Distribution of smokers by stage in three representative samples

Evaluation of a hospital-based tobacco treatment service: outcomes and lessons learned

BACKGROUND

The efficacy of smoking cessation interventions for hospital patients has been well described, but we know little regarding implementation and outcomes of real-world programs.

OBJECTIVE

To describe the services provided and outcomes of an academic medical center-based tobacco treatment service (UKanQuit) located in the Midwestern United States.

METHOD

This is a descriptive observational study. Both quantitative and qualitative data of all patients treated by UKanQuit over a 1-year period were analyzed.

RESULTS

Among 513 patients served, average interest in quitting was 7.9, standard deviation (SD) 2.9 on a scale of 0 to 10. More than 1 in 4 had been given an in-hospital medication to ameliorate withdrawal prior to seeing a counselor. Counselors recommended medication changes for 1 in 3 patients, helped 73% set a goal for quitting or reducing tobacco use, and fax referred 56% to quitlines. Six-month follow-up (response rate, 46%) found a 7-day abstinence rate of 32% among respondents for an intent-to-treat abstinence rate of 15%. Post-discharge, 74% made at least one serious quit attempt, 34% had used a quit smoking medication, but only 5% of those referred to the quitline reported using it.

CONCLUSIONS

In a hospital setting, interest in quitting is high among smokers who requested to see a tobacco counselor but administration of inpatient medications remains low. Many smokers are making unassisted quit attempts post-discharge because utilization of cessation medications and quitline counseling were low. Fax-referral to quitline may not, on its own, fulfill guideline recommendations for post-discharge follow-up.

Individual and family factors associated with intention to quit among male Vietnamese American smokers: implications for intervention development

Smoking prevalence among Vietnamese American males remains higher than the U.S. general population. This study examined the associations of individual and family factors with quit intention among Vietnamese male smokers in California to guide intervention development to reduce their smoking prevalence. Data for Vietnamese male current smokers (n=234) in the 2008 California Vietnamese Adult Tobacco Use Survey (N=1101 males) were analyzed to describe quit intention and previous quit attempts. One-third of Vietnamese male smokers (33%) had no intention to quit at any time, 36% intended to quit soon (in the next 30 days), and 31% intended to quit later (beyond the next 30 days). Half (51.7%) of the sample was in "precontemplation," indicating no intention to quit within 6 months. Many (71%) had made a serious quit attempt in the past year, but 68% of those who tried to quit used no cessation assistance. Multivariate logistic regression adjusting for age, depression, smoking intensity, nicotine dependence, health knowledge, children in the household and home smoking ban revealed that having smoking-related family conflicts and a quit attempt in the past year with or without assistance were independently associated with an intention to quit either in the next 30 days or later. Higher education was associated with no intention to quit. Findings underscore the importance of designing strategic interventions that meet the needs of smokers at both individual and family levels to promote quit intention and to facilitate successful quitting in this population.

Stages of change

The transtheoretical model, in general, and the stages of change, in particular, have proven useful in adapting or tailoring treatment to the individual. We define the stages and processes of change and then review previous meta-analyses on their interrelationship. We report an original meta-analysis of 39 studies, encompassing 8,238 psychotherapy patients, to assess the ability of stages of change and related readiness measures to predict psychotherapy outcomes. Clinically significant effect sizes were found for the association between stage of change and psychotherapy outcomes (d = .46); the amount of progress clients make during treatment tends to be a function of their pretreatment stage of change. We examine potential moderators in effect size by study outcome, patient characteristics, treatment features, and diagnosis. We also review the large volume of behavioral health research, but scant psychotherapy research, that demonstrates the efficacy of matching treatment to the patient's stage of change. Limitations of the extant research are noted, and practice recommendations are advanced.

Stages of change, smoking characteristics, and cotinine concentrations in smokers: setting priorities for smoking cessation

OBJECTIVE

We assessed whether the salivary cotinine content of daily smokers varied with the readiness to quit and smoking characteristics.

METHODS

This cross-sectional study was conducted in Barcelona, Spain (n=1245) in 2004-2005. We administered a questionnaire to assess smoking behaviour and collected saliva to determine the cotinine content. We determined the distribution of 278 adult daily smokers across different stages of change and categorised them by individual and smoking characteristics. We used medians and interquartile ranges (IQR) to relate cotinine concentrations to different stages of change, tobacco consumption, and nicotine dependence based on the Fagerström Test for Nicotine Dependence (FTND).

RESULTS

Around 68%, 22%, and 11% of smokers were in precontemplation, contemplation, and preparation stages, respectively. A mean of 17.0 cigarettes was smoked daily, with no differences among stages of change. The median cotinine concentration was 151.3 ng/ml (IQR: 83.2-227.8 ng/ml), with no differences among stages of change. The cigarette consumption scores, FTND, and time to first cigarette of the day were positively associated with cotinine concentration.

CONCLUSIONS

The cotinine concentration was similar among the stages of change, but varied within each stage according to the number of cigarettes smoked, time to first cigarette of the day, and nicotine dependence.

Baseline stage, severity, and effort effects differentiate stable smokers from maintainers and relapsers

This cross-sectional study (N = 4,144) compared three longitudinal dynatypes (Maintainers, Relapsers, and Stable Smokers) of smokers on baseline demographics, stage, addiction severity, and transtheoretical model effort effect variables. There were significant small-to-medium-sized differences between the Stable Smokers and the other two groups on stage, severity, and effort effect variables in both treatment and control groups. There were few significant, very small differences on baseline effort variables between Maintainers and Relapsers in the control, but not the treatment group. The ability to identify Stable Smokers at baseline could permit enhanced tailored treatments that could improve population cessation rates.

Feasibility, acceptability and impact of a telephone support service initiated in primary medical care to help Arabic smokers quit

Evidence-based tobacco control in ethnic minorities is compromised by the near absence of rigorous testing of interventions in either prevention or cessation. This randomised controlled trial was designed to evaluate the feasibility, acceptability and impact of a culturally specific cessation intervention delivered in the context of primary medical care in the most culturally diverse region of New South Wales. Adult Arabic smokers were recruited from practices of 29 general practitioners (GPs) in south-west Sydney and randomly allocated to usual care (n = 194) or referred to six sessions of smoking cessation telephone support delivered by bilingual psychologists (n = 213). Although 62.2% of participants indicated that telephone support would benefit Arabic smokers, there were no significant differences at 6 or 12 months between intervention and control groups in point prevalence abstinence rates (11.7% vs 12.9%, P = 0.83; 8.4% vs 11.3%, P = 0.68, respectively) or the mean shift in stage-of-change towards intention to quit. As participants and GPs found telephone support acceptable, we also discuss redesign and the unfulfilled obligation to expand the evidence base in tobacco control from which the ethnic majority already benefits.

Contingency management to reduce methamphetamine use and sexual risk among men who have sex with men: a randomized controlled trial

BACKGROUND

Methamphetamine use is associated with HIV acquisition and transmission among men who have sex with men (MSM). Contingency management (CM), providing positive reinforcement for drug abstinence and withholding reinforcement when abstinence is not demonstrated, may facilitate reduced methamphetamine use and sexual risk. We compared CM as a stand-alone intervention to a minimal intervention control to assess the feasibility of conducting a larger, more definitive trial of CM; to define the frequency of behavioral outcomes to power such a trial; and, to compute preliminary estimates of CM's effectiveness.

METHODS

We randomly assigned 127 MSM from Seattle, WA who use methamphetamine to receive a 12-week CM intervention (n = 70) or referral to community resources (n = 57).

RESULTS

Retention at 24 weeks was 84%. Comparing consecutive study visits, non-concordant UAI declined significantly in both study arms. During the intervention, CM and control participants were comparably likely to provide urine samples containing methamphetamine (adjusted relative risk [aRR] = 1.09; 95%CI: 0.71, 1.56) and to report non-concordant UAI (aRR = 0.80; 95%CI: 0.47, 1.35). However, during post-intervention follow-up, CM participants were somewhat more likely to provide urine samples containing methamphetamine than control participants (aRR = 1.21; 95%CI: 0.95, 1.54, P = 0.11). Compared to control participants, CM participants were significantly more likely to report weekly or more frequent methamphetamine use and use of more than eight quarters of methamphetamine during the intervention and post-intervention periods.

CONCLUSIONS

While it is possible to enroll and retain MSM who use methamphetamine in a trial of CM conducted outside drug treatment, our data suggest that CM is not likely to have a large, sustained effect on methamphetamine use.

Stage-based interventions for smoking cessation

BACKGROUND

The transtheoretical model is the most widely known of several stage-based theories of behaviour. It proposes that smokers move through a discrete series of motivational stages before they quit successfully. These are precontemplation (no thoughts of quitting), contemplation (thinking about quitting), preparation (planning to quit in the next 30 days), action (quitting successfully for up to six months), and maintenance (no smoking for more than six months). According to this influential model, interventions which help people to stop smoking should be tailored to their stage of readiness to quit, and are designed to move them forward through subsequent stages to eventual success. People in the preparation and action stages of quitting would require different types of support from those in precontemplation or contemplation.

OBJECTIVES

Our primary objective was to test the effectiveness of stage-based interventions in helping smokers to quit.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group's specialised register for trials, using the terms ('stage* of change', 'transtheoretical model*', 'trans-theoretical model*, 'precaution adoption model*', 'health action model', 'processes of change questionnaire*', 'readiness to change', 'tailor*') and 'smoking' in the title or abstract, or as keywords. The latest search was in August 2010.

SELECTION CRITERIA

We included randomized controlled trials, which compared stage-based interventions with non-stage-based controls, with 'usual care' or with assessment only. We excluded trials which did not report a minimum follow-up period of six months from start of treatment, and those which measured stage of change but did not modify their intervention in the light of it.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the dose and duration of intervention, the outcome measures, the randomization procedure, concealment of allocation, and completeness of follow up.The main outcome was abstinence from smoking for at least six months. We used the most rigorous definition of abstinence, and preferred biochemically validated rates where reported. Where appropriate we performed meta-analysis to estimate a pooled risk ratio, using the Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We found 41 trials (>33,000 participants) which met our inclusion criteria. Four trials, which directly compared the same intervention in stage-based and standard versions, found no clear advantage for the staging component. Stage-based versus standard self-help materials (two trials) gave a relative risk (RR) of 0.93 (95% CI 0.62 to 1.39). Stage-based versus standard counselling (two trials) gave a relative risk of 1.00 (95% CI 0.82 to 1.22). Six trials of stage-based self-help systems versus any standard self-help support demonstrated a benefit for the staged groups, with an RR of 1.27 (95% CI 1.01 to 1.59). Twelve trials comparing stage-based self help with 'usual care' or assessment-only gave an RR of 1.32 (95% CI 1.17 to 1.48). Thirteen trials of stage-based individual counselling versus any control condition gave an RR of 1.24 (95% CI 1.08 to 1.42). These findings are consistent with the proven effectiveness of these interventions in their non-stage-based versions. The evidence was unclear for telephone counselling, interactive computer programmes or training of doctors or lay supporters. This uncertainty may be due in part to smaller numbers of trials.

AUTHORS' CONCLUSIONS

Based on four trials using direct comparisons, stage-based self-help interventions (expert systems and/or tailored materials) and individual counselling were neither more nor less effective than their non-stage-based equivalents. Thirty-one trials of stage-based self help or counselling interventions versus any control condition demonstrated levels of effectiveness which were comparable with their non-stage-based counterparts. Providing these forms of practical support to those trying to quit appears to be more productive than not intervening. However, the additional value of adapting the intervention to the smoker's stage of change is uncertain. The evidence is not clear for other types of staged intervention, including telephone counselling, interactive computer programmes and training of physicians or lay supporters. The evidence does not support the restriction of quitting advice and encouragement only to those smokers perceived to be in the preparation and action stages.

Partner smoking characteristics: Associations with smoking and quitting among blue-collar apprentices

BACKGROUND

Studies suggest that the social context of blue-collar workers contribute to their low smoking cessation rates. However, little is known on the effect of partner smoking and requests to quit on workers' cessation attempts.

METHODS

Using data from a longitudinal smoking cessation intervention, multivariable logistic regression models were constructed to investigate the association of partner smoking characteristics with cessation among blue-collar apprentices.

RESULTS

Smokers were more likely to have partners who smoke (OR 13.06; 95% CI 8.52-20.01). Partner's request to quit was associated with higher odds of smoking cessation at 1 month (OR 3.74; 95% CI 2.49-5.63) and 6 months (OR 1.90; 95% CI 1.06-3.41) post-intervention. Having a partner who smoked was associated with lower odds of smoking cessation at 1 month (OR 0.41; 95% CI 0.27-0.62), but not 6 months post-intervention.

CONCLUSIONS

Results suggest that smoking cessation interventions that include partner support might improve cessation among blue-collar smokers.

Psychosocial characteristics of smokers interested in quitting

The purpose was to determine whether psychosocial factors are associated with cessation among smokers interested in quitting. This cross-sectional study included 403 current and former smokers enrolled in a 'Quit and Win' contest. After the quit period, data were collected via a telephone interview at three months post-baseline. Controlling for demographics and secondhand smoke exposure, lower depressive symptoms and more positive partner or friend support to quit predicted a greater likelihood of quitting. Integrated interventions that combine tobacco treatment with mental health strategies to reduce depressive symptoms and improve partner or friend interactions may be most effective with smokers interested in quitting.

The journey to the end of smoking: A personal and population perspective

BACKGROUND

Smoking cessation is best represented as a journey and not a single event. This article chronicles the path of change for the population of smokers in Maryland.

PURPOSE

This study compared the population of ever-smokers in Maryland over three time points (2000, 2002, and 2006) examining how the population of ever-smokers shifted over time.

METHODS

Analysis of process of change and social influence variables conducted using data from the Maryland Adult Tobacco Surveys (MATS) administered in 2000, 2002, and 2006.

RESULTS

Analyses indicated an increasing percentage of ever-smokers (100 lifetime cigarettes) who have successfully quit and maintained cessation for more than 5 years. By 2006, the population of current adult smokers (aged > or =18 years) was smaller but seemed less interested in and able to quit. More 2006 smokers were in earlier stages of change for cessation and not interested in or planning to quit in the near term. Many had unsuccessfully tried to quit, with a substantial minority finding that cessation products found effective in research were not effective for them. Despite past failures, the vast majority expects to quit, has considered quitting, and believes that they will likely succeed eventually. Larger percentages of 2006 smokers are being advised to quit by medical professionals, are accessing empirically supported quit-smoking aids, and have multiple quit attempts. They also smoked every day for more years, smoked as many cigarettes per day, and had environments as filled with smoking as their 2000 and 2002 counterparts.

CONCLUSIONS

Increasing successful cessation would require not only appropriate use of effective products but also successful negotiation of important tasks in the cessation journey. Health literacy and a consumer perspective can help to bridge gaps in the dissemination and effective use of empirically supported treatments.

Sexual violence prevention: the role of stages of change

Increasing numbers of empirical studies and theoretical frameworks for preventing sexual violence are appearing in the research- and practice-based literatures. The consensus of this work is that although important lessons have been learned, the field is still in the early stages of developing and fully researching effective models, particularly for the primary prevention of this problem in communities. The purpose of this article is to discuss the utility of applying the transtheoretical model of readiness for change to sexual violence prevention and evaluation. A review of this model and its application in one promising new primary prevention program is provided, along with exploratory data about what is learned about program design and effectiveness when the model is used. The study also represents one of the first attempts to operationalize and create specific measures to quantify readiness for change in the context of sexual violence prevention and evaluation. Implications for program development and evaluation research are discussed.

Characteristics of smokers and predictors of quitting in a smoking cessation clinic in Guangzhou, China

BACKGROUND

Smoking cessation programs are well established in the West, but reports on smoking cessation clinics (SCCs) from China are lacking. On the basis of the Hong Kong experience and with strong support from Guangzhou Health Bureau, we established the first SCC in Guangzhou, China. The objective was to describe the characteristics of smokers, measure quit rates and examine predictors of successful quitting.

METHODS

During 2006-08, 220 smokers received individual counseling following the five A's and five R's. No medications were used.

RESULTS

At baseline, the mean (SD) age was 40 (14) years. Most (96%) were males, married (73%), currently employed (75%), college educated or above (54%); 77% had previous quitting attempts. By 14 May 2008, 195 reached the 6 months follow-up period. Of them, 79% (151/195) were successfully followed up, and 46 had quit. By intention to treat, the 6-month 7-day point prevalence quit rate was 24% [95% confidence interval (CI) 18-30%]. Smokers with more confidence in quitting or were at action stage were more successful in quitting with adjusted odds ratio of 2.39 (95% CI 1.01-5.30) and 5.50 (95% CI 1.08-28) respectively.

CONCLUSIONS

A pilot-model clinic free of charge and with systemic data collection, follow-up and evaluation should be a starting point for smoking cessation program in low-income countries.

Results of the application of the American Diabetes Association guidelines regarding tobacco dependency in subjects with diabetes mellitus

The objective of the study was to evaluate the stages of change for cessation in smoking after the application of American Diabetes Association recommendations in diabetic patients who smoke. This longitudinal descriptive study involved smokers with diabetes mellitus (DM) who were attended for their DM between September 2003 and December 2006. Intervention used was dependent on the stage of change for cessation (according to Prochaska and Di Clemente). For precontemplation subjects, a brief session was carried out where information regarding the risks of smoking in conjunction with DM was given. Patients at the contemplation stage of smoking cessation were offered the chance to participate in a cessation program. Later evaluation was carried out after a follow-up of more than 6 months. Seven hundred thirty-three subjects with DM were evaluated, including 156 smokers (21.28%): 103 (66.02%) in the precontemplation stage, 25 (16.02%) in the contemplation stage, 12 (7.69%) in the preparation stage, 12 (7.69%) in the action stage, and 4 (2.56%) in the maintenance stage. By the last follow-up, 65 (41.6%) subjects had quit smoking (36 ex-smokers), of whom 20 (30.77%) had subsequently relapsed. The use of the American Diabetes Association recommendations for the treatment of tobacco dependence in diabetes treatment results in an increased change of smoking cessation stages in subjects with DM as well as a higher overall percentage in abstinence.

Styles of physician advice about smoking cessation in college students

OBJECTIVE

To examine whether young adult cigarette smokers who were in the precontemplation and contemplation stages of change for smoking cessation would differ in their evaluations of vignettes depicting 2 types of physician advice.

PARTICIPANTS

Fifty-seven young adult cigarette smokers who were undergraduate students (49.1% female, mean age = 20.4 years) attending an urban university.

METHODS

Participants evaluated 2 written vignettes. Both vignettes depicted physicians using patient-centered communication styles. One vignette depicted a physician giving a patient direct advice to quit smoking and the other a physician using a motivational style of advice. Data were collected from September 2004 through May 2005.

RESULTS

Participants rated the motivational advice vignette as significantly more favorable compared to the direct advice vignette on all assessed dimensions (global satisfaction, general satisfaction, physician affective style, physician technical style, and physician communication style).

CONCLUSION

Smokers preferred the motivational advice style to simple patent-centered advice.

A cognitive-behavioral weight control program improves eating and smoking behaviors in weight-concerned female smokers

Many people use smoking as a weight control mechanism and are averse to quitting for fear of weight gain. These weight-concerned smokers tend to be women, are significantly less likely to stop smoking or to join smoking cessation programs, and will relapse more often than smokers who are not weight-concerned. Research suggests that a woman's motivation to quit smoking correlates positively with her confidence in her ability to control her weight after quitting. Likewise, success in smoking cessation has been associated with increased self-efficacy for weight control. This randomized controlled trial investigated the effects of a weight control program on eating and smoking behaviors in a group of female, weight-concerned smokers from July 2005 to June 2006. Two hundred sixteen subjects who wanted to lose weight but were not yet ready to quit smoking were recruited to participate in a 12-week, cognitive-behavioral weight control program consisting of 12 1-hour sessions. Subjects were randomly assigned to either the weight-control program (intervention group) or the control group. Differences between the intervention and control groups were evaluated using t tests for continuous variables, Wilcoxon rank-sum tests for ordinal variables and chi(2) tests for categorical variables. The intervention group had a 14% increase (P<0.001) in self-efficacy for weight control (Weight Efficacy Life-Style Questionnaire), which was associated with improved diet quality (Healthy Eating Index) (r=0.292, P<0.01), weight loss (r=0.582, P<0.001), increased self-efficacy for quitting smoking (Smoking Self-Efficacy Questionnaire) (r=0.291, P<0.014), a decrease in number of cigarettes smoked (r=0.331, P<0.005), and positive movement in stage of change toward smoking cessation (r=0.435, P<0.001). These findings suggest that for this group of weight-concerned smokers' success in changing eating behavior may trigger a positive change in smoking behavior.

Impact of a brief motivational smoking cessation intervention the Get PHIT randomized controlled trial

BACKGROUND

Few studies have rigorously evaluated whether providing biologically based health-risk feedback is more effective than standard interventions in increasing smokers' motivation to quit and their long-term abstinence.

DESIGN

An RCT was conducted from 2005 to 2008. Data were analyzed in 2008.

SETTING/PARTICIPANTS

Smokers (N=536) were recruited from the community, regardless of their interest in quitting smoking.

INTERVENTION

Smokers either received brief ( approximately 20 minutes), personally tailored counseling sessions based on their lung functioning, carbon monoxide (CO) exposure, and smoking-related health conditions, or they received generic smoking-risk information and personalized counseling about their diet, BMI, and physical activity. All were advised to quit smoking and were offered access to a free phone-counseling program.

MAIN OUTCOME MEASURES

Treatment utilization and abstinence at 6 and 12 months post-intervention.

RESULTS

Participants who received the experimental treatment demonstrated no greater motivation to quit, use of treatment services, or abstinence compared to controls at either follow-up assessment. In fact, controls reported greater motivation to quit at 12 months (M 3.42 vs 3.20, p=0.03), greater use of pharmacotherapy at 6 months (37.8% vs 28.0%, p=0.02), and greater 30-day point prevalent abstinence at 6 months, after controlling for relevant covariates (10.8% vs 6.4%, adjusted p=0.04).

CONCLUSIONS

The present study found no support for adding a personalized health-risk assessment emphasizing lung health and CO exposure to generic cessation advice and counseling for community-based smokers not otherwise seeking treatment.

TRIAL REGISTRATION

NCT00169260.

Review: the need for smoking cessation among HIV-positive smokers

Most HIV-positive persons in the U.S. smoke cigarettes. Despite substantial clinical advances in HIV care in the era of highly active antiretroviral therapy (HAART), HIV-positive persons are at high risk of tobacco-related disease and death. HIV-positive persons have complex social, economic, psychiatric, and medical needs that may impact smoking behavior and response to smoking cessation interventions, but there is a dearth of research on smoking cessation interventions tailored to HIV-positive persons. HIV care providers should treat tobacco use with the array of evidence-based smoking cessation treatments available, updating their clinical practice as new data emerge. This article reviews the literature on the health consequences of tobacco use in HIV-positive persons, the treatment of tobacco dependence, and the research to date on smoking cessation interventions in HIV-positive persons, and it presents recommendations for future research and intervention.

Naturalistic changes in the readiness of postpartum women to quit smoking

BACKGROUND

This study involves a long-term examination of the natural behavioral changes in postpartum women undergoing smoking cessation. The analysis was based on the readiness to quit smoking as assessed using the Transtheoretical Model of intentional behavioral change. This is a secondary data analysis of a randomized controlled trial.

METHODS

Between May 2002 and March 2003, all women in the maternity wards of six hospitals in the German state of Mecklenburg-West Pomerania were screened for smoking before or during pregnancy. Of the women who answered in the affirmative, 871 (77%) participated in the study.We utilized a questionnaire to classify 345 women into stages of progress regarding their motivation to change their smoking behavior 4–6 weeks postpartum (T0). Participants were followed-up after 6 (T1), 12 (T2), and 18 months(T3). In addition to the descriptive analysis, latent transition analysis was applied as a statistical method to test models of patterns of change and to evaluate transitions in the stages of change over time.

RESULTS

During the time interval between consecutive follow-up surveys, 59.1% (T0/T1), 72.3% (T1/T2), and 67.9% (T2/T3) of women remained at the same stage of motivation to change. Most relapses into earlier stages occurred 6 months postpartum (T1) (31.5% of the stage transition). The patterns of change across the first three time points were best described by a model that includes stability, one-stage progressions,and one-to-four-stage regressions.

CONCLUSIONS

Readiness to quit smoking in study participants did not substantially change over the span of 18 months postpartum.

Intention to quit smoking: is the partner's smoking status associated with the smoker's intention to quit?

BACKGROUND

Smoking behavior among couples is often similar.

PURPOSE

The aim of the study was to examine the relationship between the partner's smoking status and the intention to stop smoking of the index person.

METHOD

Cross-sectional data of 1,044 patients in a random sample of 34 general medical practices in northeastern Germany were analyzed.

RESULTS

Among smokers with a non-smoking partner (SNP), more intended to quit smoking in the next six months (37.0% vs. 31.4%), compared to smokers with a smoking partner (SSP). Also, more SNP intended to quit in the next four weeks (4.7% vs. 2.7%) compared to SSP. SNP were more active in the use of self-change strategies than SSP.

CONCLUSION

The data confirm that the partner's smoking status is related to the intention to quit smoking. Interventions should address the different needs of both smokers with a smoking partner and those with a non-smoking partner.

MassBuilt: effectiveness of an apprenticeship site-based smoking cessation intervention for unionized building trades workers

Objective

Blue-collar workers are difficult to reach and less likely to successfully quit smoking. The objective of this study was to test a training site-based smoking cessation intervention.

Methods

This study is a randomized-controlled trial of a smoking cessation intervention that integrated occupational health concerns and was delivered in collaboration with unions to apprentices at 10 sites (n = 1,213). We evaluated smoking cessation at 1 and 6 months post-intervention.

Results

The baseline prevalence of smoking was 41%. We observed significantly higher quit rates in the intervention versus control group (26% vs. 16.8%; p = 0.014) 1 month after the intervention. However, the effects diminished over time so that the difference in quit rate was not significant at 6 month post-intervention (9% vs. 7.2%; p = 0.48). Intervention group members nevertheless reported a significant decrease in smoking intensity (OR = 3.13; 95% CI: 1.55–6.31) at 6 months post-intervention, compared to controls.

Conclusion

The study demonstrates the feasibility of delivering an intervention through union apprentice programs. Furthermore, the notably better 1-month quit rate results among intervention members and the greater decrease in smoking intensity among intervention members who continued to smoke underscore the need to develop strategies to help reduce relapse among blue-collar workers who quit smoking.

Intention to change smoking in pregnant and postpartum women according to number of pregnancies

BACKGROUND

The status of a pregnant woman might add to the motivation to stop smoking. However, little is known about whether women who are pregnant for the first time (primigravidae) show a motivation to quit smoking that is different from women who are pregnant at least the second time (multigravidae). The goal of the current study was to compare smoking status, urge to smoke and intention to change smoking behaviour of primigravidae and multigravidae. We hypothesized that amongst primigravidae there are less current smokers, that the smokers consume less cigarettes per day, have less urge to smoke and that more stop smoking after delivery when compared with multigravidae.

METHODS

Among 642 women postpartum who had smoked before pregnancy smoking status, the Fagerström Test for Nicotine Dependence and intention to change smoking behaviour were assessed. The data were analysed with the Chi-square test, Mann-Whitney's U-test and the Sign-test.

RESULTS

Primigravidae smoked less cigarettes (P < 0.01) and showed less urge to smoke (P < 0.05) than multigravidae. They did not differ according to the intention to change smoking behaviour (P > 0.05).

CONCLUSION

Experience of first pregnancy does not seem to automatically induce more smoking cessation compared to multigravidae. Prevention measures are needed for primigravida women and multigravida women to the same extent.

An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of an integrated multiple risk intervention, delivered mainly during pregnancy, in reducing such risks (cigarette smoking, environmental tobacco smoke exposure, depression, and intimate partner violence) postpartum.

METHODS

Data from this randomized controlled trial were collected prenatally and on average 10 weeks postpartum in six prenatal care sites in the District of Columbia. African Americans were screened, recruited, and randomly assigned to the behavioral intervention or usual care. Clinic-based, individually tailored counseling was delivered to intervention women. The outcome measures were number of risks reported postpartum and reduction of these risks between baseline and postpartum.

RESULTS

The intervention was effective in significantly reducing the number of risks reported in the postpartum period. In bivariate analyses, the intervention group was more successful in resolving all risks (47% compared with 35%, P=.007, number needed to treat=9, 95% confidence interval [CI] 5-31) and in resolving some risks (63% compared with 54%, P=.009, number needed to treat=11, 95% CI 7-43) as compared with the usual care group. In logistic regression analyses, women in the intervention group were more likely to resolve all risks (odds ratio 1.86, 95% CI 1.25-2.75, number needed to treat=7, 95% CI 4-19) and resolve at least one risk (odds ratio 1.60, 95% CI 1.15-2.22, number needed to treat=9, 95% CI 6-29).

CONCLUSION

An integrated multiple risk factor intervention addressing psychosocial and behavioral risks delivered mainly during pregnancy can have beneficial effects in risk reduction postpartum.

Feasibility of promoting smoking cessation among methadone users using multimedia computer-assisted education

Background

The prevalence of smoking is very high among methadone users. As a method of delivering health education, computers can be utilized effectively. However computer-assisted education in methadone users has not been evaluated systematically.

Objective

This study was aimed at assessing feasibility and patient acceptance of an interactive educational module of a multi-component smoking cessation counseling computer program for former illicit drug users treated in an outpatient methadone clinic.

Methods

The computer-mediated education for hazards of smoking utilized in this study was driven by major constructs of adult learning theories. The program interface was tailored to individuals with minimal computer experience and was implemented on a touch screen tablet PC. The number of consecutive methadone-treated current smokers enrolled in the study was 35. After providing socio-demographic and smoking profiles, the patients were asked to use the educational program for 40 minutes. The impact of the computer-mediated education was assessed by administering a pre- and post-intervention Hazards of Smoking Knowledge Survey (HSKS). An attitudinal survey and semi-structured qualitative interview were used after the educational session to assess the opinions of participants about their educational experience.

Results

The computer-mediated education resulted in significant increase of HSKS scores from 60.5 ± 16.3 to 70.4 ± 11.7 with t value 3.69 and P < .001. The majority of the patients (78.8%) felt the tablet PC was easy to use, and most of the patients (91.4%) rated the educational experience as good or excellent. After controlling for patient baseline characteristics, the effect of computer-mediated education remained statistically significant.

Conclusions

Computer-assisted education using tablet PCs was feasible, well-accepted, and an effective means of providing hazards of smoking education among methadone users.

Health decision making: lynchpin of evidence-based practice

Health decision making is both the lynchpin and the least developed aspect of evidence-based practice. The evidence-based practice process requires integrating the evidence with consideration of practical resources and patient preferences and doing so via a process that is genuinely collaborative. Yet, the literature is largely silent about how to accomplish integrative, shared decision making.

IMPLICATIONS

for evidence-based practice are discussed for 2 theories of clinician decision making (expected utility and fuzzy trace) and 2 theories of patient health decision making (transtheoretical model and reasoned action). Three suggestions are offered. First, it would be advantageous to have theory-based algorithms that weight and integrate the 3 data strands (evidence, resources, preferences) in different decisional contexts. Second, patients, not providers, make the decisions of greatest impact on public health, and those decisions are behavioral. Consequently, theory explicating how provider-patient collaboration can influence patient lifestyle decisions made miles from the provider's office is greatly needed. Third, although the preponderance of data on complex decisions supports a computational approach, such an approach to evidence-based practice is too impractical to be widely applied at present. More troublesomely, until patients come to trust decisions made computationally more than they trust their providers' intuitions, patient adherence will remain problematic. A good theory of integrative, collaborative health decision making remains needed.

Readiness to quit smoking in rural communities

The purpose of this study was to determine psychosocial and demographic factors associated with readiness to quit smoking among rural current and recent former smokers. This cross-sectional study of 333 rural adults was part of a larger quasi-experimental study testing the effect of a population-based Quit and Win Contest on quitting. Readiness to quit, partner support to quit smoking, stressful life events, depressive symptoms, and demographic characteristics were measured via a phone interview three months after the Contest. Participants with greater positive partner support to quit smoking were more ready to quit. Minority participants were more ready to quit, compared with Caucasian respondents.

Design and baseline characteristics from the KAN-QUIT disease management intervention for rural smokers in primary care

OBJECTIVE

To describe the design, implementation, baseline data, and feasibility of establishing a disease management program for smoking cessation in rural primary care.

METHOD

The study is a randomized clinical trial evaluating a disease management program for smoking cessation. The intervention combined pharmacotherapy, telephone counseling, and physician feedback, and repeated intervention over two years. The program began in 2004 and was implemented in 50 primary care clinics across the State of Kansas.

RESULTS

Of eligible patients, 73% were interested in study participation. 750 enrolled participants were predominantly Caucasian, female, employed, and averaged 47.2 years of age (SD=13.1). In addition to smoking, 427 (57%) had at least one additional major risk factor for cardiovascular disease (diabetes, hypertension, high cholesterol, heart disease or stroke). Participants smoked on average 23.7 (SD=10.4) cigarettes per day, were contemplating (61%) or preparing to quit (30%), were highly motivated and confident of their ability to quit smoking, and reported seeing their physicians multiple times in the past twelve months (Median=3.50; Mean=5.48; SD=6.58).

CONCLUSION

Initial findings demonstrate the willingness of patients to enroll in a two-year disease management program to address nicotine dependence, even among patients not ready to make a quit attempt. These findings support the feasibility of identifying and enrolling rural smokers within the primary care setting.

Theory Testing Using Quantitative Predictions of Effect Size

Traditional Null Hypothesis Testing procedures are poorly adapted to theory testing. The methodology can mislead researchers in several ways, including: (a) a lack of power can result in an erroneous rejection of the theory; (b) the focus on directionality (ordinal tests) rather than more precise quantitative predictions limits the information gained; and (c) the misuse of probability values to indicate effect size. An alternative approach is proposed which involves employing the theory to generate explicit effect size predictions that are compared to the effect size estimates and related confidence intervals to test the theoretical predictions. This procedure is illustrated employing the Transtheoretical Model. Data from a sample (N = 3,967) of smokers from a large New England HMO system were used to test the model. There were a total of 15 predictions evaluated, each involving the relation between Stage of Change and one of the other 15 Transtheoretical Model variables. For each variable, omega-squared and the related confidence interval were calculated and compared to the predicted effect sizes. Eleven of the 15 predictions were confirmed, providing support for the theoretical model. Quantitative predictions represent a much more direct, informative, and strong test of a theory than the traditional test of significance.

Motivation of trauma patients to stop smoking after admission to the emergency department

Every smoker should be offered smoking cessation treatment when they present for clinical care. The Readiness to Change-Smokers (RTC-S) questionnaire and the Heidelberg Smoking History (HSH) are brief questionnaires that divide patients into three stages. The purpose of this study was to prospectively compare the performance of each questionnaire at identifying patients who will successfully quit smoking within one year of Emergency Department (ED) discharge. Out of 1292 injured ED patients nearly half (n = 599, 46.4%) were identified as current smokers. Both questionnaires were given to all 599 subjects, and used to divide patients into three stages. At 12-months postdischarge 306 patients (51.1%) were contacted to determine smoking status. Patients were similarly classified by both tests in only 36% of cases. Concordance between tests was poor (kappa = 0.33). The RTC-S classified fewer patients as ready to quit (A = 13% vs. 22.2%). At 12 month follow-up, 55 patients (17.9%) had stopped smoking. The HSH was more successful to predict quitters. Multivariate logistic regression with respect to smoking cessation resulted in significant impact of HSH (p = 0.024).

Clinical trials and tribulations: lessons learned from recruiting pregnant ex-smokers for relapse prevention

The development of smoking cessation and relapse prevention interventions for pregnant and postpartum women is a public health priority. However, researchers have consistently reported substantial difficulty in recruiting this population into clinical trials. The problem is particularly acute for relapse prevention studies, which must recruit women who have already quit smoking because of their pregnancy. Although these individuals are an important target for tobacco control efforts, they represent an extremely small subgroup of the general population. This paper describes multiple recruitment strategies used for a clinical trial of a self-help relapse prevention program for pregnant women. The effectiveness of the strategies and the direct expense per participant recruited are provided. A proactive recruitment strategy (telephoning women whose phone numbers were purchased from a marketing firm) was ultimately much more successful than a variety of reactive strategies (advertisements, press releases, direct mail, Web placement, health care provider outreach). We found few differences between proactively and reactively recruited participants on baseline variables. The primary difference was that the former had smoked fewer cigarettes per day and reported lower nicotine dependence prior to quitting. Strengths and limitations of the recruitment strategies are discussed.

The barriers to smoking cessation in Swiss methadone and buprenorphine-maintained patients

Background

Smoking rates in methadone-maintained patients are almost three times higher than in the general population and remain elevated and stable. Due to the various negative health effects of smoking, nicotine dependence contributes to the high mortality in this patient group. The purpose of the current study was to investigate Swiss methadone and buprenorphine-maintained patients' willingness to stop smoking and to clarify further smoking cessation procedures.

Methods

Substance abuse history, nicotine dependence, and readiness to stop smoking were assessed in a sample of 103 opiate-dependent patients in the metropolitan area of Zurich, Switzerland. Patients were asked to document their smoking patterns and readiness to quit.

Results

Only a small number of patients were willing to quit smoking cigarettes (10.7%) and, even though bupropione or nicotine replacement therapy was included in the fixed daily treatment care, only one patient received nicotine replacement therapy for smoking cessation. A diagnosis of depression in patients' clinical records was associated with readiness to stop smoking. No significant associations were found between readiness to quit smoking and age, methadone treatment characteristics, and presence of co-dependencies.

Conclusion

The current prescription level of best medicine for nicotine dependence in Swiss methadone and buprenorphine-maintained patients is far from adequate. Possible explanations and treatment-relevant implications are discussed.

Secondhand tobacco smoke in children with asthma: sources of and parental perceptions about exposure in children and parental readiness to change

BACKGROUND

Secondhand smoke triggers childhood asthma. Understanding sources of exposure, parental beliefs about exposure, and readiness to change that exposure are important for designing smoke exposure reduction interventions.

METHODS

As part of screening for a clinical trial of a smoke exposure reduction intervention, 519 smoke-exposed children 3 to 12 years old with asthma provided urine specimens for cotinine testing, and their primary caregivers completed questionnaires.

RESULTS

The urine cotinine to creatinine ratio (CCR) was lowest if neither the primary caregiver nor day-care provider smoked (mean CCR, 14.0; SD, 14.4), greater if either smoked (mean CCR, 22.2; SD, 21.3; and mean, CCR, 26.3; SD, 22.2, respectively), and greatest if both smoked (mean CCR, 39.6; SD, 27.5; p < 0.01). Parental perception of their child's exposure was weakly associated with the child's CCR (r(2) = 0.11, p < 0.001). Most parents (58.3%) reported that tobacco smoke exposure had small/no negative effect on their child's asthma. Substantial proportions of those for whom a specific exposure reduction action was relevant were classified as contemplating, preparing, or had recently taken action to reduce their child's exposure, including smoking cessation (61.3%), keeping the child out of smoke-exposed places (72.7%), and making the child's home (49.2%) and areas out of the home smoke free (66.9%).

CONCLUSIONS

Smoking by the primary caregiver and day-care provider are important sources of exposure for children with asthma. Parental assessment of their child's exposure is associated with biologically confirmed exposure but cannot be relied on to assess that exposure. Although the harm of smoke exposure was frequently underestimated, many parents appeared receptive to considering action to reduce their child's exposure.

TRIAL REGISTRATION

(Clinicaltrials.gov). Identifier: NCT00217958.

Initial efficacy of MI, TTM tailoring and HRI's with multiple behaviors for employee health promotion

OBJECTIVE

This study was designed to compare the initial efficacy of Motivational Interviewing (MI), Online Transtheoretical Model (TTM)-tailored communications and a brief Health Risk Intervention (HRI) on four health risk factors (inactivity, BMI, stress and smoking) in a worksite sample.

METHOD

A randomized clinical trial assigned employees to one of three recruitment strategies and one of the three treatments. The treatment protocol included an HRI session for everyone and in addition either a recommended three TTM online sessions or three MI in person or telephone sessions over 6 months. At the initial post-treatment assessment at 6 months, groups were compared on the percentage who had progressed from at risk to taking effective action on each of the four risks.

RESULTS

Compared to the HRI only group, the MI and TTM groups had significantly more participants in the Action stage for exercise and effective stress management and significantly fewer risk behaviors at 6 months. MI and TTM group outcomes were not different.

CONCLUSION

This was the first study to demonstrate that MI and online TTM could produce significant multiple behavior changes. Future research will examine the long-term impacts of each treatment, their cost effectiveness, effects on productivity and quality of life and process variables mediating outcomes.

Acceptability and effectiveness of opportunistic referral of smokers to telephone cessation advice from a nurse: a randomised trial in Australian general practice

BACKGROUND

GPs often lack time to provide intensive cessation advice for patients who smoke. This study aimed to determine the effectiveness of opportunistic referral of smokers by their GP for telephone cessation counselling by a trained nurse.

METHODS

Adult smokers (n = 318) attending 30 GPs in South Western Sydney, Australia were randomly allocated to usual care or referral to a telephone-based program comprising assessment and stage-based behavioural advice, written information and follow-up delivered by a nurse. Self-reported point prevalence abstinence at six and 12 months was compared between groups. Characteristics of patients who accepted and completed the intervention were investigated.

RESULTS

Of 169 smokers randomised to the intervention, 76 (45%) consented to referral. Compared with smokers in 'pre-contemplation', those further along the stage-of-change continuum were significantly more likely to consent (p = 0.003). Those further along the continuum also were significantly more likely to complete all four calls of the intervention (OR 2.6, 95% CI: 0.8-8.1 and OR 8.6, 95% CI: 1.7-44.4 for 'contemplation' and 'preparation' respectively). At six months, there was no significant difference between groups in point prevalence abstinence (intention to treat) (9% versus 8%, p = 0.7). There was no evidence of differential intervention effectiveness by baseline stage-of-change (p = 0.6) or patient sex (p = 0.5). At 12 months, point prevalence abstinence in the intervention and control groups was 8% and 6% respectively (p = 0.6).

CONCLUSION

Acceptance of opportunistic referral for nurse delivered telephone cessation advice was low. This trial did not demonstrate improved quit rates following the intervention. Future research efforts might better focus support for those patients who are motivated to quit. AUSTRALIAN CLINICAL TRIALS REGISTRY NUMBER: ACTRN012607000091404.

Sociocultural Stress, Smoking Risk, and Cessation Among African American Women

The common explanation as to why individuals smoke is that the act of smoking relieves psychological stress, yet very few studies have examined the association between stress and smoking from a sociocultural perspective among African American women. The current study examined the paradigm of sociocultural stress and its association between smoking risk and likelihood of quitting among African American women. One hundred ninety-eight African American women, approximately half of whom were current smokers, completed a battery of questionnaires that included a smoking risk survey and measures of acculturation, stress, and coping. A theoretically based path analytic model revealed that the acculturative stress factors of cultural mistrust (β = .39) and socialization (β = .17) were predictive of perceptions of race-related stress (R 2 = .18), which were predictive of the number of race-related events experienced (R 2 = .51), which contributed to reports of general life stress (R 2 = .07), which was subsequently associated with smoking risk (R 2 = .03). The findings suggest that smoking cessation intervention programs for African American women should be tailored to address sociocultural issues related to stress that impacts their smoking.

The relationship between smokers' motivation to quit and intensity of tobacco control at the population level: a comparison of five European countries

Background

Smoking prevalence differs significantly across Europe. In addition, there are considerable differences in tobacco control activities across European countries. The relationship between prevalence and policy is under-researched. The present analysis examines the motivation to change smoking behaviour across 5 different European countries that differ considerably in their tobacco control activities.

Methods

A population-based, representative survey of 1750 smokers, aged 16–59, from 5 different European countries (Germany, Greece, Poland, Sweden, UK) was used. Demographic variables, smoking status and the motivation to stop smoking were assessed. Motivation was assessed as, first, intending to quit (using the stages of change plus a modified stage for Precontemplation), and second, the desire to quit.

Results

The majority of smokers want to stop smoking (73.5%), while only 35.0% want to stop definitely. Across countries, 10.2% definitely do not want to stop.

Most of the smokers can be categorised in the Precontemplation stage (between 62.6% and 77.7% depending on the country), one of the stages of change categories. The relationship between the stages of change and the country under examination is statistically significant (chi-square = 43.466, p < 0.001). In countries with a high level of tobacco control, the proportion of people in Precontemplation is lower than in countries with low tobacco control activity.

Conclusion

There are differences in the stages of change between the countries under examination. However, the categorisation of the countries into low, medium and high tobacco control activity used in this analysis does not explain these differences. Most smokers want to stop smoking, but a high proportion cannot indicate a time-frame when this is going to happen. Tobacco control efforts or other kinds of support might encourage these smokers to actually try to stop. Longitudinal studies at the population level are needed to assess, relate or monitor tobacco control activities and the intention to stop.

The impact of smoking-cessation intervention by multiple health professionals

BACKGROUND

Smokers have contact with many different types of health professionals. The impact of tobacco intervention by multiple types of heath professionals is not known.

METHODS AND MATERIALS

As part of the 2003 Minnesota Adult Tobacco Survey, smokers (n=1723) reported on tobacco treatment by medical doctors, nurses, dentists, pharmacists, or other health professionals. This analysis examined: (1) smokers' report of tobacco intervention by different types of healthcare providers, (2) the proportion of smokers who report intervention by multiple provider types, and (3) the relationship between smokers' report of intervention by multiple provider types and readiness to quit, quit attempts, and recent quitting.

RESULTS

Among past-year smokers, 65% had visits with two or more types of health professionals. Among smokers who visited health professionals (n=1523), only 34% reported being asked about smoking by two or more types of professionals. Among current smokers (n=1324), advice or assistance from more than one type of professional was uncommon (26% and 7%, respectively). Being asked about smoking by two or more types of professionals substantially increased the odds of recent quitting (OR=2.37; 95% CI=1.15-4.88). Among current smokers, being advised to quit by two or more types of professionals increased the odds of having made a quit attempt in the past year (OR=2.92; 95% CI=1.56-5.45) or intending to quit in the next 6 months (OR=2.17; 95% CI=1.10-4.29).

CONCLUSIONS

Smoking-cessation interventions by more than one type of health professional have the potential to substantially increase quitting and readiness to quit in the population.

Applying the transtheoretical model to eating behaviour change: challenges and opportunities

This review provides a rigorous investigation of the question of whether the transtheoretical model (TTM) (or stages of change model) is applicable to eating behaviour change. The TTM is currently the most popular of a number of stage theories being used to examine health behaviour change. Stage theories specify an ordered set of ‘stages of readiness to change’ into which people can be classified and identify the factors that can facilitate movement from one stage to the next. If eating behaviour change follows a stage process, then nutritionists could identify the predominant stage or stages in a population and focus resources on those issues most likely to move people to the next stage (e.g. from no intention of changing, to thinking about changing). In addressing this question, the review draws on the defining characteristics of stage theories as clarified by Weinstein et al. (1998), provides an in-depth coverage of methodological considerations, and a detailed summary table of dietary studies applying the TTM. Specific recommendations are made for improving the accuracy of dietary stage classifications. Among the key conclusions are: (1) dietary studies using the TTM have been hampered by a focus on nutritional outcomes such as dietary fat reduction, rather than clearly understood food behaviours (e.g. five servings of fruit and vegetables per day); (2) accurate stage classification systems are possible for food-based goals, but major misclassification problems occur with nutrient-based goals; (3) observation of an association between stage and dietary intake is not sufficient to demonstrate the validity of the model for dietary behaviour; (4) there is a need for valid questionnaires to measure all aspects of the TTM, and more research on the whole model, particularly the ‘processes of change’, rather than on single constructs such as ‘stage’ (5) cross-sectional studies generally support the predicted patterns of between-stage differences in decisional balance, self-efficacy, and processes of change; (6) studies which test the key hypothesis that different factors are important in distinguishing different stages are rare, as are prospective studies and stage-matched interventions. Only such studies can conclusively determine whether the TTM is applicable to eating behaviour. Since the ultimate test of the TTM will be the effectiveness of stage-matched dietary interventions, the review ends by exploring the requirements for such studies.

Transtheoretical principles and processes for quitting smoking: a 24-month comparison of a representative sample of quitters, relapsers, and non-quitters

This longitudinal study compared 14 principles and processes of change applied by successful quitters, relapsers and non-quitters over 24 months in a representative sample of 4144 smokers in intervention and control groups. The successful quitters showed a decrease in the use of experiential processes (cognitive, affective and effective) and an increase in behavioral processes (e.g., counter-conditioning and stimulus control). The non-quitters showed little change in their use of almost all of the processes. The relapsers' use of the processes tended to initially parallel the successful quitters, but over time, their use ended up between the quitters and the non-quitters. In general, the relapsers ended up working harder but not smarter than the successful quitters. The pattern of use of change processes in the treatment and control groups were remarkably similar, suggesting common pathways to change.

Appetitive nature of drug cues re-confirmed with physiological measures and the potential role of stage of change

RATIONALE

Smokers report pleasant reactions to viewing cigarettes, suggesting that smoking cues may be appetitive in nature. Two studies have investigated this hypothesis through physiological assessment. The first study found that smoking cues were physiologically appetitive in nature, with dampened startle response to smoking pictures in comparison to neutral pictures. The second found that smoking pictures did not modulate the startle response, suggesting such cues may not be physiologically appetitive.

OBJECTIVE

The goal of the present study was to further investigate how participants' motivation to quit smoking might modulate responses to smoking cues.

MATERIALS AND METHODS

Twenty-two nicotine-dependent smokers viewed standardized pleasant, unpleasant, neutral, and smoking pictures. Eleven of the subjects reported no intent to quit (precontemplators) and 11 reported planning to quit within the next 6 months (contemplators). Acoustic startle probes were randomly administered while subjects viewed the pictures, and eyeblink startle magnitude was measured with electromyography (EMG).

RESULTS

As a whole, participants exhibited dampened startle responses during smoking pictures, relative to unpleasant pictures. Precontemplators showed robust startle inhibition to smoking pictures, in comparison to both neutral and unpleasant pictures. Contemplators, however, showed blunted unpleasant picture augmentation and a lack of startle inhibition for pleasant pictures.

CONCLUSION

These findings are consistent with the idea that smoking pictures are appetitive in nature. Furthermore, they suggest that smokers at a later stage of change may exhibit a lesser response.