proportional hazards regressions assessed the hazards of nicotine replacement therapy and smoking for each diagnosis group. In the adjusted models for lung cancer, nicotine replacement therapy alone was not a significant predictor (p = .57), while smoking during the Lung Health Study was a significant predictor (p = .03). When nicotine replacement therapy and smoking were entered in the same model, nicotine replacement therapy remained not significant (p = .25) and smoking was clearly significant (p = .02). Nicotine replacement therapy and smoking were not significant predictors of cancer in the models for gastrointestinal cancer or all cancers.
Although the surveillance time was short, smoking predicted cancer in this analysis and nicotine replacement therapy did not.
Almost all descriptions of attempts to quit smoking have focused on what happens after an abrupt quit attempt and end once a smoker relapses. The current study examined the day-to-day process preceding a quit or reduction attempt in addition to the daily process after a failure to quit or reduce.
We recruited 220 adult daily cigarette smokers who planned to quit abruptly, to quit gradually, to reduce only, or to not change on their own. Participants called a voice mail system each night for 28 days to report cigarette use for that day and their intentions for smoking for the next day. No treatment was provided.
Three main findings emerged: (a) The large majority of participants did not show a simple pattern of change but rather showed a pattern of multiple transitions among smoking, abstinence, and reduction over a short period of time; (b) most of those who reported an initial goal to quit abruptly actually reduced; and (c) daily intentions to quit strongly predicted abstinence, while daily intentions to reduce weakly predicted reduction.
We conclude that the day-to-day process of attempts to change smoking among nontreatment seekers is much more dynamic than previously thought. This suggests that extended treatment beyond initial lapses and relapses and during postcessation reduction may be helpful.
There have been conflicting findings on whether metabolic syndrome (MetS) is associated with smoking and alcohol intake. This study investigated the association of MetS with smoking and alcohol intake.
MetS was defined according to the International Diabetes Federation criteria, and smoking and alcohol intake were evaluated for 1,215 Japanese male workers using a questionnaire. The association of MetS with smoking and alcohol intake was assessed using logistic regression after adjusting for potential confounders. Proportional analyses for the prevalence of MetS among smoking and alcohol intake were performed as well.
Among the subjects, 148 (12%) were diagnosed with MetS, 485 (40%) were smokers, and 954 (79%) were regular alcohol users. The prevalence of MetS was the highest (19%) in smokers who did not drink, followed by smokers who also drank (13%), nonsmokers who drank (12%), and those who neither smoked nor drank (7%). Smoking itself was positively related to MetS (odds ratio [OR] = 1.4; 95% CI = 1.1–2.1) and MetS components, including larger waist circumference (OR = 1.5; 95% CI = 1.2–1.9), elevated triglyceride (OR = 1.9; 95% CI = 1.4–2.4), and reduced high-density lipoprotein cholesterol (OR = 1.7; 95% CI = 1.1–2.7). Alcohol intake was not significantly related to MetS; it was positively correlated only to higher fasting plasma glucose (OR = 1.7; 95% CI = 1.1–2.6).
These results suggest that cigarette smoking is an independent risk factor for MetS, but the risk does not seem to be exaggerated by alcohol intake.
A smoke-free law went into effect in Spain on 1 January 2006, affecting all enclosed workplaces except hospitality venues, where only partial bans were implemented. The objective was to evaluate the impact of the law among hospitality workers who smoke.
The study design is a before-and-after evaluation. We formed a cohort at baseline, during the 3 months before the law went into effect, with 431 hospitality workers (222 smokers). From them, 288 were successfully followed-up 12 months after the ban (118 were smokers at baseline). We analyzed the quit rate, the reduction in the number of cigarettes smoked per day, changes in the Fagerström Test for Nicotine Dependence (FTND) scores, and changes in salivary cotinine concentrations in smokers from baseline to 1 year after the ban.
Among 118 smokers, six (5.1%) quit smoking. Among the 112 remaining smokers, the mean number of cigarettes smoked decreased by 8.9% after the ban (from 17.9 to 16.3 cigarettes/day, p < .01). The proportion of workers with a high nicotine dependence (FTND score >6) was reduced by half after the ban (19.5% vs. 9.7%, p = .03). Salivary cotinine decreased by 4.4% after the ban (geometric mean 104.3 vs. 99.7 ng/ml, p = .02). No meaningful differences were found in quit rates and the FTND scores according to type of regulation.
The Spanish smoking law has had beneficial effects (reduction in number of cigarettes smoked, cotinine levels, and FTND score) among hospitality workers who smoke.
While the risk for a number of medical illnesses is well established for those who smoke, the risk for psychiatric disorders is not so well studied in Singapore.
This study sought to establish the lifetime prevalence of nicotine dependence in a population of young males in Singapore and to establish its relationship with other psychiatric disorders.
The study was conducted among a cohort of males reporting for their mandatory physical examination prior to their enlistment for National Service in a 1-year period between August 2004 and August 2005. Definitive diagnoses in accordance with DSM-IV criteria were made with the Composite International Diagnostic Interview (CIDI).
In the population of 9,702 males assessed by CIDI, the prevalence of nicotine dependence was 12.3%. Academic attainments were significantly poorer in those with nicotine dependence than those without dependence. Nicotine dependence was most strongly associated with delusional disorder and major depressive disorder, which remained even after adjusting for ethnicity and educational attainments (odds ratio [OR] of 59.8 for delusional disorder and OR of 36.3 for major depressive disorder).
Our study highlights the pervasive extent of nicotine dependence among a population of young men. The pervasiveness of nicotine dependence across different psychiatric disorders suggests either a shared biological substrate or a common consequence of these disorders.
Legal restrictions have contributed to the decline in smoking prevalence in several European countries. We investigated the impact of the Italian 2005 indoor smoking ban on the efficacy of counseling alone or in combination with bupropion for smoking cessation.
Before and after the introduction of the ban (2001–2006), 550 smokers were enrolled in the smoking cessation program in Rome and were asked to choose between a 6-week group counseling therapy (GCT) given alone or in combination with 7 weeks of daily bupropion. Follow-up was completed 12, 26, and 52 weeks after the quit day. Due to the observational nature of the study, we used propensity scores to match 138 and 290 subjects (pre-/postban) in the bupropion- and GCT-only groups, respectively.
Covariate balance in the two matched samples was adequate for all variables except "coffee consumption" in the GCT-only group. The regression adjusted odds ratios indicated that the introduction of the ban resulted in 52% reduced odds of continued smoking at 12 months among the GCT + bupropion group and 41% reduced odds in the GCT-only group. We observed that the ban was associated with both increased 12-month abstinence rates and motivation to quit. In a mediation analysis, we determined that the total effect of the smoking ban on the abstinence rate was reduced after controlling for motivation, which confirmed that motivation was a partial mediator.
The introduction of an indoor smoking ban improved the efficacy of smoking cessation treatments by possibly providing a setting that increased the level of motivation to stop smoking.