Cigarette smoking: Evidence to guide measurement

Association of cigarette excise taxes and clean indoor air laws with change in smoking behavior in the United States: a Markov modeling analysis

The rates of cigarette smoking in the United States have declined over the past few decades in parallel with increases in cigarette taxes and introduction of more stringent clean indoor air laws. Few longitudinal studies have examined association of taxes and clean indoor air policies with change in smoking nationally. This study examined the association of state and local cigarette taxes and clean indoor laws with change in smoking status of 18,499 adult participants of the longitudinal 2010-2011 Tobacco Use Supplement of the Current Population Survey over a period of 1 year. Every $1 increase in cigarette excise taxes was associated with 36% higher likelihood of stopping smoking among regular smokers. We found no association between clean indoor air laws and smoking cessation nor between taxes and clean indoor air laws with lower risk of smoking initiation. Cigarette taxes appear to be effective anti-smoking policies. Some state and local governments do not take full advantage of this effective policy measure.

Smoking Behaviors Among Black and Hispanic Cancer Patients: A Systematic Review of the Literature

Smoking is the leading cause of preventable disease and death in the United States. The risk of smoking poses an even greater threat for racial/ethnic minorities, particularly Black and Hispanic cancer patients who face a range of existing disparities in healthcare. Despite these risks for poor health outcomes among this population, little is known about the smoking behaviors of Black and Hispanic cancer patients. The purpose of this review was to understand differences in smoking prevalence, intensity, and cessation between Black, Hispanic, and non-Hispanic White cancer patients and survivors. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach as our framework, we conducted a systematic review of the literature. Our review discusses the methods, population, and implications of 37 included articles. Conclusions reflect the need to establish intentional and systematic measurement of smoking behaviors to best understand the risks of smoking among Black and Hispanic cancer patients.

COPD-Related Fatigue: A Scoping Review

Millions of people worldwide have chronic obstructive pulmonary disease (COPD), and one of the most common and troublesome symptoms that must be managed is fatigue. While there are existing interventions to address COPD-related fatigue, not all patients experience benefit. A better understanding of the factors associated with COPD-fatigue could elucidate new approaches to address COPD-related fatigue, thereby offering relief to a greater number of patients. The purpose of this review was to identify the physiologic, psychologic, and situational factors associated with COPD-related fatigue. A total of four databases, PubMed, CINAHL, Scopus, and Google Scholar, were searched. Those that were peer reviewed, in English, and published between 2000 and 2021, were included in the review. A total of 25 articles were included in this scoping review. The following factors were related to fatigue in COPD: dyspnea, pain, anxiety, depression, and sleep. Fatigue is a debilitating symptom with factors influential to the symptom and outcomes. Research is indicated to explore targeted and personalized interventions addressing the factors related to fatigue to mitigate this widespread symptom.

Mortality and morbidity risk prediction for older former smokers based on a score of smoking history: evidence from UK Biobank and ESTHER cohorts

BACKGROUND

Rapid population ageing has raised the proportion of older former smokers considerably, but a comprehensive assessment tool of former smoking-related health risks is absent.

OBJECTIVE

We utilised the large-scale data of UK Biobank and ESTHER study to build a former smoking score (FSS) for older former smokers using three major former smoking traits: pack-years, smoking duration and time since smoking cessation.

DESIGN

UK Biobank and ESTHER study are two cohorts of older adults with 502,528 and 9,940 participants from the UK and Germany, respectively.

METHODS

Smoking history and covariates were retrieved from the self-administrated questionnaires and mortality and morbidity data were obtained through regular linkages to hospital records.

RESULTS

We constructed the FSS based on the 94,446 former smokers of UK Biobank by retrieving the averaged effect estimates of each trait with a 100-time random sampling. This score was robustly associated with higher risks of mortality and incidence of major smoking-related diseases, outperforming each trait. In the validation panel of 2,683 former smokers from ESTHER study, the FSS was highly predictive of mortality and morbidities. Particularly, compared with the 1st quartile of the FSS group, the 4th quartile group had 114.1, 104.5 and 158.9% higher risks of all-cause, CVD and cancer mortality, respectively, and 41.9, 31.9, 52.4 and 831.3% higher risks of incident CVD, type 2 diabetes, any cancers and lung cancer, respectively.

CONCLUSIONS

Our study demonstrates the large potential of refined risk assessment of former smokers by more comprehensive consideration of the major traits of former smoking.

Effect of smoking on periodontal health and validation of self-reported smoking status with serum cotinine levels

OBJECTIVE

To investigate whether self-reported smoking and serum cotinine levels associate with periodontal pocket development and to determine the accuracy of self-reported smoking using serum cotinine.

MATERIALS AND METHODS

This 4-year prospective cohort study included data from 294 dentate adults, aged ≥30 years, who participated in both the Health 2000 Survey and the Follow-up Study of Finnish Adults' Oral Health. Subjectively reported smoking status (daily smokers n = 62, occasional smokers n = 12, quitters n = 49, and never-smokers n = 171), serum cotinine levels, demographic factors, education level, dental behaviours and medical history were collected at baseline. The outcome measure was the number of teeth with periodontal pocketing ≥4 mm over 4 years.

RESULTS

Self-reported daily smokers had 1.82 (95% CI: 1.32-2.50) higher incidence of deepened periodontal pockets than never-smokers. A positive association was observed between serum cotinine (≥42.0 μg/L) and the development of periodontal pockets. The misclassification rate of self-reported smoking was 6%.

CONCLUSIONS

Both self-reported daily smoking and higher serum cotinine were associated with periodontal pocket development. Self-reported smoking was fairly accurate in this study. However, higher cotinine levels among a few self-reported never-smokers indicated misreporting or passive smoking. Thus, self-reports alone are not enough to assess the smoking-attributable disease burden.

Reflection on modern methods: planned missing data designs for epidemiological research

Taking advantage of the ability of modern missing data treatments in epidemiological research (e.g. multiple imputation) to recover power while avoiding bias in the presence of data that is missing completely at random, planned missing data designs allow researchers to deliberately incorporate missing data into a research design. A planned missing data design may be done by randomly assigning participants to have missing items in a questionnaire (multiform design) or missing occasions of measurement in a longitudinal study (wave-missing design), or by administering an expensive gold-standard measure to a random subset of participants while the whole sample is administered a cheaper measure (two-method design). Although not common in epidemiology, these designs have been recommended for decades by methodologists for their benefits-notably that data collection costs are minimized and participant burden is reduced, which can increase validity. This paper describes the multiform, wave-missing and two-method designs, including their benefits, their impact on bias and power, and other factors that must be taken into consideration when implementing them in an epidemiological study design.

Brief Report: Relationship Between Cotinine Levels and Peripheral Endogenous Concentrations of Oxytocin, β-Endorphin, and Orexin in Individuals With Both Alcohol and Nicotine Use Disorders

BACKGROUND AND OBJECTIVES

In this secondary analysis of a pilot clinical trial with individuals with alcohol and nicotine use disorders, we investigate the relationship between serum concentrations of oxytocin, β-endorphin, melatonin, α-melanocyte-stimulating hormone, substance P, and orexin, with objective biomarkers (salivary cotinine and serum γ-glutamyl transferase [GGT]) as well as with self-reported smoking and alcohol drinking.

METHODS

Biomarkers for a total of N = 19 participants were analyzed using multiplexed, competitive format immune-assay (peptides) and enzyme competitive immunoassay (saliva). A regression analysis using Pearson's correlation coefficient was utilized to determine correlations. We controlled for multiple comparisons, checked for collinearities, and ran two-sided statistical tests.

RESULTS

We found significant positive correlations for cotinine and oxytocin (P = .002), β-endorphin (P = .008), and orexin (P < .001), but not for either GGT or self-reported smoking or alcohol drinking.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

These preliminary results suggest a relationship between cotinine and oxytocin, β-endorphin, and orexin, which opens up new potential hypotheses on the potential role of these endocrine pathways in tobacco smokers. (Am J Addict 2021;30:88-91).

Environmental Contaminants Exposure and Preterm Birth: A Systematic Review

Preterm birth is an obstetric condition associated with a high risk of infant mortality and morbidities in both the neonatal period and later in life, which has also a significant public health impact because it carries an important societal economic burden. As in many cases the etiology is unknown, it is important to identify environmental factors that may be involved in the occurrence of this condition. In this review, we report all the studies published in PubMed and Scopus databases from January 1992 to January 2019, accessible as full-text articles, written in English, including clinical studies, original studies, and reviews. We excluded articles not written in English, duplicates, considering inappropriate populations and/or exposures or irrelevant outcomes and patients with known risk factors for preterm birth (PTB). The aim of this article is to identify and summarize the studies that examine environmental toxicants exposure associated with preterm birth. This knowledge will strengthen the possibility to develop strategies to reduce the exposure to these toxicants and apply clinical measures for preterm birth prevention.

Impact of Tobacco Versus Electronic Cigarette Smoking on Platelet Function

Electronic cigarettes (E-cigarettes) have become popular as substitutes for conventional tobacco cigarettes or to aid quitting, but little is known about the potential risks to cardiovascular health for smokers and nonsmokers. We sought to compare the impact of E-cigarettes with conventional cigarettes on platelet function in healthy adult smokers and nonsmokers. A crossover single-blind study in 40 healthy participants (20 smokers, 20 nonsmokers, matched for age and sex) was conducted. Each participant smoked a conventional cigarette then returned 1 week later to vape a study E-cigarette with the same nominal nicotine content. Blood samples were drawn shortly before and 5 minutes after each episode and analyzed for platelet aggregation, soluble CD40-ligand (sCD40L) and soluble P-selectin (sP-selectin). At baseline, smokers had significantly higher levels of sCD40L and sP-selectin (all p ≤0.01) than nonsmokers. Within 5 minutes of using either a conventional cigarette or E-cigarette, changes in the levels of sCD40L, sP-selectin, and platelet aggregation (all p ≤0.01) were detectable in both smokers and nonsmokers. In smokers, there were no significant changes in sCD40L and sP-selectin but there was a significant increase in platelet aggregation. In nonsmokers, there was a significant increase in all markers of platelet activation following both cigarette and E-cigarette use. Both traditional and E-cigarettes have short-term effects on platelet activation, although in nonsmokers the use of E-cigarettes had a less important impact. In conclusion, we provide the first comparison data of the acute impact of Tobacco-cigarette and E-cigarette smoking on the platelet function in smokers and nonsmokers.

Design and rationale of the Cardiovascular Health and Text Messaging (CHAT) Study and the CHAT-Diabetes Mellitus (CHAT-DM) Study: two randomised controlled trials of text messaging to improve secondary prevention for coronary heart disease and diabetes

INTRODUCTION

Mobile health interventions have the potential to promote risk factor management and lifestyle modification, and are a particularly attractive approach for scaling across healthcare systems with limited resources. We are conducting two randomised trials to evaluate the efficacy of text message-based health messages in improving secondary coronary heart disease (CHD) prevention among patients with or without diabetes.

METHODS AND ANALYSIS

The Cardiovascular Health And Text Messaging (CHAT) Study and the CHAT-Diabetes Mellitus (CHAT-DM) Study are multicentre, single-blind, randomised controlled trials of text messaging versus standard treatment with 6 months of follow-up conducted in 37 hospitals throughout 17 provinces in China. The intervention group receives six text messages per week which target blood pressure control, medication adherence, physical activity, smoking cessation (when appropriate), glucose monitoring and lifestyle recommendations including diet (in CHAT-DM). The text messages were developed based on behavioural change techniques, using models such as the information-motivation-behavioural skills model, goal setting and provision of social support. A total sample size of 800 patients would be adequate for CHAT Study and sample size of 500 patients would be adequate for the CHAT-DM Study. In CHAT, the primary outcome is the change in systolic blood pressure (SBP) at 6 months. Secondary outcomes include a change in proportion of patients achieving a SBP <140 mm Hg, low-density lipoprotein cholesterol (LDL-C), physical activity, medication adherence, body mass index (BMI) and smoking cessation. In CHAT-DM, the primary outcome is the change in glycaemic haemoglobin (HbA_1C) at 6 months. Secondary outcomes include a change in the proportion of patients achieving HbA_1C<7%, fasting blood glucose, SBP, LDL-C, BMI, physical activity and medication adherence.

ETHICS AND DISSEMINATION

The central ethics committee at the China National Center for Cardiovascular Disease and the Yale University Institutional Review Board approved the CHAT and CHAT-DM studies. Results will be disseminated via usual scientific forums including peer-reviewed publications.

TRIAL REGISTRATION NUMBER

CHAT (NCT02888769) and CHAT-DM (NCT02883842); Pre-results.

Comparison of SemiQuantitative Cotinine Values Obtained by the DRI Immunoassay and Values Obtained by a Liquid Chromatography-Tandem Mass Spectrometry-Based Method: The DRI Immunoassay is Suitable for Screening Purposes Only Because Semiquantitative Values May Be Unreliable

BACKGROUND

DRI cotinine assay is suitable only for screening for cotinine in urine specimens. We studied the reliability of DRI cotinine semiquantitative values by comparing them with the cotinine concentration obtained with a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method.

METHODS

Semiquantitative cotinine concentrations in 39 urine specimens obtained by the DRI immunoassay were compared with cotinine concentrations obtained by LC-MS/MS.

RESULTS

The DRI cotinine assay consistently overestimated cotinine values obtained by the LC/MS/MS method (y = 1.1529 x + 252.24, n = 39, R² = 0.8899) indicating that semiquantitative values obtained using the DRI assay may be unreliable. However, no false-negative results were observed using the DRI assay.

CONCLUSION

DRI cotinine assay is suitable only for screening cotinine in urine specimens.

Clinical Laboratory Evaluation of Electronic Cigarettes/Electronic Nicotine Delivery Systems: Methodological Challenges

OBJECTIVE

Evaluating electronic cigarettes (ECIGs) in the clinical laboratory is critical to understanding their effects. However, laboratory evaluation of ECIGs can be challenging, as they are a novel, varied, and evolving class of products. The objective of this paper is to describe some methodological challenges to the clinical laboratory evaluation of ECIGs.

METHODS

The authors gathered information about challenges involved in the laboratory evaluation of ECIGs. Challenges were categorized and solutions provided when possible.

RESULTS

Methods used to study combustible cigarettes may need to be adapted to account for ECIG novelty and differences within the class. Challenges to ECIG evaluation can include issues related to 1) identification of ECIG devices and liquids, 2) determination of short -term ECIG abstinence, 3) measurement of use behavior, and 4) assessment of dependence. These challenges are discussed, and some suggestions to inform ECIG evaluation using clinical laboratory methods are provided.

CONCLUSIONS

Awareness of challenges and developing, validating, and reporting methods used to address them aids interpretation of results and replication efforts, thus enhancing the rigor of science used to protect public health through appropriate, empirically-based, ECIG regulation.

The Effects of Auricular Acupressure on Smoking Cessation for Male College Students

The purpose of the study was to examine the effects of auricular acupressure for smoking cessation on male college students. The experimental group ( n = 27) received auricular acupressure on specific acupoints for smoking cessation, whereas the control group ( n = 26) received sham auricular acupressure on nonspecific acupoints. Participants received 6 weeks of auricular acupressure intervention. For the experimental group, auricular acupressure was applied to the shenmen, lung, subcortex, hunger, stomach, and mouth. The data of nicotine dependence, self-efficacy for smoking cessation, and exhaled carbon monoxide were collected for both group 3 times: before intervention, after 3 weeks of the intervention, and after 6 weeks of the intervention. Statistical differences between the two groups from pretest to posttest emerged in self-efficacy for smoking cessation ( p = .048) and exhaled carbon monoxide ( p < .001), but not for nicotine dependence.

A Role for Epigenetics in Broadening the Scope of Pediatric Care in the Prevention of Adolescent Smoking

Adolescence presents a critical opportunity to support the development of healthy patterns of behavior and prevent future health problems. Unfortunately, there is not yet a well-developed prevention model that allows pediatricians to initiate and monitor prevention efforts for the substantial minority of individuals who engage in risky behavior during adolescence. We suggest that recently developed epigenetic technologies may provide a bridge to a new prevention paradigm in which pediatricians screen for indicated smoking prevention services. Specifically, since currently available tobacco use screening measures are insensitive to low levels of use, newly developed methylation based approaches may enhance the sensitivity of the initial screening for nascent smoking behavior as well monitoring of outcomes. We conclude that the incorporation of Next Gen screening technologies into standard pediatric evaluations may allow for more effective referral to prevention programming for tobacco use. In addition to the potential direct impact on long-term enhancement of health outcomes secondary to smoking prevention, well-established links between smoking and other risk behaviors suggest that expanded referral for nascent smoking may also create opportunities to address other risky adolescent behaviors, and so decrease several interrelated drivers of long-term health care costs.

Role of Environmental Factors in the Development of Pediatric Eosinophilic Esophagitis

BACKGROUND

Despite accumulating data on the pathogenesis of eosinophilic esophagitis, not much is known about risk factors for the development of the disease. The role of factors such as smoking, breastfeeding, early antibiotic exposure and other factors that have been associated with other allergic diseases has not been well studied in children with eosinophilic esophagitis.

AIM

To explore the role of environmental and medication exposures in the development of pediatric eosinophilic esophagitis.

METHODS

We conducted a cross-sectional case-control study, utilizing a parent and child questionnaire and medical chart review. Urine cotinine levels, measured by high-performance liquid chromatography, were obtained as objective evidence for smoking exposure.

RESULTS

One hundred and two children with eosinophilic esophagitis and 167 controls were recruited. The controls were mainly diagnosed with functional gastrointestinal disorders (33%) and gastroesophageal reflux disease (29%). Food allergy, specifically for peanuts and tree nuts, and allergy to pollen, tree, and grass were significantly higher among eosinophilic esophagitis children. Smoking exposure, both primary and secondary, was not associated with pediatric eosinophilic esophagitis when compared to controls (odds ratio 0.96, 95% confidence interval 0.58-1.59). Furthermore, early smoking exposure in the first year of life was higher among controls. Common accepted risk factors for allergy and atopy, such as breastfeeding practices, antibiotics exposure, animals' exposure, and others, were not found to be associated with eosinophilic esophagitis in our study.

CONCLUSION

Common risk factors in other allergic and atopic conditions were not found to be associated with eosinophilic esophagitis.

Long-term smoking cessation and heart rate dynamics in an aging healthy cohort: Is it possible to fully recover?

AIM

To evaluate the long-term influence of smoking cessation on the regulation of the autonomic cardiovascular system in an aging general population, using the subpopulation of lifelong non-smokers as control group.

METHODS

We analyzed 1481 participants aged ≥50 years from the SAPALDIA cohort. In each participant, heart rate variability and heart rate dynamics were characterized by means of various quantitative analyzes of the inter-beat interval time series generated from 24-hour electrocardiogram recordings. Each parameter obtained was then used as the outcome variable in multivariable linear regression models in order to evaluate the association with smoking status and time elapsed since smoking cessation. The models were adjusted for known confounding factors and stratified by the time elapsed since smoking cessation.

RESULTS

Our findings indicate that smoking triggers adverse changes in the regulation of the cardiovascular system, even at low levels of exposure since current light smokers exhibited significant changes as compared to lifelong non-smokers. Moreover, there was evidence for a dose-response effect. Indeed, the changes observed in current heavy smokers were more marked as compared to current light smokers. Furthermore, full recovery was achieved in former smokers (i.e., normalization to the level of lifelong non-smokers). However, while light smokers fully recovered within the 15 first years of cessation, heavy former smokers might need up to 15-25 years to fully recover.

CONCLUSION

This study supports the substantial benefits of smoking cessation, but also warns of important long-term alterations caused by heavy smoking.

The impact of job strain on smoking cessation and relapse in the Canadian population: a cohort study

BACKGROUND

The aim of this study is to investigate the impact of job strain, as measured by the Karasek demand/control model (DCM), on smoking cessation and relapse in a representative general population sample.

METHODS

A secondary analysis of data from the Canadian National Population Health Survey (NPHS) was undertaken. Daily smokers and former daily smokers (n=1287 and 1184, respectively) at cycle 1 (1994/1995) of the NPHS were followed up at cycle 2 (1996/1997). Measures of job strain (the independent variables) were based on data from cycle 1, predicting smoking status at cycle 2. Logistic regression analysis was employed in two ways. Individuals were stratified into job strain quartiles while continuous measures were also employed in separate analyses for job strain and its component dimensions.

RESULTS

In the quartile analysis, no effect of job strain was observed on the likelihood of cessation, while a non-linear effect was observed on the likelihood of relapse, although this relationship lost significance (p>0.05 and <0.10) after controlling for personal characteristics. No effect was observed using the continuous measure of job strain or the continuous measure of job demand on either cessation or relapse. For job control, no effect was observed on the likelihood of cessation, but increased control was found to decrease the likelihood of relapse in the unadjusted model only.

CONCLUSIONS

Psychosocial work environments may be too diverse for uniform trends in the relationship between job stress and smoking behaviour to emerge in a population sample. Future research should avoid use of the scaled-down DCM instrument where possible.

Identifying misclassification in youth self-reported smoking status: testing different consent processes of biological sample collection to capture misclassification

INTRODUCTION

In Florida, since 1998, identical survey items have been used to measure youth smoking status for the CDC sponsored state school-based survey and the tobacco control program evaluation telephone survey. The two surveys should parallel one another to track tobacco use. Tobacco items collected in the two surveys closely paralleled one another until recently. Since 2008, data show dramatically divergent youth smoking estimates (e.g., relative differences as high as 50%), which cannot be explained by differences in survey and sampling design. As a first step in detecting misclassification of smoking status, we examined the feasibility of asking youth to self-report their smoking behavior and collect a biological sample, with the expectation that some youth will misreport their smoking status.

METHODS

Using a cross-sectional population level telephone survey, youth were randomly assigned to one of three groups to test mode effects of collecting biological data with self-reported survey data (n = 303).

RESULTS

It showed two groups of youth (those who are not asked for a biological and those asked for a biological with an indirect explanation of its use) had similar response rates and self-reported smoking status, while the third group (biological request with a direct explanation of its use) had a substantially lower response rate and self-reported smoking status.

CONCLUSIONS

The data show youth who are given an indirect explanation of how biological data are to be used were as likely to self-report their smoking status as youth who were not asked to provide a biological sample.

Zinc Sulfate, a Recently Introduced Urinary Adulterant Can Invalidate Urine Cotinine Test Using Immunoassay but Has Less Effect on Liquid Chromatography Combined With Tandem Mass Spectrometry-Based Test

OBJECTIVE

Zinc sulfate is a recently introduced urinary adulterant, which causes false-negative results with immunoassays used for screening drugs of abuse in urine but whether zinc sulfate also could invalidate urine cotinine assay using immunoassay or liquid chromatography combined with mass spectrometry has never been studied.

DESIGN AND METHOD

Four urine pools containing none detected to high levels of cotinine were analyzed using DRI cotinine immunoassay on the Olympus 640 analyzer as well as using liquid chromatography combined with tandem mass spectrometry. Specimens were reanalyzed after supplementing with various amounts of zinc sulfate that are known to invalidate immunoassays used for drugs of abuse testing.

RESULTS

Zinc sulfate in all concentrations studied caused false-negative results using immunoassays, but zinc sulfate also reduced cotinine values by approximately 2.1%-38.4% when analyzed using liquid chromatography combined with mass spectrometry.

CONCLUSIONS

Zinc sulfate caused false-negative cotinine result when DRI immunoassay was used and also had small to moderate impact on liquid chromatography combined with tandem mass spectrometry-based assay for urine cotinine.

Smoking and Preterm Birth

Premature birth is a significant global problem and the leading cause of newborn deaths. Tobacco smoking has been associated with premature birth for over 50 years. The mechanisms through which smoking exerts its effects on pregnancy outcomes remain unclear. In this review, we discuss rates of prematurity and smoking in pregnancy, the evidence of a causal relationship between tobacco and preterm birth, and proposed biochemical pathways through which the interaction is mediated. The suggested mechanisms include nicotine-induced vasoconstriction, carbon monoxide-induced fetal hypoxia, cadmium disruption of calcium signaling, altered steroid hormone production, disruption of prostaglandin synthesis, and changed responses to oxytocin. The relative importance of each of these pathways is yet to be ascertained. Further research is necessary to explore the mechanisms through which smoking exerts its effect on gestational length and the process of parturition. Moreover, the risks of nicotine replacement in pregnancy should be investigated further.

The effects and measures of auricular acupressure and interactive multimedia for smoking cessation in college students

The earlier one starts to smoke, the more likely it is that one's tobacco use will increase. Either auricular acupressure or multimedia education could improve physiological health status and reduce smoking for young smokers. This study aimed to evaluate the effects of a 10-week auricular acupressure (AA) and interactive multimedia (IM) on smoking cessation in college smokers. A pre- and posttest control research design with two experiments (AA and IM) and one control was used. Thirty-two participants were in each of three groups. A significant difference from pretest to posttest among three groups was exhibited on carbon monoxide (CO), cotinine, and nicotine dependence. Scheffe's post hoc test found significances on CO in the AA between the IM and the control and cotinine and nicotine dependence between the AA and the control. After controlling the covariates, the main effect of the group was no difference in all outcomes. The interventions, especially AA, may contribute to a decrease of CO, cotinine, and nicotine dependence along with the time change. An analysis without controlling influences may overestimate interventional effects.

Laboratory Validation of Inertial Body Sensors to Detect Cigarette Smoking Arm Movements

Cigarette smoking remains the leading cause of preventable death in the United States. Traditional in-clinic cessation interventions may fail to intervene and interrupt the rapid progression to relapse that typically occurs following a quit attempt. The ability to detect actual smoking behavior in real-time is a measurement challenge for health behavior research and intervention. The successful detection of real-time smoking through mobile health (mHealth) methodology has substantial implications for developing highly efficacious treatment interventions. The current study was aimed at further developing and testing the ability of inertial sensors to detect cigarette smoking arm movements among smokers. The current study involved four smokers who smoked six cigarettes each in a laboratory-based assessment. Participants were outfitted with four inertial body movement sensors on the arms, which were used to detect smoking events at two levels: the puff level and the cigarette level. Two different algorithms (Support Vector Machines (SVM) and Edge-Detection based learning) were trained to detect the features of arm movement sequences transmitted by the sensors that corresponded with each level. The results showed that performance of the SVM algorithm at the cigarette level exceeded detection at the individual puff level, with low rates of false positive puff detection. The current study is the second in a line of programmatic research demonstrating the proof-of-concept for sensor-based tracking of smoking, based on movements of the arm and wrist. This study demonstrates efficacy in a real-world clinical inpatient setting and is the first to provide a detection rate against direct observation, enabling calculation of true and false positive rates. The study results indicate that the approach performs very well with some participants, whereas some challenges remain with participants who generate more frequent non-smoking movements near the face. Future work may allow for tracking smoking in real-world environments, which would facilitate developing more effective, just-in-time smoking cessation interventions.

The DNA methylation signature of smoking: an archetype for the identification of biomarkers for behavioral illness

Smoking is perhaps the foremost public health challenge in the United States and in the world. In a series of rapidly emerging studies, we and others have demonstrated that cigarette smoking is associated with changes in the DNA methylation signature of peripheral blood cells. The changes associated with this type of substance use are both dose and time dependent. These changes in DNA methylation are also accompanied by changes in gene transcription and protein expression whose patterns are furthermore indicative of increased vulnerability to other forms of complex illness. In the past, our efforts to translate this knowledge into actionable information has been stymied by a lack of methods through which to systematically to assess these changes. The rapid advance of DNA methylation assessment technologies changes that dynamic and presents the possibility that methylation-based clinical tools to aid the ascertainment of smoking status or effectiveness of treatment can be developed. In this chapter, we will review the latest advances in this field and discuss how these advances allow us insight as to methods through which to prevent smoking and shed insight into optimizing strategies through which to identify biomarkers for other behavioral illnesses which share similar contributions from environmental and gene- environmental interaction effects.

The Remote Monitoring of Smoking in Adolescents

BACKGROUND/OBJECTIVES

Cigarette smoking remains the leading cause of preventable death in the United States with the vast majority of adult smokers starting prior to the age of 18. Despite the public health relevance and implications of studying smoking in adolescents, little is known about the initiation of quit attempts, the process of relapse, and the most efficacious treatment interventions in this high-risk and underserved population. Issues such as retention in research studies and accuracy of self-reports have prompted investigators to explore innovative technology-based systems to integrate into treatment studies and services delivery.

METHODS

This paper will review the remote monitoring of smoking through means of ecological momentary assessment, biochemical verification of smoking verified through video capture, physiological monitoring, and mobile-delivered interventions using self-reported smoking outcomes in adolescents, when applicable.

RESULTS

Use of remote monitoring methods in adolescent smokers has been limited thus far, though monitoring technology in adults has shown promise for understanding relapse and delivering treatment interventions.

CONCLUSIONS

Comprehensive technology-based systems that do not rely primarily on self-report to monitor smoking would be a highly fruitful and innovative avenue to explore with adolescent smokers. Technology integration holds great promise to improve health-related research, treatment delivery, cost-effectiveness, and just-in-time interventions, but its novelty comes with unique problems and concerns to be carefully considered.

Atomoxetine treatment for nicotine withdrawal: a pilot double-blind, placebo-controlled, fixed-dose study in adult smokers

BACKGROUND

Many effective treatments for nicotine addiction inhibit noradrenaline reuptake. Three recent studies have suggested that another noradrenaline reuptake inhibitor, atomoxetine, may reduce smoking behaviors.

METHODS

The present double-blind, placebo-controlled, fixed-dose study was carried out over 21 days during which administration of 40 mg atomoxetine was compared to placebo in 17 individuals. Of these, nine were randomized to atomoxetine and eight to placebo. Baseline and weekly measurements were made using the Cigarette Dependence Scale (CDS), Cigarette Withdrawal Scale (CWS), Questionnaire of Smoking Urges (QSU), reported number of cigarettes smoked, and salivary cotinine levels.

RESULTS

The study results showed that all those on placebo completed the study. In marked contrast, of the nine individuals who started on atomoxetine, five dropped out due to side effects. In a completer analysis there were statistically significant differences at 14 and 21 days in several measures between the atomoxetine and placebo groups, including CDS, CWS, QSU, number of cigarettes smoked (decreasing to less than two per day in the treatment group who completed the study), and a trend towards lower mean salivary cotinine levels. However, these differences were not seen in a last observation carried forward (LOCF) analysis.

CONCLUSIONS

In summary, this is the first study to examine the use of atomoxetine in non-psychiatric adult smokers for a period of more than 7 days, and the findings suggest that atomoxetine might be a useful treatment for nicotine addiction. However, the dose used in the current study was too high to be tolerated by many adults, and a dose-finding study is required to determine the most appropriate dose for future studies of this potential treatment for smoking cessation.

A thematic analysis of theoretical models for translational science in nursing: mapping the field

The quantity and diversity of conceptual models in translational science may complicate rather than advance the use of theory. This paper offers a comparative thematic analysis of the models available to inform knowledge development, transfer, and utilization. Literature searches identified 47 models for knowledge translation. Four thematic areas emerged: (1) evidence-based practice and knowledge transformation processes, (2) strategic change to promote adoption of new knowledge, (3) knowledge exchange and synthesis for application and inquiry, and (4) designing and interpreting dissemination research. This analysis distinguishes the contributions made by leaders and researchers at each phase in the process of discovery, development, and service delivery. It also informs the selection of models to guide activities in knowledge translation. A flexible theoretical stance is essential to simultaneously develop new knowledge and accelerate the translation of that knowledge into practice behaviors and programs of care that support optimal patient outcomes.

Auricular acupressure combined with multimedia instruction or alone for quitting smoking in young adults: A quasi-experimental study

BACKGROUND

Smoking plays a disease-related risk factor and is however the principal cause of preventable death. Many studies support the use of combined rather than single interventions to stop smoking.

OBJECTIVE

This study aimed to evaluate the effects of auricular acupressure combined with multimedia instruction in comparison with auricular acupressure alone on smoking cessation in young adults.

METHOD

A quasi-experimental research design was used and participants were assigned to experimental groups according to their preference. Group 1 received the 10-week program with auricular acupressure plus multimedia instruction; Group 2 received auricular acupressure alone. Thirty-two participants were in each group were recruited from universities in Taiwan. The physical and psychological data were collected right before and after the program.

RESULTS

This study demonstrated the effects of smoking cessation on physical and psychological factors in each group. Statistical between-group differences existed in psychological factors of smoking cessation self-efficacy and nicotine dependence, but not in physical factors of carbon monoxide and cotinine.

CONCLUSIONS

This study adds to the body of research on the benefits of using auricular acupressure combined with or without multimedia instruction for smoking cessation in adolescents. The combined intervention was more effective especially in increasing smoking cessation self-efficacy and decreasing nicotine dependence. Further study is suggested adding control groups such as placebo in order to understand a single effect of smoking cessation.

Psychometric testing of the Chinese version of the Dimensions of Tobacco Dependence Scale

AIMS

This paper reports on a study to establish the psychometric properties of the Chinese version of the dimensions of Tobacco Dependence Scale as these apply in Taiwan.

BACKGROUND

The instruments for measuring cigarette dependence among adolescent smokers are not available in Taiwan. Therefore, it has not so far been possible to assess such dependence.

DESIGN

Survey.

METHOD

A sample comprising 293 adolescent smokers was recruited. They were drawn from nine senior high schools in middle and southern Taiwan. The Dimensions of Tobacco Dependence Scale and the Fagerstrom Test of nicotine dependence were administered, with saliva being subjected to salivary cotinine analysis using competitive enzyme immunoassay kits.

RESULTS

The internal structure of the Dimensions of Tobacco Dependence Scale (DTDS) was first examined using exploratory factor analysis with promax rotation. By applying the parallel test as the means of selection, four criteria emerged from the factor analysis that accounted for 47.7% of the variance. Concerning criterion validity, the DTDS was found to have a positive and significant association with the Fagerstrom test of nicotine dependence scores (r = 0.58; p < 0.01) and with saliva cotinine levels (r = 0.30; p < 0.01). Cronbach's alpha values for the DTDS were 0.94.

CONCLUSIONS

The study confirmed that the Chinese version of the DTDS is similar to the English version in that it is multidimensional and has consistent factor structures. And, as a result of the study, it was established that the Chinese version of the Dimensions of Tobacco Dependence Scale is a reliable and valid measure of tobacco dependence among adolescents in Taiwan.

RELEVANCE TO CLINICAL PRACTICE

The DTDS can provide health professionals with a reference measure for assessing adolescents' tobacco dependence when applied in the context of a smoking cessation programme.

Methods for quantification of exposure to cigarette smoking and environmental tobacco smoke: focus on developmental toxicology

Active and passive smoking have been associated with an array of adverse effects on health. The development of valid and accurate scales of measurement for exposures associated with health risks constitutes an active area of research. Tobacco smoke exposure still lacks an ideal method of measurement. A valid estimation of the risks associated with tobacco exposure depends on accurate measurement. However, some groups of people are more reluctant than others to disclose their smoking status and exposure to tobacco. This is particularly true for pregnant women and parents of young children, whose smoking is often regarded as socially unacceptable. For others, recall of tobacco exposure may also prove difficult. Because relying on self-report and the various biases it introduces may lead to inaccurate measures of nicotine exposure, more objective solutions have been suggested. Biomarkers constitute the most commonly used objective method of ascertaining nicotine exposure. Of those available, cotinine has gained supremacy as the biomarker of choice. Traditionally, cotinine has been measured in blood, saliva, and urine. Cotinine collection and analysis from these sources has posed some difficulties, which have motivated the search for a more consistent and reliable source of this biomarker. Hair analysis is a novel, noninvasive technique used to detect the presence of drugs and metabolites in the hair shaft. Because cotinine accumulates in hair during hair growth, it is a unique measure of long-term, cumulative exposure to tobacco smoke. Although hair analysis of cotinine holds great promise, a detailed evaluation of its potential as a biomarker of nicotine exposure, is needed. No studies have been published that address this issue. Because the levels of cotinine in the body are dependent on nicotine metabolism, which in turn is affected by factors such as age and pregnancy, the characterization of hair cotinine should be population specific. This review aims at defining the sensitivity, specificity, and clinical utilization of different methods used to estimate exposure to cigarette smoking and environmental tobacco smoke.

Evaluating screening performances of the Fagerstrom tolerance questionnaire, the Fagerstrom test for nicotine dependence and the heavy smoking index among Taiwanese male smokers

AIM

To compare screening performances of the Fagerstrom Tolerance Questionnaire (FTQ), the Fagerstrom test for nicotine dependence (FTND) and the Heavy Smoking Index (HSI) with a view to determining the optimum cutoff scores using biomarkers as standards.

BACKGROUND

Previous studies proposed inconsistent cutoff scores for the FTQ, the FTND as signalling nicotine dependence and these scores were established by applying diverse standards.

METHOD

Receiver operating characteristic (ROC) analyses were used in pursuit of the study's objectives. Two hundred and forty-five male smokers were recruited in 2005 from among those attending public health stations in southern Taiwan. The three self-report measures of nicotine dependence were compared with the saliva cotinine and expired carbon monoxide (CO). The expired CO level was tested by means of a Micro Smokerlyzer, while salivary cotinine was analysed using an enzyme-linked immunosorbent assay.

RESULTS

The areas under the ROC curves for the FTQ, the FTND and the HSI were 0.71, 0.76 and 0.76 for the salivary cotinine and 0.71, 0.79 and 0.80 for the exhaled CO respectively. The sensitivity and specificity of the FTND and the HSI were slightly greater than those for the FTQ. The optimum cutoff scores for the FTQ, the FTND and the HSI as screening tools to establish nicotine dependence would be 5+, 4+ and 3+ respectively.

CONCLUSION

The results indicate that the FTND and the HSI may be more efficacious than the FTQ in assessing nicotine dependence. Further research is needed to confirm these findings, especially among female smokers and for nicotine substitution trials. Relevance to clinical practice. To decrease tobacco-attributable morbidity and mortality, nurses and healthcare professionals need to implement effective smoking cessation interventions. The FTND and the HSI as well as their cutoff scores will be suitably used to assess nicotine dependence in these interventions.

Identifying risk factors for postpartum tobacco use

PURPOSE

To identify factors associated with becoming a mother that may contribute to postpartum smoking-related outcomes.

DESIGN

Cross-sectional, correlational.

METHODS

Postpartum women (N=133) who were clients in a nutrition supplement program for low-income families responded to questionnaires about smoking and early motherhood experiences. Inferential statistical tests included hierarchical multiple and logistic regression.

FINDINGS

After controlling for factors known to be associated with smoking outcomes for the general population, factors associated with becoming a mother significantly contributed to the amount of explained variance in both postpartum self-efficacy to refrain from smoking and smoking within 2 weeks after delivery.

CONCLUSIONS

Study findings indicated that prenatal intentions about postpartum tobacco use and maternal response to infant cry episodes were areas for risk assessment that might lead to effective smoking cessation interventions uniquely tailored to women who experience becoming a mother.

Effects of passive smoking on heart rate variability, heart rate and blood pressure: an observational study

BACKGROUND

Exposure to environmental tobacco smoke (ETS) has been shown to increase the risk for cardiovascular diseases and death, and autonomic dysfunction (specifically, reduced heart rate variability (HRV)) is a predictor of increased cardiac risk. This study tests the hypothesis that ETS exposure reduces HRV in the general population and discusses possible pathways.

METHODS

This cross-sectional study was conducted between 2001 and 2003 and is part of the SAPALDIA (Swiss Cohort Study on Air Pollution and Lung Diseases in Adults) study. The analysis included 1218 randomly selected non-smokers aged 50 and above who participated in 24-h electrocardiogram recordings. Other examinations included an interview, investigating health status (especially respiratory and cardiovascular health and health relevant behaviours and exposure to ETS) and measurements of blood pressure, body height and weight.

RESULTS

Subjects exposed to ETS at home or at work for more than 2 h/day had a difference of -15% in total power (95%CI: -26 to -3%), low frequency power (-28 to -1%), low/high frequency ratio (-26 to -3%) and -18% (-29 to -4%) in ultralow frequency power of HRV compared with subjects not exposed to ETS at home or work. We also found a 2.7% (-0.01 to 5.34%) higher heart rate during the recording in exposed subjects.

CONCLUSIONS

Exposure to ETS at home and work is associated with lower HRV and with higher heart rate in an ageing population. Our findings suggest that exposure to ETS increases cardiac risk through disturbances in the autonomic nervous system.

Validity of Expired Carbon Monoxide and Urine Cotinine Using Dipstick Method to Assess Smoking Status

OBJECTIVES

We investigated the validity of the dipstick method (Mossman Associates Inc. USA) and the expired CO method to distinguish between smokers and nonsmokers. We also elucidated the related factors of the two methods.

METHODS

This study included 244 smokers and 50 ex-smokers, recruited from smoking cessation clinics at 4 local public health centers, who had quit for over 4 weeks. We calculated the sensitivity, specificity and Kappa coefficient of each method for validity. We obtained ROC curve, predictive value and agreement to determine the cutoff of expired air CO method. Finally, we elucidated the related factors and compared their effect powers using the standardized regression coefficient.

RESULTS

The dipstick method showed a sensitivity of 92.6%, specificity of 96.0% and Kappa coefficient of 0.79. The best cutoff value to distinguish smokers was 5-6 ppm. At 5 ppm, the expired CO method showed a sensitivity of 94.3%, specificity of 82.0% and Kappa coefficient of 0.73. And at 6 ppm, sensitivity, specificity and Kappa coefficient were 88.5%, 86.0% and 0.64, respectively. Therefore, the dipstick method had higher sensitivity and specificity than the expired CO method. The dipstick and expired CO methods were significantly increased with increasing smoking amount. With longer time since the last smoking, expired CO showed a rapid decrease after 4 hours, whereas the dipstick method showed relatively stable levels for more than 4 hours.

CONCLUSIONS

The dipstick and expired CO methods were both good indicators for assessing smoking status. However, the former showed higher sensitivity and specificity and stable levels over longer hours after smoking, compared to the expired CO method.

Psychometric evaluation of the Chinese version of the Fagerstrom Tolerance Questionnaire as a measure of cigarette dependence

AIM

The aim of this study is to estimate the psychometric properties of the Chinese version of the Fagerstrom Tolerance Questionnaire as a measure of nicotine dependence.

BACKGROUND

The Chinese Fagerstrom Tolerance Questionnaire has been used in smoking cessation programmes in Taiwan. However, the psychometric properties of the Chinese version have not been tested.

METHODS

A cross-sectional, descriptive study was conducted from June 2004 to July 2005 with 247 adult smokers. The criterion validity of the Chinese Fagerstrom Tolerance Questionnaire was determined using two biomarkers (exhaled CO and saliva cotinine levels). Because the responses to the items are dichotomous or nominal, the validity and factorial structures were examined using tetrachoric techniques. Construct reliability was evaluated to accommodate the lack of tau-equivalence assumed in computing Cronbach's alpha.

FINDINGS

The item 'smoke more in the morning' was not statistically significantly correlated with either biomarker because many participants expressed the desire to smoke after meals instead of in the morning. The items 'nicotine yield' and 'inhalation' performed poorly in terms of criterion validity and construct validity. This evidence supports modification of the Chinese version of the Fagerstrom Tolerance Questionnaire to the six-item Fagerstrom Test for Nicotine Dependence. In addition, the item 'difficulty refraining from smoking in forbidden places' had relatively poor psychometric performance. The reason may be culturally specific, having to do with the relative lack of forbidden places and restrictions on tobacco use in Taiwan. The predictive ability of the Chinese version of the Fagerstrom Tolerance Questionnaire for biomarkers is higher than the English version. The reliability coefficient (0.65) was higher than Cronbach's alpha, but did not meet the satisfactory standard of 0.70.

CONCLUSION

The Chinese version of the Fagerstrom Tolerance Questionnaire is a fairly reliable and valid scale, but needs to be revised to accommodate cross-cultural differences.

Quantifying smoking cessation outcomes: from The Women's Initiative for Nonsmoking Study (X): methodological implications

BACKGROUND

Classification of smoking status has a major impact on the conclusions drawn from smoking cessation intervention research, yet few studies have addressed this critical issue.

OBJECTIVES

The aim of this study was to compare three classifications (naïve, optimistic, and pessimistic) of smoking cessation outcomes or smoking status from the Women's Initiative for Nonsmoking Study (WINS).

METHODS

This is a longitudinal prospective study nested within a randomized clinical trial (RCT) design of WINS, an RCT of 277 women over the age of 18 years who reported smoking cigarettes continuously for 1 month prior to a cardiovascular event requiring hospital admission. Women were randomized to either the usual care group (UC) or the intervention group (IG). Recruitment for WINS occurred between October 1996 and December 1998 in 10 hospitals in the San Francisco Bay area. Follow-up data on smoking status was obtained from the UC and the IG using a structured telephone interview at 6 and 12 months from baseline and was confirmed by family members and salivary cotinine levels.

RESULTS

Seven-day point prevalence(self-report of not smoking in the past 7 days; "not even a puff") using the naïve (the most liberal) classification yields a greater number of nonsmokers than the pessimistic or most conservative classification (cotinine level verification of smoking status). The classification of smoking status also affects time to continuous smoking. The pessimistic classification results in the shortest time to continuous smoking, whereas the opposite is observed with the naïve classification.

DISCUSSION

It is important to critically evaluate the underlying assumptions made by study investigators when measuring and reporting smoking status. The classification of smoking status and the selection of analysis, meaning point prevalence versus survival analysis, affect study results and contribute to the variability observed in the research findings of smoking cessation intervention trials and the challenges faced in making appropriate comparisons across studies.

Children's hedonic judgments of cigarette smoke odor: effects of parental smoking and maternal mood

Age-appropriate tasks were used to assess 3- to 8-year-old children's liking, identification, and preference for a variety of odors, including that of exhaled cigarette smoke. Children whose parents smoke took longer to decide whether they liked the cigarette odor and were significantly more likely to prefer the odor of cigarette to the neutral and unfamiliar odor of green tea compared with children of nonsmokers. Among children of smokers, relative preferences for the cigarette odor were related to maternal mood disturbance and depression scores. These findings suggest that some early learning about cigarette smoke odor is based on sensory experiences at home and anchors it to the emotional context in which their mothers smoke.

Guided health imagery for smoking cessation and long-term abstinence

PURPOSE

To examine the effectiveness of guided imagery for immediate smoking cessation and long-term abstinence in adult smokers.

DESIGN

A repeated measures design was used with 71 smokers recruited from a hospital outpatient clinic, 38 in the intervention group, and 33 in the control group.

METHODS

Both study groups received educational and counseling sessions in their homes. The intervention group was provided with additional instruction in the use of guided imagery and was encouraged to practice this imagery at least once per day with a 20-minute audio-taped exercise for reinforcement. The repeated measures included smoking rates (cigarettes per day) that were measured and confirmed through corroborating friends and family.

FINDINGS

At 24-months after the intervention, smoking abstinence rates were significantly higher for the guided health imagery intervention group (26% abstinence rate versus 12% abstinence rate for the placebo-control group).

CONCLUSIONS

Guided imagery was an effective intervention for long-term smoking cessation and abstinence in adult smokers.