The Brief Addiction Science Information Source (BASIS)

ASHES, Vol. 8(1): Who’s winning at quitting? A state-by-state look at smoking cessation quitlines

States and the federal government have enacted public policies that assist with smoking cessation. A popular line of treatment is over-the-phone counseling via quitline. Quitlines can and often do serve as the first and sometimes the only line of help for smokers who want to quit. Since 2004, every state in the U.S., the District of Columbia, and Puerto Rico has operated a tobacco cessation quitline (American Lung Association, 2011). This week’s ASHES focuses on these state quitlines by examining data presented in the American Lung Association’s State of Tobacco Control Report (2011).

Methods

• The American Lung Association’s State of Tobacco Control Report (2011) provides information at the state level about the following quitline statistics:

                    1.  Dollars spent, per smoker, on quitlines;                 
                    2.  percentage of all smokers who receive treatment via the quitlines

• We calculated an additional variable, quitline cost effectiveness, operationalized as % of smokers who received treatment / money spent per smoker
  • If states spend large amounts of money but serve few of their smokers, their score on this variable will be low; if, conversely, they spend less money but serve more of their smokers, their score will be high.

Results

Table 1. State Spending on Quitlines and Smokers Served

• There was a highly significant correlation (r = .667, p < .001), between the money spent per smoker, and the percentage of smokers who received treatment via quitline counseling.
• The five states that spent the most money per smoker were South Dakota, Wyoming, Maine, North Dakota, and Delaware.
• The five states that served the greatest number of smokers were South Dakota, New York, Oklahoma, Montana, and Iowa.
• The five most “cost effective” states (% served / spending) were Connecticut, New York, Wisconsin, Iowa, and Missouri.  There was little overlap between the highest-spending states and the most cost-efficient states.

Limitations

• This is a correlational study; therefore it cannot inform us about the causal connection between spending and treatment.
• The fact that more smokers are receiving treatment in a given state does not tell us about the quality of that treatment. Greater dollars spent might equate to better care, not just more care.

Discussion

Though dollars spent was positively associated with treatment engagement, states that were most cost effective in their quitline treatment programs were not the same states that reported the most spending. The CDC and the North American Quitline Consortium report that quitline services are not receiving the optimal rate of funding ($10.53 per tobacco user) to provide best practice-level services. However, appeals for increased funding must be considered carefully. Throwing more money into state-funded quitlines might not necessarily be predictive of better overall treatment efficiency.

-  Kat Belkin and Sarah Nelson

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References

American Lung Association (2011). Helping smokers quit: Tobacco cessation coverage 2011. Accessible at http://www.lungusa.org/assets/documents/publications/smoking-cessation/helping-smokers-quit-2011.pdf

ASHES, Vol. 7(10) - Nicotine… a gateway drug?

Many people refer to marijuana as a gateway drug to other illicit drug use. However, some researchers have questioned whether this presumption has distracted researchers from considering the possibility that other more easily attainable substances might act as gateway drugs – for example, nicotine (Volkow, 2011). The week’s ASHES reviews an animal model study that explores whether nicotine exposure is associated with later cocaine use behavior (Levine et al., 2011).

Methods

• Researchers separated mice into three groups: control group (exposed to saline); cocaine only group (exposed to cocaine for 7 days); and nicotine and cocaine group (exposed to nicotine for 7 days followed by cocaine for 4 days).
• The researchers monitored cocaine-related behavior and physiological changes/differences among experimental groups following substance exposure.
  • Conditioned place preference (CPP) measured a study subject’s preference (i.e., time spent in an area) for the area where they received a reward (e.g., a drug), compared to a control area (Levine, et al., 2011).
  • Brain ΔFosB levels – ΔFosB is a protein in the brain that increases in response to cocaine use. Researchers administered nicotine and/or cocaine and tested for the extent of ΔFosB among the experimental groups.
  • Long Term Potentiation (LTP) – Long-term cocaine administration decreases LTP (Levine, et al., 2011). Researchers observed group-based differences for neuronal LTP responses.

Results

• As Figure 1 shows, the cocaine only group displayed significantly greater CPP than the control group (76.5s versus 247.1s, p < 0.05, 223.2% difference). Similarly, the mice pretreated with nicotine showed significantly greater CPP than the cocaine only group (247.1s versus 441.2s, p < 0.05, 78.6% difference).
• The nicotine and cocaine group had 74.9% greater ΔFosB levels compared with the cocaine only group (from cocaine only at 3.5 ± 0.69 to nicotine and cocaine at 6.12 ± 0.8, P < 0.05). 
• Neurons in brain slices from the nicotine and cocaine group differed, evidencing a 46.6% LTP decrease compared with the control group and by a 27.3% decrease compared with the cocaine only group (control: 129 ± 6%, cocaine only: 112 ± 5%, nicotine and cocaine: 88 ± 6%).

Figure 1 – Conditioned Place Preference (CPP) Results among Groups

Limitations

• This research was conducted with mice. There is preliminary evidence to suggest that nicotine could have the same priming effects for enhancing cocaine’s effects among humans (Grant, Kaplan, Shepard, & Moore, 2003; Kandel, Yamaguchi, & Chen, 1992), but more research is needed to determine if this is accurate.
• The researchers did not control for the priming effects of other substances prior to cocaine.

Discussion

Nicotine exposure altered the brain’s response to cocaine for the above behavioral and physiological/molecular measures. This suggests that nicotine primes the brain to  enhance cocaine-associated rewards. The research design could be stronger if the researchers added an additional group, such as saline followed by cocaine, to control for the experiential effects of consuming a substance prior to cocaine. Without additional information it is difficult to attribute the priming to nicotine only. Nevertheless, this preliminary research could facilitate research for the development of new medication for cocaine addiction based on an understanding of the brain’s response to cocaine following nicotine exposure. It is also possible to speculate that smoking cessation could have an effect for cocaine addiction among those who are comorbid (Volkow, 2011).

-Tasha Chandler and Daniel Tao

What do you think? Please use the comment link below to provide feedback on this article.

References

Grant, B. F., Kaplan, K. D., Shepard, J., & Moore, T. (2003). Source and Accuracy Statement for Wave I of the 2001-2002 National Epidemiologic Survey on Alcoohl and Related Conditions. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism.

Kandel, D. B., Yamaguchi, K., & Chen, K. (1992). Stages of progression in drug involvement from adolescence to adulthood: Further evidence for the gateway theory. Journal of Studies on Alcohol, 53, 447-457.

Levine, A., Huang, Y., Brisaldi, B., Griffin, E. A., Jr., Pollak, D. D., Xu, S., . . . Kandel, E. R. (2011). Molecular mechinisms for a gateway drug: Epigenetic changes initiated by nicotine prime gene expression by cocaine. Science Translational Medicine, 3(107), 107ra109. doi: 10.1126/scitranslmed.3003062

Volkow, N. D. (2011). Epigenetics of nicotine: Another nail in the coughing. Science Translational Medicine, 3(107), 107ps143. doi: 10.1126/scitranslmed.3003278

ASHES, Vol. 7(9) – e-interventions for smoking cessation

Although research has shown a decline in the number of people smoking cigarettes in the United States, the annual premature death rate associated with smoking (440,000+) remains a cause for concern (U.S. Department of Health & Human Services). One potential strategy for promoting smoking cessation is to provide many readily accessible options for smokers who wish to quit. This week, ASHES reports on a study that tested the efficacy of a smoking cessation program delivered via video messages for cellular phones (cell phone) (Whittaker et al., 2011).

Methods

• The researchers recruited participants using radio, Internet, cell phone, magazine, newspaper, and media release advertisements in New Zealand.
  • Eligibility: Participants had to be 16 years or older, smoke every day, have a desire to quit smoking, and have a cell phone that could receive video messages.
• After selecting a quit date, the researchers randomly assigned participants to an intervention or control group: each received mobile messages¹  for 6 months.
  • Control group – This group received one general health video message every 2 weeks.
  • Intervention group – This group received a tailored set of video messages, text messages, other video messages (e.g., “truth” campaign), and on-demand support via texting key words (e.g., crave, stress, drinking) and a website. The tailored set included more options and contact (e.g., the ability to select and change role model, chronological schedule of messages – 1 video and text message/day for 1 week prior to quit date, 3 video and text messages/day on quit date, 3 video and text messages/day for 4 weeks following quit date, 1 message or other video every 2 days for the next 2 weeks, and then 1 message or other video every 4 days for the rest of the study).
• The researchers compared past week abstinence rates at 4 weeks, 12 weeks, and 6 months among the control and intervention groups.

Results

• 868 people registered to participate in the study; 642 people were ineligible, withdrew from the study, or did not complete a baseline interview; leaving 226 participants (control group n=116 and intervention group n=110).
  • Control group completion rates –  80.2% (n = 93) at 4 weeks, 75% (n = 87) at 12 weeks, and 77.6% (n = 90) at 6 months.
  • Intervention group completion rates – 73.6% (n = 81) at 4 weeks, 71.8% (n = 79) at 12 weeks, and 68.2% (n = 75) at 6 months.
• Figure 1 illustrates abstinence rates over the course of the study for controls and the intervention group. The groups’ abstinence rates differed the most at 12 weeks, but were very similar at 4 weeks and 6 months.
  • The control and intervention groups failed to evidence statistically significant differences at these time points (P = 0.8 at 4 weeks, P = 0.3 at 12 weeks, and P = 0.99 at 6 months).
  • Researchers assumed 35 participants in the intervention group and 26 participants in the control group who had missing data were not abstinent.

Figure 1 – Past week abstinence rates during study

Limitations

• The researchers aimed to recruit a much larger sample. The low participation rate suggests that these results might not be generalizable to the New Zealand population or other populations.
• The researchers compare one type of video messaging intervention against a more complex type of video messaging intervention for smoking cessation. Without a “control” group of people who did not receive any video messages, it is difficult to determine whether either intervention system was effective or if people were quitting on their own.

Discussion

The results indicate that a more personalized smoking cessation video messaging system with additional resources was not more effective at helping people achieve abstinence than an automated video messaging system. It is unclear if this type of intervention is effective, and it is impossible to interpret these null findings. In this instance, it might be that the intervention was not successful, or that the selection of participants and low participation rate might be responsible or other methodological problems might be responsible for the absence of significant results.

However, video and text messaging intervention programs might hold promise because most people carry their cell phones with them at all times and this type of system could allow for intervention at any time and potentially when it is needed the most. Future research should test the efficacy of this type of intervention among different populations, age groups, and addictions (e.g., gambling, substance use, drinking).

-Tasha Chandler

What do you think?  Please use the comment link below to provide feedback on this article.

References

U.S. Department of Health & Human Services. Tobacco prevention and control: New actions to end the tobacco epidemic  Retrieved Jul. 13, 2011, from http://www.hhs.gov/tobaccocontrol/index.html

Whittaker, R., Dorey, E., Bramley, D., Bullen, C., Denny, S., Elley, R., . . . Salmon, P. (2011). A theory-based video messaging mobile phone intervention for smoking cassation: Randomized controlled trial. Journal of Medical Internet Research, 13(1), e10. doi: 10.2196/jmir.1553

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¹The video messages were a diary of role models who shared their difficulties, techniques, and strategies for quitting.

ASHES, Vol. 7(8) – Smoking tobacco with a hookah: Replacing the cigarette as high schoolers' smoke of choice?

Cigarette use among high school students has been on a steady decline during recent years (SAMHSA, 2010). Media and regulatory campaigns have targeted and attempted to reduce cigarette smoking, but more exotic forms of tobacco smoking, such as hookah, have received relatively little attention (Smith, Novotny, Edland, Hofstetter, Lindsay & Al-Dalaimy, 2011). Because Hookah smoking can involve the use of many substances (e.g., opium, marijuana, or tobacco), we want to note that for the remainder of this article, ‘hookah use’ will refer to specifically and only to smoking tobacco. Previously, the BASIS published a history and introduction to hookah, as well as a study about hookah use among college students. Today’s ASHES explores hookah use and attitudes towards hookah smoking among high school students (Smith, et al., 2011).

Figure 1: A typical hookah. 

Methods

• Researchers surveyed junior (11^th grade) and senior (12^th grade) students from three high schools in San Diego. Six hundred and eighty-nine students participated in the study, out 691 potential students (99.7%).
• Students answered a questionnaire assessing hookah use and cigarette use, as well as perceived danger and social acceptability of hookah, chewing tobacco, cigar, and cigarette use. 

Results

• Eighty-three percent of students had “heard of a tobacco-smoking device called a hookah or waterpipe”.  
• More than a quarter (26.1%) of students reported ever smoking a hookah and 10.9% reported past-month hookah use.  
  • Thirty-eight percent reported ever smoking a cigarette and 11% reported past-month cigarette smoking.
  • Hookah users were significantly more likely than non-users to have tried cigarettes or be current cigarette smokers [1] (p < .001).
  • Almost sixty percent (59.5%) of students thought hookah use was more socially acceptable than cigarette, cigar, and chewing tobacco use. Nearly half (46.3%) thought hookah use was safer than any other tobacco product.

Limitations

• The study only uses self-report and cross-sectional (i.e., only includes data from one time point) data.
• The study population is from a limited geographical area, which potentially limits the generalizability of the data to the general high school population.

Conclusions

These results show that many students know about hookah and a good percentage have tried hookah. Also, many students perceive hookah smoking as a safer, more socially acceptable alternative to cigarettes. Previous research has shown that hookah smoking is more harmful than cigarette smoking, given the greater amount of smoke inhaled (Jacob, Abu Raddaha, Dempsey, Havel, Peng, Yi & Benowitz, 2011) during comparatively longer smoking sessions (hookah sessions averaged 47.5 minutes in this study; Smith, et al., 2011). Furthermore, studies have shown that hookah use is predictive of future regular cigarette use among Danish youth (Jensen, Cortes, Engholm, Kremers & Gislum, 2010). For American high school students, hookah is a non-traditional nicotine delivery method, one that has not received much attention in the media or literature. Hookah use is harmful and predictive of future cigarette smoking, suggesting that closer parental, societal, and regulatory attention should be afforded to high school hookah use.

-Daniel Tao

What do you think? Please use the comment link below to provide feedback on this article.

References

Jacob, P. III, Abu Raddah, A.H., Dempsey, D., Havel, C., Peng, M., Yu, L., Benowitz, N.L. (2011). Nicotine, carbon monoxide and carcinogen exposure after a single use of a waterpipe. Cancer Epidemiology, Biomarkers & Prevention, online first.

Jensen, P.D., Cortes, R., Engholm, G., Kremers, S., Gislum, M. (2010). Waterpipe use predicts progression to regular cigarette smoking among Danish youth. Substance Use and Misuse, 45, 1245-1261.

Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011.

Smith, J.R., Novotny, T.E., Edland, S.D., Hofstetter, C.R., Lindsay, S.P., Al-Delaimy, W.K. (2011). Determinants of hookah use among High School students. Nicotine & Tobacco Research, 13(7), 565-572.

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[1] No t statistics provided. 

 

ASHES, Vol. 7(7) – What’s the best way to quit smoking?

Many smoking cessation programs recommend abrupt (i.e., “cold turkey”) versus gradual smoking cessation (Fiore et al., 2008; West et al., 2000). However, most heavy smokers attempt the latter approach (Levinson, Shapiro, Schwartz, & Tursky, 1971; Shiffman, Ferguson, & Strahs, 2009). This week, ASHES reports on a large randomized control study that compares gradual versus abrupt versus minimal treatment smoking cessation approaches (Hughes, Solomon, Livingston, Callas, & Peters, 2010).

Methods

Participants

• The researchers recruited 746 adult daily smokers (48% women, 91% Caucasians) through newspaper and radio ads. Participants smoked at least 15 cigarettes per day, wanted to quit smoking during the next 30 days, were willing to use nicotine lozenges, and preferred to quit gradually rather than abruptly. The researchers randomly assigned participants to the gradual (N = 297), abrupt (N = 299), or minimal treatment (N = 150) conditions

Procedure

• All participants set a quit day during the first session
• Gradual cessation condition. Throughout a pre-quit period the researchers mailed participants nicotine lozenges. Participants also received 4 calls from a counselor during the pre-quit period and and 1 call after. The researchers recommended participants to reduce by 25% during the first week, 50% during the second week, and 75% during the third week. 
• Abrupt cessation condition. Participants received 2 calls before the quit day and three calls after. They received lozenges after the quit day. Participants were instructed not to change their cigarettes per day until the quit day. 
• Minimal treatment condition. Participants received 1 call before the quit day and 1 call and the lozenges after the quit day. Participants were encouraged to set a quit date during the first call. 

Assessments

• At baseline, participants indicated their smoking dependence on a visual analog scale from low to high and self-efficacy to quit smoking on a Velicer’s scale (Velicer et al., 1990) . 
• A research assistant obtained a breath carbon monoxide (CO) level at study entry, immediately before the quit day, and at 6 month follow up from those who reported abstinence. The research assistant also called participants 2 weeks, 4 weeks, 6 weeks, 3 month and 6 months after to inquire about reduction and non-reduction.

Results

• Table 1 indicates that participants in all three conditions demonstrated the same rate of abstinence at 6-month follow-up (p > .05).
• Smokers who rated themselves as low dependent had a longer time-to-lapse; however, smokers who rated higher dependence demonstrated the same time to relapse in abrupt and gradual conditions (χ² = 3.91, p < .05).
• Smokers with high self-efficacy did better (i.e., demonstrated longer time to lapse) in the abrupt condition. However, smokers with low self-efficacy demonstrated the same results in both conditions ( χ² = 4.98, p < .05).

Table 1. Percent of abstinence

	Gradual   N = 227	Abrupt   N = 237	Minimal treatment N  = 118	Odd ratio gradual vs abrupt
6 month self-report	9	13	12	.7
6-month CO-verified	4	7	5	.6

Limitations

• The results of self-reported abstinence did not agree with the CO test results in about half cases. This challenges validity of the self-reports in the study (Hughes, et al., 2010).
• The conditions varied in several ways other than reduction vs. abrupt. For example, the gradual condition received more pre-cessation calls and fewer post-cessation calls than the abrupt condition.

Conclusion

The study demonstrated that for those smokers who prefer to reduce number f cigarettes and then quit, the gradual smoking cessation method works the same as the abrupt method, particularly in the time-to-lapse measure and for those with low self-efficient and high smoking dependence. Due to overall popularity of the gradual cessation method among smokers, more studies should be done to investigate and improve its effectiveness.

-Julia Braverman

What do you think? Please use the comment link below to provide feedback on this article.

References

Hughes, J. R., Solomon, L. J., Livingston, A. E., Callas, P. W., & Peters, E. N. (2010). A randomized, controlled trial of NRT-aided gradual vs. abrupt cessation in smokers actively trying to quit. Drug and Alcohol Dependence, 111(1-2), 105-113.

Levinson, B. L., Shapiro, D., Schwartz, G. E., & Tursky, B. (1971). Smoking elimination by gradual reduction. Behavior Therapy, 2(4), 477-487.

Shiffman, S., Ferguson, S. G., & Strahs, K. R. (2009). Quitting by Gradual Smoking Reduction Using Nicotine Gum: A Randomized Controlled Trial. American Journal of Preventive Medicine, 36(2), 96-104.e101.

Velicer, W.F., DiClemente, C.C., Rossi, J.S., Prochaska, J.O., 1990. Relapse situations and self-efficacy: an integrative model. Addict. Behav. 15, 271–283.

West, R., McEwen, A., Bolling, K., Owen, L., 2001. Smoking cessation and smoking patterns in the general population: a 1-year-follow-up. Addiction 96, 891–902.

ASHES, Vol. 7(6) – FDA issues new graphic cigarette warning labels, but will they change behavior?

Beginning in September 2012, the United States Food and Drug Administration (FDA) will require cigarette companies to include new health warning statements and accompanying graphic images on cigarette packs and advertisements (U.S. Food and Drug Administration, 2011). In a previous Addiction & the Humanities, we reviewed critics’ claims that graphic warning labels, while emotionally impactful, might not be particularly effective in changing behavior. This week’s ASHES reports on a recent study the FDA used to inform their selection of graphic warning images (Nonnemaker, Farrelly, Kamyab, Busey, & Mann, 2010). The FDA designed the study to evaluate the relative efficacy of 36 proposed warning images and used study findings, along with public comments and a scientific literature review, to winnow the 36 proposed images to nine.^[1]

Methods

• The FDA used an online research company to recruit participants randomly using a convenience sample of adult smokers (age 25+; n = 4,890).
• The control group saw only warning statements and the treatment group saw both statements and graphic images.
  • Participants described how much the packs made them feel a variety of emotions (e.g., worried, depressed, disgusted). Researchers combined the items onto a single scale where higher values indicate more emotional responses.
  • Participants described the extent to which the material was difficult to look at.
  • Participants described their intention to quit smoking in the next 30 days.
• For all statistical analyses, the researchers entered experimental condition (i.e., control versus treatment) as an independent variable and outcomes as dependent variables, controlling for demographic characteristics. The researchers used linear regression to interpret continuous measures (i.e., emotional reaction) and logistic regression to interpret the dichotomous measures (i.e., difficulty looking at the pack and intent to quit smoking) that were derived from exposure to the images.

Results

• Figure 1 displays the results for each of the nine warning statements ultimately selected.
• The accompanying graphics for all warning statements except # 9 (i.e., “Quitting smoking now greatly reduces serious risk to your health.”) significantly heightened the participants emotional response.
• Participants reported that the packs were significantly more difficult to look at when accompanied with graphic images than without, except for warning statement #9.
• The warning statements accompanied with graphics did not have a significant impact on self-reported smoking cessation plans except for warning statement 7 (“Smoking can kill you”). Graphics accompanying that statement resulted in more likely intentions to quit smoking.

Figure 1 – Adult Group Results (adapted from Nonnemaker, et al., 2010)

 
Click here for a larger view of the figure.
Click here for a larger view of the warning labels.
Note: More positive betas indicate stronger emotional reactions among people who viewed both warning statements and accompanying images (i.e., the treatment group). Odds ratios greater than 1 indicate greater likelihood of experiencing the outcome among the treatment group.

 Limitations

• The study uses self-report to estimate future actions; the “behavior” of ceasing smoking is a self-report of participants’ beliefs and thoughts about their potential future action, not an observation of their actual behavior following the study. Stated intentions and the actual behaviors often are discrepant.
• The study uses a convenience sample, and the sample was predominantly Caucasian. These results might not generalize to other groups.
• Participants only saw the cigarette package once during the study. A longitudinal study of exposure over time to warning statements and labels (i.e., repeated doses) might have had a different effect (e.g., stronger or weaker) on participants’ desire to quit smoking.

Discussion

Perhaps most startling about this research is that, although people seem to have strong reactions to the graphics accompanying the warnings, this reaction did not have an effect on their plan to quit smoking. Quitting smoking is a main goal of the new labels (i.e., increase smoking cessation). A population-based longitudinal study measuring actual future smoking behavior before and after the introduction of the new warning labels could be a better indicator of the effectiveness of these materials.

The United States experienced a significant decline in tobacco use during the last 40 years. However, those rates of decline have recently begun to level out. Estimates reveal that 20.6% of adults and 19.5% of students in high school are current smokers (U.S. Department of Health & Human Services). From a public health standpoint, the remaining smokers’ behavior might be the most difficult to change. It will be interesting to see if new warnings have an impact.

-Tasha Chandler

What do you think? Please use the comment link below to provide feedback on this article.

References

Nonnemaker, J., Farrelly, M., Kamyab, K., Busey, A., & Mann, N. (2010). Experimental study of graphic cigarette warning labels. Research Triangle Park, NC: RTI International.

U.S. Department of Health & Human Services. Tobacco prevention and control: New actions to end the tobacco epidemic  Retrieved Jul. 13, 2011, from http://www.hhs.gov/tobaccocontrol/index.html

U.S. Food and Drug Administration. (2011, Jun. 22). Cigarette Health Warnings  Retrieved Jul. 13, 2011, from http://www.fda.gov/TobaccoProducts/Labeling/CigaretteWarningLabels/default.htm

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^[1] Although the study reported about all 36 proposed graphic images to accompany the nine new warning statements, this week’s ASHES only reports about the nine graphic images that were selected. The study also included a young adult smoking group (18-24) (n=4,584) and a group comprised of youth smokers and youth susceptible to smoking (13-17) (n=4,600), as well as other study measures. We only report about the outcomes for the adult smoking group for certain measures.

ASHES, Vol. 7(5) - Fatal Attraction: Affiliative attachment with cigarettes among depressed individuals

The National Institute on Drug Abuse estimated that people with psychiatric disorders purchase 44 % of the cigarettes sold in the United States (NIDA, 2011). Young adult smokers in particular are more likely to exhibit negative affect and psychiatric disorders (Magid, Colder, Stroud, Nichter, & TERN members, 2009; NIDA, 2011). Interestingly, research has shown that a friendship-like affiliation with cigarettes, among other additional smoking motives, can differentiate between smokers with high and low numbers of depressive symptoms (Vinci, Carrigan, & Copeland, 2010). These researchers recently conducted a study exploring the extent to which such an affiliative attachment to smoking adds to depressive symptoms among college student daily smokers, above and beyond their positive or negative reinforcement motives (Vinci, McVay, Copeland, &Carrigan, 2011). This week’s ASHES article reviews their findings.

Method

• Participants were recruited from a larger, longitudinal study examining smoking cue exposure. They were 79 moderately nicotine-dependent undergraduate college students (M age= 20.19; SD= 3.75; 57% female; 84% Caucasian, 7.6% African American, and 7.6% “Other”) who smoked an average of 8.25 (SD= 5.29) cigarettes per day for a mean duration of three years.
• Participants completed a survey assessing:
  • Nicotine dependence- Fagerström Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Reckler, & Fagerström, 1991).
  • Current depressive symptoms- Center for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977). 
  • Smoking motives- Three subscales of the WISDM-68 (Piper et al., 2004):  1) positive reinforcement subscale (i.e., perceptions of positive effects experienced through smoking); 2) negative reinforcement subscale (i.e., perceptions that smoking alleviates negative emotional states); and 3) affiliative attachment subscale (i.e., endorsing the belief that “cigarettes…share many of the same affective and motivational properties as attractive social stimuli”; Piper et al., 2004).

Results

• A hierarchical linear regression found that positive/negative reinforcement beliefs about smoking cigarettes (combined into a single variable because of their high inter-correlations) and a friendship-like attachment to smoking both were positively associated with increased depressive symptoms after adjusting for gender and number of cigarettes smoked per day.
• As shown in Table 1, the addition of affiliative attachment to the estimation model doubled the amount of explained variance: adjusted R ² = .245.

Table 1- Hierarchical Models Estimating CED-D Depression Levels from Gender, Cigarettes Smoked per Day, Smoking Attitude Reinforcement, and Affiliative Attachment (adapted from Vinci et al., 2011)

 
 Note. * = p < .05.  **= p < .01.  *** = p < .001.

Limitations

• The study used an undergraduate sample, so these results might not generalize to other populations.
• Researchers did not assess alcohol consumption or other factors known to impact smoking and depression.
• The CES-D score range associated with being clinically depressed is 16-60, and the subjects in the present study had an average score of 15.36 (SD=9.85). Because 60% scored between 0 and 15, the majority of the sample was not considered clinically depressed. This potentially limits conclusions of a link between smoking motives and depression.

Conclusions

The present study found that among college students a friendship-like attachment to smoking was associated with more current depressive symptoms. The association persisted after adjustment for gender, number of cigarettes smoked daily, and positive/negative reinforcement smoking motives.   The authors speculated that smokers with depressive symptoms, in particular, might develop a friendship-like relationship with cigarettes as a means of coping with their poor social skills and reduced social functioning.  This affiliative relationship with cigarettes, in turn, might further perpetuate their depressive symptoms by superseding the need for social interaction and thus limiting opportunities to improve their social competence.  However, more research is needed to test the reciprocal influence of smoking behaviors and social functioning on depressive symptoms among other populations (e.g., a clinically depressed sample with higher levels of nicotine dependence).  If these results hold, future research might wish to examine further the effects of incorporating a social support component in smoking cessation interventions and therapy for depressed smokers.

-Brittany Bannon

What do you think? Please use the comment link below to provide feedback on this article.

References

Magid V., Colder, C. R., Stroud, L. R., Nichter, M., & TERN Members (2009). Negative affect, stress, and smoking in college students: Unique associations independent of alcohol and marijuana use. Addictive Behaviors, 34, 973-975.

Vinci, C., Carrigan, M., & Copeland, A. L. (2010). Impact of depression levels on motives for smoking.  Poster presented at the meeting of the Association for Behavioral and Cognitive Therapies, San Fransisco, CA.

Vinci, C., McVay, M. M., Copeland, A. L., & Carrigan, M. H. (2011, May 9). The Relationship Between Depression Level and Smoking Motives in College Smokers.  Psychology of Addictive Behaviors. DOI: 10.1037/a0023772

U.S. Department of Health and Human Services.  Tobacco Use and Comorbidity: Research Report Series. National Institute on Drug Abuse (NIDA), National Institutes of Health. Available at: http://www.nida.nih.gov/researchreports/nicotine/useRisks.html

ASHES, Vol. 7(4) – When the parents stop smoking what does the child think?

Children whose parents quit smoking are less likely to become daily smokers than children whose parents keep smoking (Bricker et al., 2003). Perhaps watching a parent quit smoking changes children’s smoking-related beliefs in beneficial ways. For example, children who see their parents quit smoking might have stronger beliefs that they can avoid smoking. This week’s ASHES describes a longitudinal study that examines the extent to which children’s smoking-related beliefs mediate the effect of parental smoking cessation on children’s decision to start smoking (Wyszynski, Bricker, & Comstock, 2011).

Methods

• Participants 
  • Wyszynski et al. surveyed 2,656 third graders from 40 Washington State school districts. To be eligible for the study, students had to have at least one parent who was either a current smoker or a previous smoker. The final cohort consisted of 2,230 students (48% females, 91% Caucasian). About 86% of participants completed the ninth grade follow-up survey, and about 97% of those completed the twelfth grade follow-up survey.
•  Major measures
  • Parental smoking cessation by the time children were in third grade. For each child participant, one parent indicated the smoking status of both parents. The researchers used a binary coding scheme (i.e., assigning a “0” = one parent currently smoking and “1” = at least one parent who quit smoking but no parent currently smoking).
  • Child smoking-related cognitions during ninth grade. The 8-item survey measured global attitudes toward smoking, intentions to smoke, normative beliefs about smoking, belief in one’s ability to refuse tobacco, and negative expectations about smoking.
  • Child smoking status during twelfth grade. The participants self-reported if they smoke.

Results

• Children with at least one parent who quit smoking reported widespread healthier beliefs about smoking when they were in ninth grade.
• Children with healthier smoking-related beliefs in ninth grade were less likely to be daily smokers in twelfth grade
• Children with at least one parent who quit smoking were 30% less likely to be daily smokers in twelfth grade (odds ratio = 0.70, 95% confidence interval = 0.58-0.84). 
• The influence of parental smoking cessation on twelfth grade smoking status was mediated by three significant factors that were measured during the child’s ninth grade (see Figure 1).

Figure 1. Mediator Variables for the Relationship between Parental Smoking Cessation Behavior and Children’s 12^th Grade Smoking Status

Limitations

• Caucasians comprised 90% of the sample; this limits generalizability of the results. 
• The researchers did not compare children of quitters and current smokers against children of parents who never smoked. 

Conclusion

As predicted, children whose parents had quit smoking by the time children were in third grade were less likely to be daily smokers during the twelfth grade. Children’s healthier cognitions during the ninth grade appear to mediate this effect. These results have some implications for anti-smoking campaigns. First, smoking cessation programs targeted to parents should emphasize the role that parents can play in promoting negative attitudes toward smoking and increasing children’s confidence in their ability to refuse tobacco. In addition, these results highlight the importance of smoking-related cognitions among all children, even those whose parents continue to smoke. 

-Julia Braverman

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References

Bricker, J. B., Leroux, B. G., Peterson, A. V., Kealey, K. A., Sarason, I. G., Andersen, M. R., et al. (2003). Nine-year prospective relationship between parental smoking cessation and children's daily smoking. Addiction, 98(5), 585-593.

Wyszynski, C. M., Bricker, J. B., & Comstock, B. A. (2011). Parental smoking cessation and child daily smoking: A 9-year longitudinal study of mediation by child cognitions about smoking. Health Psychology, 30(2), 171-176.

ASHES, Vol. 7(3) - Smoke, or e-Smoke?

Previously, we have discussed the safety and efficacy of e-cigarettes (i.e., a battery-powered device with a refillable nicotine cartridge and a heater that vaporizes a nicotine solution; ASHES, Vol. 6(4)). Current research indicates that e-cigarette liquid and vapor contain significantly fewer chemicals than tobacco cigarettes. In fact, research suggests that harmful chemicals, if any, occur in trace amounts; these characteristics are similar to other nicotine replacement tools (Cahn & Siegel, 2011). This week’s ASHES reviews a study of the effectiveness of e-cigarettes for smoking cessation (Siegel, Tanwar, & Wood, 2011).

Methods

• Siegel et al. (2011) sent an online survey to the first 5,000 people who bought a new e-cigarette seven months after their initial purchase.
  • Of the sample, 222 participants responded (4.5% response rate), but six were excluded from the survey because they did not meet the inclusion criteria for having been a smoker (i.e., lifetime cigarettes smoked ≥ 100).
• Participants (n = 216) completed an online survey that 1) described their typical pattern of e-cigarette and cigarette use at six months post-purchasing e-cigarettes, and 2) compared their overall smoking behavior during the six months following their initial e-cigarettes purchase to their smoking behavior prior to purchasing e-cigarettes.

Results

• Participants reported the following changes in smoking behavior during the six months following purchasing e-cigarettes: 143 reported smoking fewer cigarettes daily, 106 reported reduced nicotine use, and 104 reported they quit smoking for a period of time.
• Table 1 shows participants’ reported smoking patterns at six months follow-up.
  • Thirty percent of the sample (67 of 216, 30%) reported that they were not smoking cigarettes.
  • Among the 149 smokers, nearly equal numbers were using (52%) or not using (48%) e-cigarettes.
  • Among the 67 non-smokers, there were proportionately more participants using e-cigarettes (61%) than not (39%).
• The relationship between using e-cigarettes and smoking was not statistically significant (² (1 df) = 1.46, p = .23). 

Table 1 - Smoking status by use of e-cigarettes

 

Limitations

• This study uses retrospective self-report without chemical verification.
• The results might not be generalizable to all people who use e-cigarettes because (a) the researchers only surveyed one e-cigarette brand and (b) the response rate was extremely low suggesting that the participants might not represent e-cigarette users.

Discussion

These results suggest that there might be an association between smoking reductions and using e-cigarettes (i.e., as the number of daily e-cigarette usage increased, the percentage of participants not smoking at six months increased). However, the results are not statistically significant when investigators compared participants who smoked and used e-cigarettes to those who smoked and did not use e-cigarettes. The same distribution in a sample containing about 100 more cases would be statistically significant, however, suggesting that the e-cigarette effect is small. Nonetheless, small effects can have considerable impact if this approach to stopping smoking was widely accepted.

Current research is mixed about whether e-cigarettes reduce craving (Bullen et al., 2009; Eissenberg, 2010), but some evidence suggests that simply holding a cigarette can help fight craving (Barrett, 2010). Using e-cigarettes mimics traditional cigarette use, so this could be the reason for the observed association between not smoking and/or reducing smoking tobacco cigarettes. Nevertheless, more research is needed to determine the efficacy of e-cigarettes as a smoking cessation tool, including more comprehensive safety tests.

-Tasha Chandler

What do you think? Please use the comment link below to provide feedback on this article.

References

Barrett, S. P. (2010). The effects of nicotine, denicotinized tobacco, and nicotine-containing tobacco on cigarette craving, withdrawal, and self-administration in male and female smokers. Behavioural Pharmacology, 21(2), 144-152. doi: doi:10.1097/FBP.0b013e328337be68

Bullen, C., McRobbie, H., Thomley, S., Glover, M., Lin, R., & Laugesen, M. (2010). Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: Randomised cross-over trial. Tobacco Control, 19, 98-103. doi: 10.1136/tc.2009.031567

Cahn, Z., & Siegel, M. B. (2011). Electronic cigarettes as a harm reduction strategy for tobacco control: A step forward or a repeat of past mistakes? Journal of Public Health Policy, 32, 16-31. doi: 10.1057/jphp.2010.41

Eissenberg, T. (2010). Electronic nicotine delivery devices: Ineffective nicotine delivery and craving suppression after acute administration. Tobacco Control, 19, 87-88. doi: 10.1136/tc.2009.033498

Siegel, M. B., Tanwar, K. L., & Wood, K. S. (2011). Electronic cigarettes as a smoking-cessation tool results from an online study. American Journal of Preventive Medicine, 40(4), 472-475. doi: 10.1016/j.amepre.2010.12.006

ASHES, Vol. 7(2) - Slight prick, all better? Stage II trial results of a nicotine vaccine

Nicotine vaccines represent a potentially important treatment option for quitting and preventing tobacco smoking. Nicotine vaccines work by inducing the immune system to create antibodies (Ab) that bind to nicotine in the bloodstream and prevent it from reaching the brain. By keeping nicotine from the reward pathways in the brain, nicotine Ab eliminate the pleasurable (i.e., reinforcing) aspect of smoking (Hatsukami, et al., 2011). Today’s BASIS examines the results from the recently completed Stage II trials of NicVAX, the vaccine furthest along in development (Hatsukami, et al., 2011).

Methods

• This study employed a double-blind, placebo-controlled design.
• 301 participants responded to recruiting advertisements across nine US sites.
  • A total of 194 participants completed the study. All participants reported smoking more than 15 cigarettes per day and expressed motivation to quit smoking.
• Researchers randomly assigned participants to experimental (i.e., one of five possible doses of NicVAX) and control (i.e., placebo) conditions.
• Using an electronic diary, participants recorded their cigarette use and researchers collected blood and urine to objectively measure cigarette consumption.
• The study utilized blood antibody concentration as the independent variable.
  • Researchers divided participants into three groups: high Ab (top 30% of participants; n = 38), low Ab (remaining 70% of those who received vaccine; n = 89) and placebo (n = 67).

Results

• The high Ab group was roughly twice as likely to achieve eight weeks of complete abstinence (24.6%) compared to the placebo group (12.0%; p = .024, odds ratio (OR) = 2.69, 95% CI [1.14-6.37]). However, low Ab participants (9.3%) did not differ statistically from the placebo group (p = .46). The high Ab group also was about two and a half times as likely to remain abstinent 26 weeks after the final infusion (19.7%) compared to the placebo group (10.0%; p = .44, OR = 2.46, CI [1.53-7.13]). Again, the low Ab group (7.1%) did not differ from the placebo group (10.0%, p = .43). Researchers defined abstinence as self-reported abstinence confirmed by blood and urine testing. Figure 1 shows the rates of 8-week abstinence for the three analysis groups.
• Participants in the high Ab group who did not completely abstain from smoking smoked on average 4.6 fewer cigarettes per person per day compared to placebo participants. The authors do not report the difference compared to the low Ab group.
• Participants did not report any differences in withdrawal symptoms across groups.

Figure 1: Rates of eight-week continuous abstinence for the three analysis groups. Adapted from Hatsukami et al. (2011)

 

Limitations

• All participants expressed motivation to change, and the vast majority had previously attempted to quit smoking. These results might not generalize to smokers who are not motivated to quit.
• The investigators used vaccine dosages that only yielded high Ab for 30% of the sample. The study does not provide a recommended dosage regimen to reliably reach therapeutically relevant Ab levels.  

Discussion

Although not a miracle cure, NicVAX shows promise as a treatment option. Six month abstinence rates for those in the high Ab group are more than twice as high as those reported for nicotine replacement therapy and four times higher than those who attempt to quit ‘cold turkey’. Further research and development is needed to perfect precise dosage regimens, but NicVAX might be a very useful tool in the arsenal of treatment options against nicotine addiction. If stage III trials run smoothly, NicVAX may be FDA approved by the end of 2011 and available as a treatment by 2012 (Drugwatch.com, 2009).

-Daniel Tao

What do you think? Please use the comment link below to provide feedback on this article.

References

Drugwatch.com. (2009). Nicotine Vaccine NicVAX is first to reach late-stage trials.   Retrieved Feb. 24, 2011, from http://www.drugwatch.com/news/2009/11/12/nicotine-vaccine-nicvax-first-reach-late-stage-trials/

Hatsukami, D. K., Jorenby, D. E., Gonzales, D., Rigotti, N. A., Glover, E. D., Oncken, C. A., et al. (2011). Immunogenicity and smoking-cessation outcomes for a novel nicotine immunotherapeutic. Clinical Pharmacology & Therapeutics, 89(3), 392-399.