The Brief Addiction Science Information Source (BASIS)

ASHES Vol. 4(4): Nicotine without All the Smoke: Smokers’ Preferences for Medicinal Nicotine or Smokeless Tobacco

As a result of the many difficulties associated with quitting smoking (e.g., psychological and physiological withdrawal) and even the challenges to reducing smoking (e.g., unintended increase in smoking intensity via deeper puffs), tobacco control experts have recommended the use of pure nicotine products as a “harm-reduction strategy”.  Studies show that the use of medicinal nicotine (MN; e.g., nicotine gum, an inhaler) significantly reduces smoking (Bolliger et al., 2000; Wennike, Danielsson, Landfelt, Westin, & Tonnesen, 2003).  Alternatively, people occasionally advocate smokeless tobacco (SLT) as another potential aid in smoking reduction; SLT products contain chemical toxins but are arguably less harmful than smoking (Royal College of Physicians of London, 2000).  This week’s ASHES reviews an investigation of the comparative appeal of MN and SLT to current smokers.

Shiffman, Gitchell, Rohay, Hellebusch, and Kemper (2007) conducted two studies comparing smokers’ self-reported preference for MN or SLT.  In Study 1, the researchers contacted participants via a random-digit-dial telephone interviewing system using numbers from the United States Scientific Telephone Sample; 66% of those contacted completed the survey. The interviewer played current smokers (n=283) a recording of a 1-minute advertisement describing each product (as seen in Table 1), and asked them standard market research questions about which one they preferred. Study 2 followed the same procedure.  However, in Study 1, the advertisements introduced prototypical forms of both MN and SLT (e.g., nicotine gum, chewing tobacco, respectively) whereas in Study 2, both products were introduced in a novel manner, as lozenges.  Here we only report the findings of Study 1 because the results refer to the more widely known forms of MN and SLT.

Table 1. MN and SLT Readings (adapted from Shiffman et al., 2007)

Analyses indicated participants reported a significant preference for MN:  59% of participants preferred MN whereas only 22% of participants reported preferring SLT (p<0.0001).  Previous SLT users (n=69) expressed a greater preference for MN than SLT (44% vs. 39%), as did nonusers (n=214; 64% vs. 17%).  However, a chi-square analysis indicated independence between the groups; nonusers’ preference was significantly greater than that of previous SLT users (p=.0003).  Both previous MN users (n=37) and nonusers (n=246) preferred MN to SLT (67% vs. 19%, 58% vs. 23%, respectively), but there was no interaction between the groups’ preferences (p=ns).   

There are two intertwined limitations of this study.  First, participants assessed their preference for a product based only on a 1-minute description; without a more detailed explanation of the product or the opportunity to experiment with it, it is unlikely that participants could form a valid opinion.  Second, people’s intended or expected actions often differ from their actual behaviors (Baumeister, Vohs, & Funder, 2007).  Therefore, although participants expressed an increased likelihood of using MN, it is possible that given the opportunity, participants would choose SLT or an entirely different option. 

The results of this study serve as an initial aid in creating both safe and appealing ways for smokers to obtain nicotine without smoking.  Although public health strategies previously encouraged people to quit nicotine consumption altogether, the use of replacement nicotine has been shown to reduce smoking, which reduces the amount of toxins ingested into the body.  Further investigations are needed to determine the least harmful and most attractive forms of pure nicotine products before this concept of replacement nicotine can be seriously utilized as a public health strategy.

What do you think?  Comments can be addressed to Sara Kaplan.

References

Bates, C., Fagerstrom, K., Jarvis, M. J., Kunze, M., McNeill, A., & Ramstrom, L. (2003). European Union policy on smokeless tobacco:  A statement in favour of evidence based regulation for public health. Tobacco Control, 12(4), 360-367.

Baumeister, R. F., Vohs, K. D., & Funder, D. C. (2007). Psychology as the science of self-reports and finger movements:  Whatever happened to actual behavior? Perspectives on Psychological Science 2(4), 396-403.

Bolliger, C. T., Zellweger, J. P., Danielsson, T., van Biljon, X., Robidou, A., Westin, A., et al. (2000). Smoking reduction with oral nicotine inhalers:  Double blind, radnomized clinical trial of efficacy and safety. British Medical Journal, 321, 329-333.

Royal College of Physicians of London. (2000). Nicotine addiction in Britain:  A report of the Tobacco Advisory Group of The Royal College of Physicians. London: Royan College of Physicians.

Shiffman, S., Gitchell, J., Rohay, J. M., Hellebusch, S. J., & Kemper, K. E. (2007). Smokers' preferences for medicinal nicotine vs. smokeless tobacco. American Journal of Health Behavior 31(5), 462-472.

Wennike, P., Danielsson, T., Landfelt, B., Westin, A., & Tonnesen, P. (2003). Smoking reduction promotes smoking cessation: Results from a double blind randomized, placebo-controlled trial of nicotine gum with 2-year follow-up. Addiction, 98(10), 1395-1402.

ASHES Vol.4(3) - Bet You Can't Have Just One

During the 1970s, Russell (1971) made the claim that smoking more than 20 cigarettes a day would result in a nicotine addiction and associated withdrawal symptoms. In 2000, the Dependence and Assessment of Nicotine Dependence in Youth (DANDY) study challenged Russell’s claim and reported that withdrawal symptoms could appear from smoking as few as 5 cigarettes a day (J. DiFranza, Savageau, & Fletcher, 2002). In this week’s ASHES, we review DiFranza et al’s 2007 article examining how quickly nicotine dependence symptoms appeared among an adolescent population.

Researchers recruited 1,246 sixth graders from Massachusetts public schools and used a trained interviewer to administer three surveys per year from January 2002 to January 2006. Nearly 1000 (i.e., 970) participants completed all the surveys. Each subject used a calendar to record the following personal smoking milestones at each assessment: first puff, inhalation, start of monthly, weekly, and daily smoking, and changes in type, duration, frequency (including periods of abstinence) of smoking. Researchers also collected responses to the Hooked on Nicotine Checklist (HONC; J. R. Difranza & Wellman, 2006), and the International Statistical Classification of Diseases, 10th Revision (ICD-10; World Health Organization, 1992) criteria for tobacco dependence. Endorsement of one or more of the 10 HONC scale items indicated a loss of autonomy (1). Researchers classified participants as tobacco dependent if they experienced three or more of the 22 ICD-10 items.

The study found that both loss of autonomy and development of tobacco dependence occurred soon after first tobacco use. Focusing on the 217 participants who inhaled, researchers found that 127 had indeed lost autonomy over tobacco use and that 10% did so within two days of their first cigarette inhalation experience. Smoking an estimated minimum of seven cigarettes per month resulted in a loss of autonomy. Researchers also found that 83 participants, all of whom inhaled, developed ICD-10 defined dependence as soon as 13 days after their first inhalation, and that approximately 50% of them did so upon reaching a 46-cigerette per month smoking frequency (~1-2 cigarettes a day; J. R. DiFranza et al., 2007). Table 1 presents the percentage of participants (n=217) who endorsed HONC Scale items and how frequently these symptoms occurred before and after the onset of daily smoking.

Table 1: Smoking Milestones & Their Association with Daily Smoking*

*adapted from Table 3, Incidence of Milestones and Their Association With Daily Smoking in DiFranza, J. R., Savageau, J. A., Fletcher, K., O'Loughlin, J., Pbert, L., Ockene, J. K., et al. (2007). Symptoms of Tobacco Dependence After Brief Intermittent Use. Archives of Pediatric & Adolescent Medicine, 7(161), 704-710.
*The milestones are listed sequentially as they occur before and after the onset of daily (e.g, loss of autonomy occurred before smoking everyday and failed quit attempts occurred after.

The study was limited by its use of interviews as its main data collection source. This methodology risks recall errors due to length of time between subsequent interviews. Furthermore, there are also personal biases that arise from and skew self-reported data. Lastly, researchers included biological tests of tobacco dependence through the collection of saliva samples (to test cotinine levels), for some but not all participants.

DiFranza et al.’s research suggests that a relatively brief time lag exists between the first tobacco use experience and the appearance of physiological dependence to tobacco and the withdrawal symptoms that emerge upon cessation. The study’s findings serve to remind adolescents that first time experimentation with various dependence producing substances is not innocuous. The days following first tobacco experience are crucial in determining whether an adolescent will experience dependence-related symptoms. The implication for substance abuse prevention programs and health administrators is that this brief time lag necessitates readily available and rapid responses to experimenting adolescents in order to interrupt the onset of withdrawal symptoms and the development of addiction.

What do you think? Comments can be addressed to Ingrid Maurice.

Note: 1 Full autonomy is lost when the sequelae of tobacco use, either physical or psychological, present a barrier to quitting.(J. DiFranza et al., 2002)

References

DiFranza, J., Savageau, J., & Fletcher, K., et al. (2002). Development of symptoms of tobacco dependence in youths: 30 month follow up data from the DANDY study. Tobacco Control, 11(3), 228-235.

DiFranza, J. R., Savageau, J. A., Fletcher, K., O'Loughlin, J., Pbert, L., Ockene, J. K., et al. (2007). Symptoms of Tobacco Dependence After Brief Intermittent Use. Archives of Pediatric & Adolescent Medicine, 7(161), 704-710.

Difranza, J. R., & Wellman, R. J. (2006). Hooked on Nicotine Checklist (HONC).   Retrieved March 11, 2008, 2008, from http://fmchapps.umassmed.edu/honc/TOC.htm

Russell, M. (1971). Cigarette smoking: natural history of a dependence disorder. British Journal of Medical Psychology, 44(1), 1-16.

World Health Organization. (1992). International Classification of Diseases, 10th Revision (ICD-10). Geneva, Switzerland.

ASHES Vol. 4(2) - Can You Teach an Old Dog New Tricks? Smoking Cessation Interventions among Older Adults

Smoking cessation interventions vary in effectiveness (West, McNeill, & Raw, 2000) and scant research has examined how age impacts effectiveness.  Most participants in smoking cessation studies are relatively young (Connolly, 2000).  Perhaps investigators assume that older adults would not be interested in, or benefit from, smoking treatment, or that it would be easier to enroll younger adults in research.  However, there is evidence that older adults are as responsive to cessation programs as younger adults (Glynn, 1988; Morgan et al., 1996).  In this week’s ASHES, we examine recent research on a smoking cessation intervention among older adults.

Tait, Hulse, Waterreus, Flicker, Lautenshlager, Jamrozik, and Almeida (2007) recruited 215 current smokers, aged 68 years or older, from a community study of older men (Norman et al., 2004).  This sample hailed from Perth, Western Australia and surrounding communities. The volunteers responded to media advertisements soliciting participants.  Fifty participants (23%) reported that they did not want to quit smoking (i.e., continuing smokers) and 165 participants (77%) reported that they were interested in quitting (i.e., non-randomized intervention group).  All participants provided demographic information, detailed smoking histories, and responded to the Fagerström Test of Nicotine Dependence (FTND).  Investigators provided participants in the intervention group counseling, personalized educational materials, information about local services that help people to quit, and if requested, nicotine replacement therapy (NRT) patches.  Trained staff members also called participants in the intervention group six different times during the study to offer support and guidance with weight management and coping strategies.  Nearly all participants returned six months later (88% follow-up rate) for interviews; during this interview, they exhaled carbon monoxide (ECO) for a confirmation assessment.

Follow-up interviews indicated that 88.5% of the intervention group had attempted to quit smoking during the previous six months; at follow-up, 29% of the intervention group had remained abstinent for the 30 days prior to the follow-up, and an additional 20% of the group reported abstinence during the entire six-month period.  None of the continuing smokers attempted to quit.  In fact, Figure 1 shows, participants in the intervention group significantly decreased the median number of cigarettes smoked per day (Z=6.30, p<0.001), whereas the median number of daily cigarettes among continuing smokers remained the same. 

Figure 1:  Median daily cigarettes among continuing smokers and the intervention group   

This study has limitations. These results might not generalize to other older adults.  Participants self-selected either the control group or intervention group.  Therefore, the cessation rates among the intervention group, a group of adults electing to quit smoking, might be higher than that of older adults in general.  Moreover, the effectiveness of the specific intervention used in this study cannot be assessed; the success of the intervention group cannot be compared to that of the control group since the control participants did not share a fundamental characteristic with the intervention participants (i.e., expressing interest in quitting smoking).

This study’s findings indicate that some older adults are both interested in and capable of quitting smoking.  Although this conclusion is simple, its implications are substantial.  Firstly, the success of these older adults should influence future examinations of smoking cessation interventions (e.g., the populations targeted).  Developing a greater understanding of older adults’ motivations to quit smoking could help engage a greater percentage of older adults in smoking cessation interventions.  Secondly, the significant responses to this intervention should encourage physicians to provide advice about smoking cessation to all patients, no matter how old. 

What do you think?  Comments can be addressed to Sara Kaplan.

References

Connolly, M. J. (2000). Smoking cessation in old age:  Closing the stable door? Thorax, 29, 193-195.
Glynn, T. J. (1988). Relative effectiveness of physician-initiated smoking cessation programs. Cancer Bulletin 40, 359-364.

Morgan, G. D., Noll, E. L., Orleans, C. T., Rimer, B. K., Amfoh, K., & Bonney, G. (1996). Reaching midlife and older smokers:  Tailored interventions for routine medical care. Preventative Medicine 25, 346-354.

Norman, P. E., Jamrozik, K., Lawrence-Brown, M. M., Le, M. T., Spencer, C. A., Tuohy, R. J., et al. (2004). Population based randomized controlled trial on impact of screening on mortality from abdominal aortic aneurysm. British Medical Journal 329, 1259-1262

Tait, R. J., Hulse, G. K., Waterreus, A., Flicker, L., Lautenshlager, N. T., Jamrozik, K., et al. (2007). Effectiveness of a smoking cessation intervention in older adults. Addiction 102, 148-155.

West, R., McNeill, A., & Raw, M. (2000). Smoking cessation guidelines for health professionals:  An update. Thorax, 55, 987-999.

ASHES Vol. 4(1) - Is Honesty Always the Best Policy? How the TRUTH and “Think. Don’t Smoke.” Anti-Smoking Campaigns Influence Adolescent Perceived Smoking Prevalence

Research has shown that some adolescents tend to overestimate smoking among their peers (Sherman, Presson, Chassin, Corty, & Olshavsky, 1983; Tyas & Pederson, 1998). Longitudinal and cross-sectional studies show that such overestimation predicts smoking in the future (Miller & McFarland, 1987; Prentice & Miller, 1996).  Anti-smoking campaigns have worked to correct adolescents’ inaccurate perceptions about smoking prevalence; however, there is a paucity of research assessing the effect of these programs.  This week’s ASHES reviews a comparison of the TRUTH and the “Think. Don’t Smoke.” (TDS) campaigns’ influence on adolescents’ perceived smoking prevalence.

To evaluate the influence of two anti-smoking public health campaigns, TRUTH and TDS, on youth smoking rates, Davis, Nonnemaker, and Farrelly (2007) analyzed data from eight cross-sectional waves of the Legacy Media Tracking Survey (LMTS), which were conducted between winter 1999 and fall 2003 (response rates = 52.5%, 52.3%, 60.4%, 46.7%, 51.7%, 53.1%, 42.5%, 30.1%, respectively).  The TRUTH campaign featured adolescents stating facts about the tobacco industry and the TDS campaign featured adolescents declaring their personal reasons for not smoking. LMTS assessed the extent of adolescents’ (n=35,074; ages 12-7 years) exposure to both antismoking campaigns by confirming (1) exposure to at least one television advertisement, (2) prompted recall of a specific campaign slogan, or (3) unprompted recall of a specific campaign slogan. The survey also asked participants to estimate the prevalence of smoking among their peers, and to report their own smoking behavior. 

Linear trend tests indicated a significant decrease in the perception about peer smoking prevalence among adolescents between the first and last LMTS wave (45.4% to 37.5%, p<.05).   Figure 1 shows that this decline in perceived smoking prevalence was similar to a significant decrease in actual smoking prevalence among participants during the same period (12.7% to 7.6%, p<.05). Regression analyses indicated that participants who confirmed exposure to the TRUTH campaign in measures (1), (2), or (3) all estimated the smoking prevalence among adolescents to be significantly lower (campaign awareness regression coefficients were 1.4, 1.6, and 1.7 percentage points lower, respectively) than those who were unaware of the campaign (p <.02, p<.03, p<.04, respectively).  However, there were no significant differences in the estimation of smoking prevalence between participants who confirmed exposure to the TDS campaign and those who did not.

Figure 1: Smoking Prevalence Among 12 to 17 Year-Olds

This study is not without its limitations.  The study found statistically significant but clinically small differences due to exposure to the TRUTH campaign, and only for the comparison between first and last wave estimates. This difference might be confounded by the large decline in the response rate at these observation points (i.e., 52.5% to 30.1%). 

The results of this investigation indicate that adolescents find actual information about the tobacco industry more compelling than their peers’ personal beliefs.  Future research should focus on the components of the TRUTH campaign that have led to the program’s success; developing successful marketing methods to correct adolescents’ magnified perception of smoking prevalence indirectly might help to reduce future smoking behavior.

What do you think? Comments can be addressed to Sara Kaplan.

References

Davis, K. C., Nonnemaker, J. M., & Farrelly, M. C. (2007). Association between national smoking prevention campaigns and perceived smoking prevalence among youth in the United States. Journal of Adolescent Health, 41, 430-436.

Miller, D. T., & McFarland, C. (1987). Pluralistic ignorance:  When similarity is interpreted as dissimilarity. Journal of Personality and Social Psychology, 53, 298-305.

Prentice, D. A., & Miller, D. T. (1996). Pluralistic ignorance and the perpetuation of social norms by unwitting actors. Advances in Experimental Social Psychology 28, 161-209.

Sherman, S. J., Presson, C. C., Chassin, L., Corty, E., & Olshavsky, R. (1983). The false consensus effect in estimates of smoking prevalence:  Underlying mechanisms. Personality and Social Psychology Bulletin, 9, 197-207.

Tyas, S. L., & Pederson, L. L. (1998). Psychosocial factors related to adolescent smoking:  A critical review of the literature. Tobacco Control, 7, 409-420.

ASHES Vol. 3(10) - Beyond Cigarettes: The Prevalence of Polytobacco Use in the United States

Much tobacco research and public health reporting has focused on cigarettes, but seven billion dollars worth of cigars, pipes, and smokeless tobacco are sold in the United States each year (U.S.D.A.).  The few studies of polytobacco use (i.e., cigarette use in combination with other tobacco products) suggest that such use can lead to increased risk of tobacco-related diseases and nicotine addiction (Gilpin & Pierce, 2003; Wetter et al., 2002).  This week’s ASHES reviews a study which explores the prevalence and characteristics of polytobacco users across the United States.

Bombard, Pederson, Nelson, and Malarcher (2007) analyzed the Behavioral Risk Factor Surveillance System (BRFSS) data from the ten states (i.e., Arkansas, Colorado, Delaware, Indiana, Nebraska, New Jersey, North Carolina, North Dakota, Texas, and Wyoming) whose surveys incorporated a module focusing on the consumption of tobacco products.  The random-digit-dialed telephone survey included items about whether participants (n=56,099) ever smoked cigarettes (i.e., smoked 100 or more cigarettes), used cigars, smokeless tobacco, pipes, and bidis, and currently smoked cigarettes and used cigars, smokeless tobacco, pipes, and bidis. 

Results indicated that 22.4% of adults currently used cigarettes (i.e., using every day or most days) but only 3.4% of adults were polytobacco users. Table 1 shows that the predictive value of many characteristics included in the multivariate analysis is weak.  However, gender, education level, and “more-than-moderate” alcohol use predicted both cigarette and polytobacco use.  Men reported a slightly higher likelihood of smoking cigarettes than women and were 9.6 times more likely than women to be polytobacco users.  Respondents with less than a high school education were equally likely to be cigarette smokers as polytobacco users; respondents who reported “more-than-moderate” alcohol use were more likely to be cigarette smokers and significantly more likely to be polytobacco users. 

Table 1. Prevalence and characteristics associated with cigarette use among adults and current polytobacco use among adult smokers (adapted from Bombard et al., 2007).

This study is limited to respondents from the ten states that included a tobacco product module within their BRFSS surveys; findings from the study might not generalize well to populations in other states.  Also, responses were self-report, possibly underestimating or biasing the prevalence of tobacco use.

This study is one of the first to examine the prevalence of, and characteristics associated with, polytobacco use; the findings provide significant insight into tobacco use beyond cigarettes.  Although these results indicate a low prevalence of polytobacco use, especially among women, clinicians and scientists should not overlook this phenomenon.  More information is needed about the escalated risk profile associated with polytobacco use. Hopefully, a better understanding of the extent of polytobacco use and the population of polytobacco users will stimulate enhanced intervention and prevention programs.

What do you think? Comments can be addressed to Sara Kaplan.

References

Bombard, J. M., Pederson, L. L., Nelson, D. E., & Malarcher, A. M. (2007). Are smokers only using cigarettes?  Exploring current polytobacco use among an adult population. Addictive Behaviors, 32, 2411-2419.

Gilpin, E. A., & Pierce, J. P. (2003). Concurrent use of tobacco products by California adolescents. Preventive Medicine, 36, 575-584.

U.S.D.A. Briefing Room.  Tobacco:  Data tables.  Expenditures for tobacco products and disposable personal income, 1989-2005. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service.

Wetter, D. W., McClure, J. B., de Moor, C., Cofta-Gunn, L., Cummings, S., Cinciripini, P. M., et al. (2002). Concomitant use of cigarettes and smokeless tobacco:  Prevalence, correlates, and predictors of tobacco cessation. Preventive Medicine, 34, 638-648.

ASHES Vol. 3(9): Varenicline vs. Bupropion SR - Two pharmacotherapy options for smoking cessation go head to head in a clinical trial

Most everyone in the developed world knows the health effects of tobacco smoke and more than 70% of smokers report that they want to quit (Schroeder & Cox, 2006). Those wishing to quit have a variety of tools to choose from, including, Nicotine Replacement Therapy (NRT) (see ASHES Vol. 3(6)), smoking cessation treatment programs (see ASHES Vol. 3(5), ASHES Vol. 3(4), and ASHES Vol. 2(9)), and drug therapy, which until recently was limited to bupropion SR (ALA, 2006).  This week ASHES reviews a clinical trial that studied the safety and efficacy of varenicline, a drug treatment option recently approved by the FDA, to help people with nicotine dependence.

Gonzalez et al. (2006) used a randomized double-blind, parallel-group, placebo-and active-treatment-controlled, phase 3, multi-site clinical trial of varenicline to study its effectiveness in helping people to quit smoking.  Participants, recruited through media advertisements, included healthy people 18 to 75 years of age, who smoked at least 10 cigarettes per day, were not abstinent during the previous 3 months, and who had a desire to quit.  Researchers randomized 1,025 eligible participants in a 1:1:1 ratio to receive either varenicline 1mg twice daily, bupropion SR 150mg twice daily, or matching placebo for 12 weeks, and then followed participants for 40 weeks.  Gonzalez et al. reported similar compliance rates for the groups, with the median treatment time being 84 days.   Participant completion rates varied from 60.5% for varenicline, 56% for bupropion SR, and 54% for placebo. 

Researchers measured continuous abstinence through exhaled carbon monoxide. As Table 1 shows, at weeks 9-12 and weeks 9-24 the group taking varenicline had a higher continuous abstinence rate than both bupropion SR and placebo.  At week 52, the group taking varenicline had a continuous abstinence rate of 21.9% that was no longer statistically different from the 16.1% continuous abstinence rate of the group taking bupropion SR.  However, both groups were statistically different from the 8.4% continuous abstinence rate of the placebo group.

Note. P<.001 for all comparisons except varenicline vs. bupropion SR at weeks 9-24 (P=.007),
varenicline vs. bupropion SR at weeks 9-52 (P=.057), and bupropion SR vs. placebo at weeks 9-52 (P=.001).

Limitations to this study include restricting the study to only healthy individuals.  The study also excluded those who had previously used bupropion SR for either depression or to help them quit smoking.  The researchers did this to study the true difference between the drugs and prevent a negative bias against bupropion SR.  Consequently, it is possible that both groups might be more motivated to quit. This extra motivation might increase the continuous abstinence rate.

Despite these limitations, this study suggests that, for some, varenicline is an effective treatment for smoking cessation.  Results showed that 22% of participants who used varenicline were able to remain abstinent for the full 52 weeks of the study, a rate two-and-a-half times that of the placebo.  Importantly, the results indicate that people in the varenicline group quit smoking more quickly. Improving health more quickly is an important effect even if over the long-term rates of improvement equal out.  That said, there is no cure-all, no magic pill for everyone, only options that people should use with trial and error until they are able to maintain, in the case of tobacco, abstinence.  When discussing smoking cessation options, doctors, psychiatrists, and patients should remain open to other forms of treatment or consider taking varenicline in concert with nicotine replacement, counseling, or online help.  Although quitting smoking is a difficult task, it is possible, and many people succeed everyday. Perhaps most importantly, they succeed using a variety of methods.

What do you think? Comments can be addressed to John Kleschinsky.

References

ALA. (2006). Nicotine Replacement Therapy (NRT) and Other Medications Which Aid Smoking Cessation, Quit Smoking.

Gonzales, D., Rennard, S. I., Nides, M., Oncken, C., Azoulay, S., Billing, C. B., et al. (2006). Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial. Jama, 296(1), 47-55.

Schroeder, S. A., & Cox, H. C. (2006). Trials that Matter: Varenicline: A Designer Drug to Help Smokers Quit. Annals of Internal Medicine, 145(10), 784-785.

ASHES Vol. 3(8) - Pregnant and Smoking: Differences from Women who Abstain

Conventional medical care discourages pregnant women from smoking. However, quitting might be more difficult for some than others. For example, people with psychiatric disorders are more likely to smoke tobacco (Breslau, Kilbey, & Andreski, 1993; Gonzalez-Pinto et al., 1998), possibly because of self-medicating features of nicotine (Pomerleau, Marks, & Pomerleau, 2000). This week’s ASHES examines research detailing rates of various psychiatric disorders and certain demographic features of pregnant women who smoke, women who quit smoking because of their pregnancy, and pregnant women who never smoked.

Flick et al. (2006) administered the Diagnostic Interview Schedule, Version IV (DIS; Robinson & Killen, 1997) to 733 of 878 Medicaid–eligible women they approached (response rate = 83.5%) who were enrolled in the Missouri-based Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).  The researchers also collected information about the women’s educational status, income, and parity (i.e., how many children they already delivered). 

Table 1.  Prevalence of selected psychiatric disorders and demographic variables that yield the greatest difference by smoking status (n=733; adapted from Flick et al., 2006)

 

The sample ranged in age from 13 to 43 (SD 22.3); 42% never finished high school, 42% were white, 42% were having their first child, 59% lived in an urban area, and 78% had never married.   Figure 1 shows that persistent smokers and those who quit were both more likely to have a psychiatric disorder than non-smokers; more specifically, persistent smokers were 2.5 times more likely than non-smokers, and those who quit were 2 times more likely than non-smokers.  However, non-smokers and those who quit were more likely than those who continued smoking to have more education and higher incomes.

This study has some limitations. The study utilized a self report methodology, so smoking rates and psychiatric symptoms risk underreporting.  Further, the researchers conducted interviews at a single point during the pregnancy, so they were unable to account for all changes in smoking status participants might have made during pregnancy (e.g., quitters who resumed smoking).

Compared to abstainers, the higher rates of psychiatric comorbidity among the two groups of smokers, persistent and those who quit, suggest that lifetime smoking status among pregnant women is a predictor of mental health. However, mental health among lifetime smokers could not distinguish persistent smokers from those who quit during pregnancy. Rather, better predictors of quitting smoking during pregnancy included education and means. Interventions that target pregnant women smokers should incorporate aspects of mental health and socioeconomic improvements.

* Adjusted annual median income for a family of four = $8,224.

What do you think?  Comments can be addressed to Leslie Bosworth.

References

Breslau, N., Kilbey, M. M., & Andreski, P. (1993). Vulnerability to psychopathology in nicotine-dependent smokers: An epidemiologic study of young adults. American Journal of Psychiatry, 150, 941-946.

Flick, L. H., Cook, C.A., Horman, S.M., McSweeney, M., Campbell, C., Parnell, L. (2006). Persistent Tobacco Use During Pregnancy and the Likelihood of Psychiatric Disorders. American Journal of Public Health, 96(10), 1799-1807.

Gonzalez-Pinto, A., Gutierrez, M., Ezcurra, J., Aizpuru, F., Mosquera, F., Lopez, P., et al. (1998). Tobacco smoking and bi-polar disorder. Journal of Clinical Psychiatry, 59, 225-228.

Pomerleau, C. S., Marks, J. L., & Pomerleau, O. F. (2000). Who gets what symptom? Effects of psychiatric cofactors and nicotine dependence on patterns of smoking withdrawal symptomatology. Nicotine and Tobacco Research, 2(3), 275-280.

Robinson, T. N., & Killen, J. D. (1997). Do cigarette warning labels reduce smoking? Paradoxical effects among adolescents. Archives of Pediatric & Adolescent Medicine, 151(3), 267-272.

ASHES Vol. 3(7) - Are Psychiatry Residents Prepared to Work with Patients Who Use Nicotine?

Nicotine dependence is the most common substance use disorder among people with mental illness (Lesser, Boyd et al. 2000; Grant, Hasin et al. 2004).  Mentally ill patients who use tobacco are not only at great risk for developing tobacco-related diseases, but tobacco dependence also can disrupt psychiatric treatment (Hurt, Offord et al. 1996) .  Nevertheless, on average, psychiatrists offer advice about smoking cessation during only 12% of patient visits (Himelhoch and Daumit 2003).  This week’s ASHES reviews a national study that surveyed directors of psychiatry residency programs in the United States about nicotine dependence training in their programs.

Prochaska, Fromont, Louie, Jacobs, and Hall (2006) mailed questionnaires to the training directors of psychiatry residency programs identified on the American Medical Association’s Fellowship and Residency Electronic Interactive Database (N=181). These surveys included questions about the amount of time the programs devoted to tobacco dependence, perceptions of the residents’ skills in aiding patients with quit attempts, and interest in implementing a model tobacco treatment aspect to the curriculum.  Approximately 63% of the targeted participants completed the surveys. 

Results indicated that all of the programs included some form of addiction training, but only half of the programs specifically mentioned nicotine; further, only 43% of those that mentioned nicotine provided clinical experience with nicotine dependent psychiatric patients. Eighty-five percent of the programs including nicotine training only dedicated one hour to the subject, and 10.5% said their nicotine training program was optional.  For more details about the content of the training programs see Table 1.

Table 1.
Prevalence of Content and Materials of Psychiatry Residency Programs with Tobacco Treatment Training (N=57) (Prochaska, Fromont et al, 2006)

 
      
This study is not without limitations. Fewer than two-thirds of the targeted training programs responded. Consequently, there is potential for a response bias. The results also might not be representative of all training programs because of the large proportion of respondents from New York and California (23%). Despite these concerns, this research provides us with a map to the content of psychiatry program tobacco treatment training.

Hughes (1998) reported, “In terms of lives saved, quality of life, and cost efficacy, treating smoking is considered one of the most important activities a clinician can do.”  Incorporating smoking cessation efforts into psychiatric treatment is strongly recommended (1996; Dalack and Glassman 1992) and therefore, psychiatry residency programs should expand their nicotine dependence treatment training. In addition, we encourage primary care and other training programs to integrate treatment training into their curriculum. Nicotine dependent patients enter the medical care system through various portals, and thus all health care providers need to be prepared for every opportunity.
      

References

(1996). "American Psychiatric Association:  Practice guidelines for the treatment of patients with nicotine dependence." American Journal of Psychiatry 153: 1-31.

Dalack, G. and A. Glassman (1992). "A clinical approach to help psychiatric patients with smoking cessation." Psychiatry Quarterly 1992(63): 27-39.

Grant, B., D. Hasin, et al. (2004). "Nicotine dependence and psychiatric disorders in the United States:  results from the national epidemiological survey on alcohol and related conditions." Arch Gen Psychiatry 61: 1107-1115.

Himelhoch, S. and G. Daumit (2003). "To whom do psychiatrists offer smoking-cessation counseling?" American Journal of Psychiatry 160: 2228-2230.

Hurt, R., K. Offord, et al. (1996). "Mortality following inpatient addictions treatment:  role of tobacco use in a community based cohort." JAMA 275: 1097-1103.

Lesser, K., J. Boyd, et al. (2000). "Smoking and mental illness:  a population based prevalence study " JAMA 284: 2606-2610.

Prochaska, J. J., S. C. Fromont, et al. (2006). "Training in tobacco treatments in psychiatry:  A national survey of psychiatry residency training directors " Academic Psychiatry 30: 372-278.

ASHES Vol. 3(6) - Nicotine Gum, Patches, and Lozenges: Do They Work for Real-World Smokers?

Clinicians have identified nicotine replacement therapy (NRT), such as nicotine gum, patches, and lozenges, as one of the most cost-effective, life-preserving interventions available to medical science (National Institute for Clinical Excellence, 2002; Silagy, 2004). However, many smokers might use NRT sub-optimally, leading to a lower level of efficacy outside of clinical trials.  This week’s ASHES reports on a multinational cohort study testing the effectiveness of NRT as a smoking cessation tool in the ‘real world’.

West & Zhou (2007) used the Internet to recruit participants who smoked five or more cigarettes per day, were 35 to 65 years old, and intended to quit.  Researchers sent an email invitation to complete a 25-minute online survey three and six months after participants initiated a quit attempt (West et al, 2006). This follow-up measure assessed continuous abstinence since the previous assessment, methods used to quit, and nicotine dependence. 

Of the 1561 smokers from five countries who had made a quit attempt, 1089 (69.8%) were followed three and six months later.  Of these, 344 (31.6%) used NRT and 745 (68.4%) did not.  The success rate of those using NRT was 7.8%, and of those not using NRT was 4.0%.  The odds of achieving six months of abstinence, adjusted for nicotine dependence, among those using NRT were 2.2 times higher than those not using NRT.

Limitations of the study include the fact that the sample was recruited using the Internet. Individuals seeking smoking information on the Internet might not be representative of ‘real world’ smokers attempting to quit.  Self-reported quit rates could be another source of bias, but there is no reason to assume it would contribute to a difference in success rates as a function of NRT use versus non-NRT use.   

Table 1:  Advice for the Effective Use of Nicotine Replacement Therapies (adapted from Kozlowski et al (2007))

This study supports the findings of clinical trials suggesting that NRT use is associated with improved chances of long-term abstinence when used by smokers attempting to quit in the ‘real world’.  To ensure the effectiveness of NRT, these medications should be used properly; Table 1 provides information about correct NRT use.  Further research should be conducted to determine if certain nicotine replacement therapies are more effective than others.

What do you think? Comments can be addressed to Andrew Boudreau.

References

Kozlowski, L., Giovino, G., Edwards, B., DiFranza, J., Foulds, J., Hurt, R., et al. (2007). Advice on using over-the-counter nicotine replacement therapy - patch, gum, or lozenge - to quit smoking. Addictive Behaviors.

National Institute for Clinical Excellence. (2002). National Institute for Clinical Excellence Technology Appraisal Guidance No. 38 Nicotine replacement therapy (NRT) and bupropion for smoking cessation.

Silagy, C., Lancaster T, Stead L, Mant D, & Fowler G. (2004). Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews, 3.

West, R., Gilsenan, A., Coste, F., Zhou, X., Brouard, R., Nonnemaker, J, et al. (2006). The ATTEMPT cohort: a multi-national longitudinal study of predictors, patterns and consequences of smoking cessation; introduction and evaluation of internet recruitment data collection methods. Addiction, 101(9), 1352-1361.

West, R., Zhou, X. . (2007). Is nicotine replacement therapy for smoking cessation effective in the "real world"?  Findings from a prospective multinational cohort study. Thorax Online First.

ASHES Vol. 3(5) - Online Smoking Cessation Treatment

Websites designed to help smokers quit are a relatively new treatment alternative. Treatment is complex and those who subscribe to online help sites deserve to know whether the approach is effective.  This week’s ASHES reviews a study evaluating the online smoking cessation website http://www.quitnet.com/ 

The quitnet.com website offers a variety of resources, including diagnostic tools, information about medication options, social support through forums, chat rooms, and email.  At registration, users provide information about their smoking frequency and motivation to quit.  Cobb, Graham, Bock, Papandonatos, and Abrams (2004) invited consecutive registrants during a fourteen day window to complete a follow-up survey three months later.  This survey collected information about various outcome measures, including 7-day abstinence rates, longest period of abstinence, use of other treatment resources, and, if still not quit, cigarettes smoked per day.  Furthermore, these researchers monitored participant activity on the site during the three months leading up to the follow-up; observations included the number of logins, duration of each login, and which resources registrants used. 

Table 1. Median (interquartile range) of outcomes at 3 months and site use patterns for baseline smokers.



Some registrants were excluded because of incorrect emails or because they never smoked.  Of the 1,024 people included in the study who smoked at the time they registered, 223 received, completed, and returned the follow-up survey.  Thirty percent  of this group (67 people) reported not smoking for at least 7 consecutive days before taking the survey three months after registration (see Table 1).  People in the sample who quit used the interactive web site support services more than people who continued to smoke.  Among quitters and smokers, there were no differences in baseline smoking rate or motivation to quit.

There are a few limitations to the study results.  The response rate was low, risking a selection bias, and there were no control conditions. Simply put, it is not possible to determine whether the site influenced the observed changes or whether influences that already were at work when people registered for the site services caused the smoking changes. Placing the follow-up survey at three months might not have allowed enough time to measure some who successfully quit or who might have relapsed after the three month period. Finally, the follow-up survey was based on self report, which is subject to recall and self presentation biases. 

Without a control group, this study had no method to determine the role the website played in participants’ ability to quit.  Although the number of survey respondents was small, 100,000 people access the site per year.  This suggests that there is a demand for help online. However, whether online resources help people quit, play an ancillary supportive role, or do not help at all is still left to further research.

What do you think?  Comments can be addressed to Leslie Bosworth.

References

Cobb, N. K., Graham, A. L., Bock, B. C., Papandonatos, G., & Abrams, D. B. (2004). Initinal evaluation of a real-world Internet smoking cessation system. Nicotine and Tobacco Research, 7(2), 207-216.

ASHES Vol. 3(4) - Addiction and Technology - Good help is hard to find: Why quitting smoking might be easier than finding smoking cessation resources on the Internet

During 2002, more than 73 million Americans accessed the Internet in search of health information (Fox & Rainie, 2002). As more people gain access to computers, the Internet is becoming a more viable outlet for doing large scale smoking cessation interventions. The anonymity of e-mail and chat rooms helps people feel more comfortable; thus, they might be more likely to talk to counselors and others about smoking and quitting. The Internet offers convenience by allowing users to move at their own pace when attempting to quit. Bock et al., (2004) recently reviewed and evaluated smoking cessation treatment on the Internet.

Researchers utilized four different search engines to locate smoking cessation websites on the Internet including Google because of its mass appeal. Key search terms included phrases such as “stop smoking,” “quit smoking,” and “smoking cessation.” For the study, they reviewed the first ten pages from each search engine. This strategy identified 202 unique websites. Trained coders using structured instruments assessed the quality of content and usability of these websites. Bock et al. assessed content using the U.S. Public Health Service’s national guidelines, which include items such as assessing readiness to quit, assisting with a quit plan, and many other key components. They assessed usability by following guidelines set out by the National Cancer Institute (www.usability.gov) covering four site aspects: design, reading, navigation, and accessibility.

Researchers excluded websites if they did not provide direct Internet based treatment (77%). For example, websites were excluded that had any of the following: product sales only (29%); online libraries with articles about smoking cessation, but no guidance about quitting (13%); websites that only included a list of links to other smoking cessation websites (5%); advertisements for clinics, political action websites, education written for health care providers, and abandoned websites. After applying all exclusion criteria, the investigators eliminated 156 websites from the analysis (See Table 1).

Table 1: Categories of smoking cessation Internet websites

The investigators analyzed the 46 included websites for content, quality, usability, and accessibility. These sites represent only 23% of the total websites found on the first ten pages of each of the four search engines. Consequently, the odds are greater than 3:1 against finding a website that provides even minimal treatment for tobacco cessation. Only 5 (10.7%) of the analyzed websites provided adequate to extensive coverage of the key components laid out by the U.S. Public Health Service (see Table 2). Approximately two-thirds of the websites had content that was easy or very easy to locate. However, the mean reading level for the websites was grade 8.8, which for many people might be demanding, especially people for whom English is a second language.

Table 2. The five highest rated websites in terms of coverage, accuracy, and use of interactivity (Bock et al., 2004)

We identified three potential limitations to this study. First, the Internet is a fluid entity, websites are continuously created, destroyed, and updated and the results only reflect the websites available on the day the search was done.

Second, this was not an exhaustive search, but a search limited to the first ten pages of each of the four search engines used. Although it is probably true that most people would give up well before they reach page 10 of any search engine, people with a strong desire to quit smoking might reach beyond page 10 in an attempt to find an appropriate Internet tool to help them quit smoking. Third, due to the breadth of information available on each of these websites, the researchers might have missed some content on each of the websites.

Despite these concerns, the study findings indicate that quality smoking cessation treatment is available on the Internet, but smokers likely will have difficulties distinguishing among the numerous websites. Future efforts should try to improve content to satisfy the guidelines established by the U.S. Public Health Service. Websites should implement technology that interacts with clients and helps them monitor and comply with their smoking cessation therapies. This innovative technology might increase the usefulness and effectiveness of web-based smoking cessation intervention and ultimately help more smokers to quit.

What do you think? Let us know. Comments can be sent to John Kleschinsky.

References

Bock, B., Graham, A., Sciamanna, C., Krishnamoorthy, J., Whiteley, J., Carmona-Barros, R., et al. (2004). Smoking cessation treatment on the Internet: content, quality, and usability. Nicotine & Tobacco Research, 6(2), 207-219.

Fox, S., & Rainie, L. (2002). E-patients and the online health care revolution. Physician Executive, 28(6), 14-17.

ASHES Vol. 3(3) - Addiction and Technology: Is Tobacco Legislation On-line?

Anyone, including children, with online access and limited computer skills can enter input and receive output via the Internet. Security is a major concern of parents and lawmakers seeking to protect children from pornography, pedophiles, alcohol and tobacco, which are all present within a sovereign Internet nation. Since the 1990’s and the birth of stricter tobacco legislation, it has become more difficult for minors to purchase cigarettes from convenience stores and other tobacco vendors. However, with a new generation of technology-savvy minors, this legislation stands to be undermined by Internet tobacco sales. This week’s ASHES will focus on the sale of tobacco to minors over the Internet.

Abrams, Hyland and Cummings (2003) set out to determine the prevalence of Internet cigarette purchasing among underage youth. They conducted an anonymous survey including questions about tobacco use and access to cigarettes with 7,621 ninth graders in three different Western New York counties. Of the eligible schools, 58% (N=46) participated and 95 to 98% of students per school completed the survey representing 47% of eligible ninth graders overall. Researchers defined current smokers as anyone who smoked at least once in the past 30 days. Smokers were asked additional questions about past and future use of the Internet to purchase cigarettes.

Overall 18% (n=1,402) of the sample was classified as current smoker. Few of the smokers, 2.3% (n=31), reported ever buying cigarettes over the Internet, and 1.7% (n=22) reported buying cigarettes over the Internet in the past 30 days. Despite these low rates, 9% (n=126) of current smokers reported that they intended to buy cigarettes over the Internet in the next year. Additionally, only nine of the 31 students who had purchased cigarettes over the Internet in the past 30 days were asked for proof of age. This lack of oversight makes the Internet a viable purchasing alternative to the stricter tobacco legislation in real-world venues.

There are several limitations to this study including restricting the study to ninth grade students. Older minors might use the internet more frequently to purchase cigarettes because they make more Internet purchases. A study including multiple age groups would more accurately measure Internet cigarette purchasing among underage students. Additionally, the authors used a broad definition of current smoking that included occasional smokers who might have no need to purchase their own cigarettes. In this study, the majority, 57.8% (n=764), of the study’s smokers were occasional smokers. Finally, the study content, asking about Internet purchasing of cigarettes, might have alerted some students to this option and prompted their intentions.

Despite these limitations, the present study offers two important conclusions. First, new legislation is necessary to enforce age verification practices by Internet tobacco vendors because based on this survey, the majority failed to do so. Second, the rising instance of underage smokers intending to purchase cigarettes over the Internet will counteract current tobacco control efforts unless immediate actions are taken. The goal of policy reform will be to assure that the off-line laws are enforced online as well.

What do you think? Let us know. Comments can be sent to Erinn Walsh.

References

Abrams, S. M., Hyland, A., & Cummings, K. M. (2003). Internet cigarette purchasing among ninth-grade students in Western New York. Preventive Medicine, 36(6), 731-733.

ASHES Vol. 3(2) - Nicotine Dependence—It’s All in the Head

The central nervous system plays a key role in developing and maintaining a variety of pathologies, including addiction (WAGERS 8(34); 8(27); 4(34)). For example, smoking cigarettes activates the brain’s reward-system, which, in turn, stimulates pleasurable feelings (Winger, Woods, Galuska, & Wade-Galuska, 2005); (also see WAGERS 8(30); 8(38); 3 (34)). The effect of brain disease or injury provides a natural opportunity to better understand the functioning of the central nervous system by comparing injured and normal brains. To illustrate, this week’s ASHES reviews Naqvi, Rudrauf, Damasio, & Bechara's (2007) study of individuals with brain lesions, implicating a function of the brain’s insular region in the maintenance of addictive behavior. The present study is important because researchers have not understood the nature of the structure’s role in addictive behavior. Naqvi et al. (2007) connect the insula’s role in bodily representation, cue-induced drug urges, decision making activity prior to drug relapse, and conscious urges. Although the authors use the term smoking addiction, they fail to distinguish between dependence and addiction, therefore it is unclear whether findings apply to nicotine dependence or smoking addiction. We maintain that the current research demonstrates the role the insula might play in maintaining nicotine dependence.

Figure 1. The left insula in the brain shown above along with the right insula, are linked to smoking addiction (Gray, 1918).



The brain learns after repeated exposure that smoking induces pleasurable effects (Winger, Woods, Galuska, & Wade-Galuska, 2005), therefore, it is possible that the insula maintains the behavior of smoking based on its role in bodily representation. Further Critchley et al. (2004), note that the insula shows enhanced activity during interoceptive tasks which involved judging subjective feeling states. This evidence adds support to Naqvi et al.’s (2007) research examining how the insula might influence processes associated with addictive behavior by studying smokers who also have insular brain lesions. Naqvi et al. (2007) identified cigarette smokers with brain damage (N=69), 19 of whom had damage to the insula and 50 with damage to other areas of the brain. All participants met two qualifications: (1) they smoked ≥ 5 cigarettes a day prior to lesion onset; and (2) they smoked for ≥ 2 years prior to the lesion. The two groups, insula-damaged and non-insula damaged were matched on several characteristics including number of years and number of cigarettes smoked before lesion, and the area of the lesion. We present results from analyses that compared those patients who stopped smoking after incurring brain lesions.

Of the patients with insular damage, 68.42% (N=13) quit smoking following the lesion; only 38.0% (N=19) of patients with damage to other parts of the brain quit. Researchers identified patients experiencing “addiction disruption,” meaning they reported quitting <1 day after lesion, they reported not relapsing, rated themselves as <3 on a 1-7 scale of easy to difficult quitting, and reported no smoking urges since quitting. Results indicated that all five patients with right insular lesions and seven of eight patients with left insular lesions met standards of addiction disruption, but only four of the nineteen patients who quit after non-insula lesions (odds ratio = 136.49, χ 2 = 15.48, and P < .001) met the criteria for addiction disruption. To eliminate the possibility that concurrent brain damage in many patients with insular lesions might confound these findings, researchers conducted a region-by-region logistic regression, to find the likelihood of smoking disruption by region of lesion1. The results of this analysis showed only lesion patterns including the right and/or left insula significantly increased the likelihood of smoking disruption.

Although this study is important to the field of addiction research, it also has several limitations. It is unclear whether participants were dependent or addicted based on the inclusion criteria used by researchers, therefore the role of the insula in smoking addiction is overstated at best. The more conservative claim links the insula with nicotine dependence which does not necessarily mean addiction. It is also unclear if researchers are arguing the role of the insula in the processing of nicotine in the brain or its role in the behavioral patterns resulting from nicotine exposure, making it difficult to assess the findings. Further research is necessary due to the small number of participants with damage to the insular region (N=19). Longitudinal research is required to see if recidivism eliminates these statistically significant differences. Prospective research also is required to study non-quitters with insula damage.
Despite these limitations, the present study suggests a new approach to the treatment of nicotine dependence because it encourages clinicians to develop ways of targeting the insula. The research shows participants with damage to the insula smoked less but the nature of the insula’s role remains unclear. This suggests further treatment options that may help individuals for which other methods failed. In this respect the use of nicotine free cigarettes might be one way of tricking the insula into satisfying its conscious urges by smoking without nicotine. Future research is necessary to investigate the insula’s involvement in the maintenance of addictive behavior by studying its role in other expressions of addiction.

What do you think?  Let us know. Comments can be sent to Erinn Walsh.

Notes

1. This analysis included all participants.

References

Critchley, H., Wiens, S., Rotshtein, P., Ohman, A., & Dolan, R. J. (2004). Neural systems supporting interoceptive awareness. Nature Neuroscience, 7(2), 189-195.

Gray, H. (1918). Fig. 731: The insula of the left side, exposed by removing the opercula. Anatomy of the Human Body Retrieved February 20, 2007, from  http://www.bartleby.com/107/illus731.html

Naqvi, N. H., Rudrauf, D., Damasio, H., & Bechara, A. (2007, 26 January 2007). Damage to the Insula Disrupts Addiction to Cigarette Smoking. SCIENCE, 315, 531-534.

Winger, G., Woods, J. H., Galuska, C. M., & Wade-Galuska, T. (2005). Behavioral Perspectives on the Neuroscience of Drug Addiction. Journal of Experimental Analysis of Behavior, 84(3), 667-681.

 

ASHES 3(1) - “Just Say NO,” to advertising?

 

Using meta-analysis, researchers observed that exposure to pro-tobacco marketing increased the odds of youth holding positive attitudes toward tobacco use, and more than doubled the odds of initiating tobacco use compared to young people that had not been exposed (Wellman, Sugarman, DiFranza, & Winickoff, 2006). These researchers concluded that pro-tobacco marketing and media stimulated tobacco use among youth; the investigators suggested that, to protect children, societies ban all tobacco promotions. It is uncertain, however, whether such bans will have the desired significant protective effect. This week’s ASHES examines a study by Galduroz, Fonseca, Noto, and Carlini (In press), which examines tobacco use before and after Brazil instituted a pro-tobacco media ban.

Researchers conducted two surveys (i.e., 1997 and 2004) in the ten largest cities in Brazil; these surveys targeted middle school (i.e., fifth grade to eighth grade) and high school students. Both surveys used identical methodologies and questionnaires to ensure the comparability of results. Students answered a self-administered questionnaire, developed by the WHO’s Research and Reporting Project on the Epidemiology of Drug Dependence, about sociodemographic data (i.e., gender, age, school grade, socioeconomic status) and patterns of use of several drugs (e.g., tobacco, marijuana, cocaine, etc.). Researchers defined lifetime tobacco use as at least once in an individual’s lifetime and heavy use as using tobacco twenty or more times in the month prior to the survey. Researchers analyzed the results by comparing group membership using Chi-Square statistical tests.

The distribution of gender among the respondents was similar in both survey years; in 1997, there were 41.6% males and 54.2% females, compared to 44.2% males and 50.5% females in 2004. This difference was not statistically significant. Overall, the age group with the largest concentration of participants was the 13-15 year-old age group. Furthermore, middle school students comprised the majority of participants (i.e., 65.2% in 1997 and 71.0% in 2004).

In 1997, 32.7% of students surveyed in Brazil had used tobacco during their lifetime; by 2004, the prevalence decreased to 25%. Overall lifetime use of tobacco was significantly lower in 2004 compared to 1997 for 7 of the 10 cities surveyed. For the remaining three cities, Fortaleza, Recife, and Rio de Janeiro, there were no significant changes. Across age groups, rates of lifetime use also were significantly lower in 2004 than in 1997. However, there was a significant increase in lifetime use among the 11-12 year-olds in Fortaleza as well as the 16-18 year-old age group in both Brasilia and Recife (Table 1).

Table 1. Comparison of lifetime use of tobacco between age groups for both survey years (1997-2004)

There were several important limitations to this study. First, the results of the study do not necessarily mean that the ban on pro-tobacco media is a cause for the drop in tobacco use. It is possible that other unmeasured anti-smoking initiatives in Brazil helped to bring down these rates. Therefore, the effectiveness of the ban remains uncertain. Also, the lack of a control group further hinders researcher’s ability to assess the effectiveness of the ban. Researchers were not able to compare Brazil to a similar country that did not institute the same policy regulating against pro-tobacco media. Finally, the sample was not randomized and only included 11-18 year-olds who were in the education system. Therefore, the sample might not have been representative of Brazil; in addition, the sample did not include the most at risk children – those who did not attend school during the data collection period or not at all.

Despite these limitations, this study provides us with a unique examination of how an anti tobacco media policy might affect youth. Nevertheless, the desired effect of such a ban seems to be limited. Future research is needed to assess the mechanisms on which a ban on pro-tobacco media might work. It is important to explore this and other options (e.g., raising cigarette prices, raising the tobacco tax, other prohibitions, etc) in light of the excessive medical and societal costs caused by tobacco-related morbidity and premature mortality.

What do you think? Let us know. Comments can be sent to Juan Molina.

References

Galduroz, J. C. F., Fonseca, A. M., Noto, A. R., & Carlini, E. A. Decrease in tobacco use among Brazilian students: A possible consequence of the ban on cigarette advertising? Addictive Behaviors, In Press, Corrected Proof.

Wellman, R. J., Sugarman, D. B., DiFranza, J. R., & Winickoff, J. P. (2006). The Extent to Which Tobacco Marketing and Tobacco Use in Films Contribute to Children's Use of Tobacco: A Meta-analysis. Arch Pediatr Adolesc Med, 160(12), 1285-1296.

ASHES Vol. 2(10) Institutions of Higher Learning Smoking?

During the past decade, the number of smokers in Mexico increased from 9 million to 13 million (Rasmussen-Cruz, Hidalgo-San Martín, Nuño-Gutiérrez, & Hidalgo-Rasmussen, 2006). The prevalence of Mexican smokers contrasts sharply with decreasing trends among other more wealthy western countries; in these settings, smoking has decreased 5-15% during recent years (Disease Control Priorities Project, 2006). The majority of smokers in Mexico are 18-29 years old. In addition, smoking in Mexico among people under the legal age of 18 has risen (Rasmussen-Cruz et al., 2006). Given increased awareness of the dangers associated with smoking, the observed increases among adolescent and young adult smokers are surprising. This week’s ASHES reviews a study that focused on motivation for tobacco use among Mexican college students. Understanding students’ motivation for smoking could help public health workers develop more effective prevention and intervention programs, with particular emphasis on programs that target young adults.

Rasmussen-Cruz, Hidalgo-San Martín, Nuño-Gutiérrez, and Hidalgo-Rasmussen (2006) surveyed Mexican university health sciences students (N=321) about their tobacco use and motives for tobacco use(1). Two hundred eighty two students aged 16-24 (M=20.3) completed an online questionnaire, which included questions about tobacco use, smoking-related motivations, knowledge about smoking-related diseases, risk behavior questions, sociodemographic characteristics such as socioeconomic status (SES), and age. Four theories guided the development of the motivation items; Table 1 provides a summary of these theories. The questionnaire also measured individuals’ overall functionality as defined by the five-parameters of growth, adaptation, decision-making ability, feelings of affection, and the quality of family life or friendship developed in the Apgar Family and Apgar Peer test (Smilkstein et al., 1982; as cited in (Rasmussen-Cruz, Hidalgo-San Martín, Nuño-Gutiérrez, & Hidalgo-Rasmussen, 2006).

Table 1. Theories endorsed by smokers and non-smokers

The results of this survey indicated that 22.3% of students had smoked within the past month and 22% reported that they felt a deep need to smoke during the past year. In total, 23% of the sample admitted smoking (25.5% of males and 20.7% of females) during the past month. No significant statistical differences in tobacco consumption were observed for age, gender, SES, or functionality. The majority of smokers (65%) began between the ages of 15 and 19. Students endorsed many motivations for smoking: notably, 75.6% of smokers reported smoking to deal with problematic emotional behavior, and 20.7% reasoned that their smoking was logical because they had healthy friends who smoked. Male smokers were more likely to endorse the reasoned action theory (OR 3.35, CI 0.97—12.38, x2 4.47, p < .02) and female smokers were more likely to endorse the theory of problem behavior (OR 3.63, CI 1.61—8.20, X2 5.96, P < .01). Reported motivations for not smoking varied: 47.7% reported that they abstained because it is harmful, 46.2% saw it as a problematic form of behavior, and 29% of students said that one motive for abstinence was their lack of access to cigarettes. There were no differences in the motives given by females and males non-smokers.

There are several limitations to this study, including the sample population. These findings might not generalize because voluntary health science students might not accurately represent all smokers. In addition to the population specificity, the voluntary nature of the study might have biased the survey results. It is possible that there are differences between smokers and non-smokers that also might have influenced choosing to volunteer or not.

Within an institution of higher education, why are so many students lighting up? The authors suggest that motivation accounts, in part, for smoking behavior. Although it would seem logical that students who study health sciences (35% medicine, 15% dentistry, 11% nursing and 16% other disciplines such as psychology) would know better than to smoke. The evidence from this study suggests otherwise. Further, awareness of smoking risks might not be a sufficient deterrent to starting to smoke. Therefore intervention and prevention programs should address motivation as a core factor. Further, the motivations reported by non-smoking college students might also provide valuable information that can be used to strengthen prevention programs for college students that do smoke. Moving forward, researchers and public health works should develop different messages targeting separate population segments based on their differing motivations and smoking behaviors. A long-term smoker with entrenched tobacco dependence should not be targeted in the same way as a university student who recently began to smoke and is not yet dependent. Public health workers must address the unique demographic attributes of population segments to effectively prevent or treat smoking and its associated motivations. This study lends further support for the involvement of school counselors and other mental health professionals in designing prevention and treatment interventions due to the heavy influence emotional motivation has among smokers. More research on smoking motivation among different age groups and populations is needed to enhance prevention and intervention strategies.
What do you think? Let us know. Comments can be sent to Erinn Walsh.

Notes

1. Among these students 28 were excluded because they did not fall between the required age range of 15-24 and 11 were not included because they did not complete the survey.

References

Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.

Becker, M., & Rosenstock, I. (1974). Health Behavior Theories. Retrieved December 7, 2006
Disease Control Priorities Project. (2006). Tobacco Addiction: Tobacco Controls Could Save 3 Million Lives a Year By 2030. Retrieved December 7, 2006, 2006

Fishbein, M., & Ajzen, I. (1975). Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley.

Jessor, R. (1987). Problem-behavior theory, psychosocial development, and adolescent problem drinking. British Journal of Addiction, 82(4), 331-342.

Rasmussen-Cruz, B., Hidalgo-San Martín, A., Nuño-Gutiérrez, B. L., & Hidalgo-Rasmussen, C. (2006). Tobacco Consumption and Motives for use in Mexican University Students. Adolescence, 41(162), 355-368.

ASHES Vol. 2(9) Teen smoking cessation programs can be effective

Rates of tobacco use are high among teens worldwide (see, ASHES vol. 2(2)). Researchers and public health officials direct most of their efforts to influence teen tobacco use toward the prevention of teen smoking and relatively little effort toward teen smoking cessation (Centers for Disease Control and Prevention, 2006). Although curbing tobacco use demands preventing initiation of smoking, cessation programs also are necessary to reduce the likelihood that teen smokers will smoke into adulthood. This week’s ASHES presents evidence about the effectiveness of teen smoking cessation programs.

Sussman, Sun, and Dent (2006) (1) performed a meta-analysis of 48 smoking cessation studies of girls and boys aged 12 to 19 years. The researchers located those studies by searching Internet databases of scientific literature. They included studies that were published in the English language between 1970 and 2003, focused on cigarette smoking cessation, and used a comparison condition. They defined eligible teen smoking cessation programs as any type of cessation intervention that occurred in any setting. Thus, they included any cessation theory (i.e., motivational enhancement, cognitive-behavior, social influence, medical, other) and any modality of intervention (i.e., classroom, school clinics, medical clinics, family, system wide, computer, sensory deprivation, court diversion). To evaluate the effectiveness of interventions, they calculated the net effect of each study as the difference in the quit rates between the intervention and control conditions and pooled the net effects across studies.

The main finding of the meta-analysis was that the interventions increased the average quit rate by a statistically significant average of 2.90% over the control conditions (see Figure 1). Compared with the control conditions, the intervention conditions resulted in 46% more teens that quit smoking. Further analyses indicated that interventions using motivational enhancement, cognitive-behavioral, or a social influence theory produced positive effects. Interventions applied in a classroom or school clinic setting showed positive effects. Programs had to consist of five or more sessions to be effective.

Figure 1. Mean and Standard Error of Quit Rates for Control and Intervention Conditions across 48 Teen Smoking Cessation Studies (Adapted from Sussman, Sun, and Dent, 2006)

Some limitations should be mentioned. The studies included in the meta-analysis did not use a standard definition for smoking cessation. Some studies defined cessation as not smoking for at least 1 week and other studies required no smoking in the last 30 days. The treatment effects by theory and by modality were tested independently without regard to the interactions between theory and modality. Thus, we do not know whether a specific theory will produce positive effects in different modalities. Further, the studies often did not provide information about intervention characteristics such as the training and experience of the treatment providers, or about the demographic composition of the study samples. Also, the article does not define ‘controlled study’ or ‘comparison group’, and it is not clear whether the control conditions were no-treatment assessment-only groups, or minimal or alternative intervention groups, or some combination of both.

The article presents the first meta-analysis of its kind. It shows that intervention programs targeting smoking cessation in teenage girls and boys appear to be effective. The study is useful for deriving both current guidelines for treatment recommendations and future lines of research. Regarding treatment recommendations, the study suggests that interventions should include motivational enhancement, social influence, and cognitive-behavioral approaches, are probably best be delivered in a school-based setting, and should consist of at least five sessions. The study points to the specific need for further research to employ standard definitions of smoking measures and the general need for additional theory-based, methodically well-conducted trials on teen smoking cessation.

What do you think? Let us know. Comments can be sent to Anja Schumann.

Notes
1.  Sussman and colleagues have completed additional systematic reviews of research on teen smoking cessation.

References

Centers for Disease Control and Prevention. (2006). Youth Tobacco Surveillance - United States 2001-1002. MMWR Surveillance Summaries, 55(SS-3), 1-56..

Sussman, S., Sun, P., & Dent, C. W. (2006). A meta-analysis of teen cigarette smoking cessation. Health Psychology, 25(5), 549-557.

Sussman, S., Lichtman, K., Ritt, A. & Pallonen, U. E. (1999). Effects of thirty-four adolescent tobacco use cessation and prevention trials on regular users of tobacco products. Substance Use and Misuse, 34, 1469-1505.

Sussman, S. (2002). Effects of sixty six adolescent tobacco use cessation trials and seventeen prospective studies of self-initiated quitting. Tobacco Induced Diseases, 1(35-81).

ASHES Vol. 2 (8) - Public Policies and Adolescent Cigar Use: Close But No Cigar?

Research suggests that cigar smoking is on the rise, and that smoking cessation programs rarely address cigar use (Symm et al. 2005). Although, both cigarette smokers and cigar users are at an increased risk of several medical conditions (e.g., lung cancer and coronary heart disease) (Ringel, Wasserman, & Andreyeva, 2005), many people still believe that cigar smoking is a safe alternative to cigarettes. Compared to non-cigar smokers, cigar smokers are more likely to believe cigars are less dangerous than cigarettes (Symm, Morgan, Blackshear, & Tinsley, 2005). Adolescents particularly might be susceptible to thinking that cigars are safe because, as ASHES previously reported, some research suggests that more teens smoke cigars than adults. This week’s ASHES takes another look at adolescent cigar smoking and more specifically, public policy’s influence on current adolescent cigar use (Ringel, Wasserman, & Andreyeva, 2005).

The National Youth Tobacco Survey indicated that 20% of the participants reported cigar use in the past month. Using the 1999 and 2000 waves of this survey, Ringel and colleagues analyzed data from 33,632 adolescent participants aged nine to seventeen. The majority of the participants were White (64.7%). The rest of the participants were African American (17.6%), Hispanic (11.7%), or another race (6%). The same number of males and females participated in the survey. The investigators conducted logistic regression analyses to examine whether increased cigar prices and state tobacco control policies related to cigar use. In addition, the researchers calculated the “price participation elasticity”, which they defined as the percentage change in cigar smoking that would result from a 1% change in price of cigars.

Table 1: Logistic Regression Models of the Probability of Current Cigar Use in Adolescents: Data From The National Youth Tobacco Survey (1999-2000)

Adapted from Ringel et. al (2005)

Table 1 shows that increased cigar prices significantly decreased the probability of male adolescent cigar use, but not female adolescent cigar use. However, the price effect was not apparent for cigarette and smokeless tobacco use. The results showed that state tobacco control policies (e.g., the clean indoor air law, possession or use law, and state-sponsored media campaigns) did not affect teen cigar use. However, the presence of a Purchase law significantly increased the probability of cigar use among female adolescents, but not males. The study’s findings also found the participation price elasticity to be -0.336. Thus, a 10% increase in cigar prices would reduce the sample’s cigar use by 3.4%.

This study has several limitations. First, the data are cross-sectional; thus, the researchers were unable to examine if increased cigar prices are effective in reducing adolescent cigar use over the long term. Another limitation is that the study did not examine other factors, like peer influences, that might mediate cigar use and or explain the existence of gender differences. Also, the study only assessed the presence of state tobacco control policies and did not measure students’ exposure to or awareness of these policies. This is an important matter to consider because students who were exposed to media campaigns might differ in their cigar use compared to students who were not exposed, despite living in the same jurisdiction.

Increasing cigar prices can deter male adolescents from cigar smoking, but media campaigns seem not to have much influence on adolescent cigar use. Further research should explore issues surrounding price sensitivity and cigar use, as well as examine gender differences and other group differences. More comprehensive research about adolescent cigar use is necessary to determine risk factors of cigar use and effective prevention strategies. Researchers also should study other forms of tobacco use (e.g., cigarettes, pipe, hookah, etc.) in addition to cigars to determine if there are differences in how public policies impact these various tobacco forms. Furthermore, smoking cessation programs should integrate these findings into their services.

What do you think? Let us know. Comments can be sent to Sarbani Hazra.

References

ALA. (2006). State Legislated Action on Tobacco Issues. Retrieved September 27, 2006, from
http://slati.lungusa.org/StateLegislateAction.asp

Ringel, J. S., Wasserman, J., & Andreyeva, T. (2005). Effects of Public Policy on Adolescents' Cigar Use: Evidence From the National Youth Tobacco Survey. American Journal of Public Health, 95(6), 995-998.

Symm, B., Morgan, M. V., Blackshear, Y., & Tinsley, S. (2005). Cigar smoking: An ignored public health threat. The Journal of Primary Prevention, 26(4), 363-375.

ASHES Vol. 2 (7) - The influence of peers and families on adolescents’ decision to smoke

There are a variety of relationships and experiences that might influence a person’s decision to smoke. In the last issue of ASHES 2(6), we reviewed a study that examined the influence of parental smoking on the smoking habits of 12th graders. However, it is important to acknowledge that parents are not the only source of pressure and influence in an adolescent’s life. This week we review an article by Bricker, Peterson, Anderson, Rajan, Leroux, and Sarason (2006), which compares the influence of parental smoking and peers/friends smoking on adolescents’ decision to try smoking, and smoking regularly.

Participants for this study were selected from the 7,046 students enrolled in the Hutchinson Smoking Prevention Project (HSPP). Eligible participants reported whether parents and close friends smoked; 4,744 teens (49% female, 91% Caucasian), of those eligible in both control and intervention cohorts of the HSPP, participated in this study. Parents completed mail surveys when their children were in 3rd grade. Participants provided information about friends’ smoking during the 5th grade, and provided information about their own smoking behavior (i.e., age at which the participant reported first smoking a cigarette, first smoking monthly, and first smoking daily) during the 12th grade. Children completed surveys while in class. Saliva samples confirmed recent cigarette smoking.

In the 12th grade, 66% of participants had at least tried smoking and 56% reported smoking monthly: 69% of those who reported smoking monthly also reported smoking daily. Of the participants with no smoking parents, 58% of those with no smoking friends tried smoking, 79% of participants with one smoking friend tried smoking, and 88% of participants with two or more smoking friends tried smoking. Figure 1 illustrates these results. Of the participants with one smoking parent, 70% of those with no smoking friends tried smoking, 89% of participants with one smoking friend tried smoking, and 96% of participants with two or more smoking friends tried smoking. Of the participants with two smoking parents, 76% of those with no smoking friends tried smoking, 88% of participants with one smoking friend tried smoking and 87% of participants with two or more smoking friends tried smoking.

Of the participants with non-smoking parents who tried smoking and reported smoking monthly, 60% of those with non-smoking friends reported smoking daily, 69% of those with one smoking friend reported smoking daily, and 78% of those with two or more smoking friends reported smoking daily. Of the participants with one smoking parent who tried smoking and reported smoking monthly, 71% of participants with non-smoking friends reported smoking daily, 74% of participants with one smoking friend reported smoking daily, and 72% of participants with two or more smoking friends reported smoking daily. Of the participants with two smoking parents who tried smoking and reported smoking monthly, 79% of those with non-smoking friends reported smoking daily, 80% of participants with one smoking friend reported smoking daily, and 91% of participants with two or more smoking friends reported smoking daily.

FIGURE 1: PERCENT OF PARTICIPANTS WHO EVER TRIED SMOKING AND SMOKE REGULARLY, BY NUMBER OF PARENTS AND FRIENDS WHO SMOKE (ADAPTED FROM BRICKER ET AL., 2006)

* Please note that the ‘Smoking Regularly’ group is a subset of the ‘Ever Tried Smoking’ group.

These findings suggest that having smoking friends contributes more to a child’s decision to try smoking than do non-smoking parents. Further, there seems to be a direct relationship between number of smoking friends and the participants’ decision to try smoking among participants with non-smoking parents. However, the number of smoking friends does not seem to be as important among participants with smoking parents, except among participants with two smoking parents and two or more smoking friends; this irregularity might be the result of the small sample size for this group.

There are several limitations to the study. The participants are mostly Caucasian (91%), and are from a very similar socio-economic background. Also, researchers did not evaluate the impact of other covariates on smoking, such as socio-economic status and education. Nonetheless, this study brings demonstrates important factors that can influence an adolescent’s decision to try smoking and possibly continue smoking.

Among adolescents with non-smoking parents, the influence of smoking friends and peers increase the chances that the adolescent will try smoking. However, smoking parents have greater influence regarding participants’ long-term smoking habits. Though adolescents with smoking friends might feel pressure from peers to try cigarettes, behavior at home remains the strongest predictor for long-term behavior and lifestyle/health choices. Public health workers should consider this finding when creating treatment and prevention programs for youth and their families.

What do you think? Let us know. Comments can be sent to Siri Odegaard.

REFERENCES

Bricker, J. B., Peterson, A. V., Anderson, M. R., Rajan, K. B., Leroux, B. G., & Sarason, I. G. (2006). Childhood friends who smoke: Do they influence adolescents to make smoking transitions? Addictive Behaviors, 31(5), 889-900.

ASHES Vol. 2 (6) - Influence of parents on adolescent smoking

According to the syndrome model of addiction (see The WAGER 10(1) ), each person has a unique combination of three primary types of influences and risk factors for the development of addiction: biological, psychological, and environmental. Researchers have learned about biological influences, such as genetics (see WAGERS 3(30), 3(34), 11(2), and DRAM 1(3) among others), as well as psychological influences (see WAGERs 8(2), 8(23), and DRAMs 2(4) and 2(5), among others). Resear