Gender differences in the outcome of an unaided smoking cessation attempt

Effects of Smokeless Tobacco Use on the Upper Gastrointestinal Tract Mucosa: Gross and Histopathological Changes

BACKGROUND/AIM

Tobacco addiction is prevalent in South and Southeast Asia. This study aimed to assess upper gastrointestinal (GI) tract changes in smokeless tobacco (SLT) users through upper GI endoscopy (UGIE).

MATERIALS AND METHODS

A cross-sectional observational study, including 108 SLT users and 90 controls who did not use tobacco, was conducted at an Indian tertiary care hospital from March 2022 to February 2023. Participants were categorized into three groups: Non-SLT users (Group A), SLT users for <10 years (Group B), and SLT users for >10 years (Group C). UGIE and biopsies from the lower esophagus, stomach, and duodenum were performed, noting gross and pathological findings.

RESULTS

There were 89 males and 19 females. More than 60% of patients used SLT for more than 10 years. Grossly, erosive and ulcerative lesions of the esophagus and stomach were the most common findings. Barrett's esophagus (14/108 patients) and esophageal neoplasms (5/108 patients) were found in 19/108 patients (17.59%). Common biopsy findings were chronic gastritis and duodenitis. Group C had a significantly high finding of gastric ulcers compared to other 2 groups. A total of 68/108 SLT users (62.96%) had Helicobacter pylori infection which was significantly higher compared to the controls ( P < 0.05).

CONCLUSION

Chronic SLT use was found to be associated with gross and histological changes in the upper GI tract such as chronic erosions, peptic ulcers, and neoplastic growths. UGIE must be done routinely in all these patients whenever they develop chronic dyspepsia for early diagnosis and management.

Smoking as a risk factor for lower extremity peripheral artery disease in women compared to men: A systematic review and meta-analysis

BACKGROUND

To investigate whether the relationship between smoking and peripheral artery disease (PAD) differs by sex (PROSPERO CRD42022352318).

METHODS

PubMed, EMBASE, and CINAHL were searched (3 March 2024) for studies reporting associations between smoking and PAD in both sexes, at least adjusted for age. Data were pooled using random effects. Between-study heterogeneity was examined using I2 statistic and Cochran's Q test. Newcastle-Ottowa Scale was adopted for quality assessment.

RESULTS

Four cohort studies (n = 2,117,860, 54.4% women) and thirteen cross-sectional studies (n = 230,436, 59.9% women) were included. In cohort studies, former and current smokers had higher risk of PAD than never smokers. Compared to those who never or previously smoked, women current smokers (relative risk (RR) 5.30 (95% confidence interval 3.17, 8.87)) had higher excess risk of PAD than men (RR 3.30 (2.46, 4.42)), women-to-men ratio of RR 1.45 (1.30, 1.62)(I2 = 0%, p = 0.328). In cross-sectional studies, risk of PAD was higher among former and current compared to never smokers, more so in men, women-to-men ratios of odds ratio: 0.64 (0.46, 0.90)(I2 = 30%, p = 0.192), 0.63 (0.50, 0.79)(I2 = 0%, p = 0.594), respectively. For both sexes, risk of PAD was higher among current smokers compared to those who were not currently smoking. Cohort studies and five cross-sectional studies were of good quality, scoring 6 to 8 of a possible maximum 9 points. Eight cross-sectional studies scored 2 to 5.

DISCUSSIONS

Further research is required to elucidate sex differences in the relationships between smoking and PAD, as the current evidence is limited and mixed. Tobacco-control programs should consider both sexes.

Neurobiology of Stress-Induced Nicotine Relapse

Tobacco smoking is the leading cause of preventable death and disease. Although there are some FAD-approved medicines for controlling smoking, the relapse rate remains very high. Among the factors that could induce nicotine relapse, stress might be the most important one. In the last decades, preclinical studies have generated many new findings that lead to a better understanding of stress-induced relapse of nicotine-seeking. Several molecules such as α3β4 nicotinic acetylcholine receptor, α2-adrenergic receptors, cannabinoid receptor 1, trace amine-associated receptor 1, and neuropeptide systems (corticotropin-releasing factor and its receptors, dynorphine and kappa opioid receptor) have been linked to stress-induced nicotine relapse. In this review, we discuss recent advances in the neurobiology, treatment targets, and potential therapeutics of stress-induced nicotine relapse. We also discuss some factors that may influence stress-induced nicotine relapse and that should be considered in future studies. In the final section, a perspective on some research directions is provided. Further investigation on the neurobiology of stress-induced nicotine relapse will shed light on the development of new medicines for controlling smoking and will help us understand the interactions between the stress and reward systems in the brain.

Gender differences in weight gain during attempted and successful smoking cessation on dulaglutide treatment: a predefined secondary analysis of a randomised trial

Background

Women seem to have more difficulty quitting smoking than men. This is particularly concerning as smoking puts women at a higher risk of developing smoking-associated diseases. Greater concerns about postcessation weight gain in women have been postulated as a possible explanation.

Methods

Predefined secondary analysis of a placebo-controlled, double-blind, parallel-group, superiority randomised trial including 255 adults who smoke daily (155 women, 100 men). Participants received weekly dulaglutide (1.5 mg) or placebo (0.9% sodium chloride) in addition to standardised smoking cessation care (varenicline 2 mg/day plus behavioural counselling) over 12 weeks. We aimed to investigate gender differences in weight change after dulaglutide-assisted smoking cessation. Weight change between baseline and week 12 was analysed as absolute and revative weight change and as substantial weight gain (defined as >6% increase).

Results

No gender differences were observed in absolute or relative weight change neither on dulaglutide nor placebo treatment. However, substantial weight gain (defined as >6% increase) in the placebo group was almost five times more frequent in females than males (24% vs 5%). Female patients were less likely to have substantial weight gain on dulaglutide compared with placebo (1% (n=1/83) vs 24% (n=17/72); p<0.001), while this dulaglutide effect was less pronounced in males (0% (n=0/44) vs 5% (n=3/56); p=0.333).

Conclusion

Dulaglutide reduced postcessation weight gain in both genders and was very effective in preventing substantial weight gain, which seems to be a specific observation in females.

Trial registration number

NCT03204396.

Selective Inhibition of Phosphodiesterase 7 Enzymes Reduces Motivation for Nicotine Use through Modulation of Mesolimbic Dopaminergic Transmission

Approximately 5 million people die from diseases related to nicotine addiction and tobacco use each year. The nicotine-induced increase of corticomesolimbic dopaminergic (DAergic) transmission and hypodopaminergic conditions occurring during abstinence are important for maintaining drug-use habits. We examined the notion of reequilibrating DAergic transmission by inhibiting phosphodiesterase 7 (PDE7), an intracellular enzyme highly expressed in the corticomesolimbic circuitry and responsible for the degradation of cyclic adenosine monophosphate (cAMP), the main second messenger modulated by DA receptor activation. Using selective PDE7 inhibitors, we demonstrated in male rats that systemic PDE7 enzyme inhibition reduced nicotine self-administration and prevented reinstatement to nicotine seeking evoked by cues or by the pharmacological stressor yohimbine. The effect was also observed by direct application of the PDE7 inhibitors into the nucleus accumbens (NAc) shell but not into the core. Inhibition of PDE7 resulted in increased DA- and cAMP-regulated neuronal phosphoprotein and cAMP response element-binding protein and their phosphorylated forms in the NAc. It also enhanced the DA D1 receptor agonism-mediated effects, indicating potentiation of protein kinase A-dependent transmission downstream of D1 receptor activation. In electrophysiological recordings from DA neurons in the lateral posterior ventral tegmental area, the PDE7 inhibitors attenuated the spontaneous activity of DA neurons. This effect was exerted through the potentiation of D1 receptor signaling and the subsequent facilitation of γ-aminobutyric acid transmission. The PDE7 inhibitors did not elicit conditioned place preference and did not induce intravenous self-administration, indicating lack of reinforcing properties. Thus, PDE7 inhibitors have the potential to treat nicotine abuse.SIGNIFICANCE STATEMENT The World Health Organization estimates that there are 1.25 billion smokers worldwide, representing one-third of the global population over the age of 15. Nicotine-induced increase of corticomesolimbic DAergic transmission and hypodopaminergic conditions occurring during abstinence are critical for maintaining drug-use habits. Here, we demonstrate that nicotine consumption and relapse to nicotine seeking are attenuated by reequilibrating DAergic transmission through inhibition of PDE7, an intracellular enzyme responsible for the degradation of cAMP, the main second messenger modulated by DA receptor activation. PDE7 inhibition may represent a novel treatment approach to aid smoking cessation.

Reasons for and Scenarios Associated with Failure to Cease Smoking: Results from a Qualitative Study Among Polish Smokers Who Had Unsuccessfully Attempted to Quit

PURPOSE

Most smokers attempt to quit smoking, but few are successful. Data regarding the reasons for this relapse and the course of the relapse process may be helpful for determining efficient methods of smoking cessation. This study aimed to identify the causes of and scenarios associated with smoking relapse after effective smoking cessation.

PATIENTS AND METHODS

We conducted 20 semi-structured interviews with smokers who had previously unsuccessfully attempted to quit. The data underwent qualitative content analysis.

RESULTS

Three major themes were identified: reasons for smoking relapse; smoking relapse scenarios; and perception of the influence of personal environments, including family and physicians, on refraining from smoking after cessation. The first theme comprised the following subthemes: insufficient willpower and self-discipline, contact with smokers, exposure to stressful situations, lack of family support, weight gain, and insufficient improvement in one's mental and physical well-being. The second theme contained enjoyable social events, professional life, critical events, and encouragement to smoke from family members. The respondents frequently emphasized the large role of interaction with other smokers.

CONCLUSION

The predominant factors underlying smoking relapse include insufficient willpower and self-discipline and exposure to stress. The most frequent relapse scenario concerned experiencing negative or positive emotions when interacting with other smokers.

Sex Differences in Use of Smoking Cessation Services and Resources: A Real-World Study

Objectives:

Smoking cessation interventions with sex considerations have been found to effectively increase cessation rates. However, evidence is limited and weak. This study examined sex differences in the use of smoking cessation services or resources among Ontario adults.

Methods:

Data are from the Smokers’ Panel, an ongoing online survey of Ontario adult smokers and recent quitters. The analysis included 1009 male and 1765 female participants. Bivariate analysis was used to examine differences in sociodemographic characteristics and smoking-related variables by use of cessation services/resources. Logistic regression was then used to identify sociodemographic characteristics and smoking-related variables associated with the use of cessation services/resources.

Results:

The analysis shows that there were significant sex differences in the use of individual interventions. Female participants were more likely to use nicotine patch (63% vs 58%; adjusted odds ratio, AOR: 1.39, 95% confidence interval [CI]: 1.16-1.67), varenicline (29% vs 24%; AOR: 1.37, 95% CI: 1.13-1.66), Smokers’ Helpline phone (14% vs 10%; AOR: 1.39, 95% CI: 1.07-1.79), Smokers’ Helpline online (27% vs 21%; AOR 1.43, 95% CI: 1.18-1.74), self-help materials (23% vs 16%; AOR: 1.81 95% CI: 1.46-2.26), and alternative methods (23% vs 19%; AOR: 1.40, 95% CI: 1.14-1.73) compared with male participants, after adjusting for covariates.

Conclusion:

Consistent with other findings, the study shows sex differences in the use of smoking cessation services or resources among adult smokers. Women are more likely to use recommended cessation resources such as nicotine patch, varenicline, and Smokers’ Helpline than men. Health professionals should use this increased willingness to help female smokers quit. However, men may be underserved and more men-specific interventions need to be developed and evaluated.

A smartphone app intervention for adult cannabis users wanting to quit or reduce their use: a pilot evaluation

Background

Smartphone applications (apps) offer a promising alternative to face-to-face treatment due to their ease of access and convenience. However, there is a lack of evidence-based apps for cannabis users wishing to reduce their use.

Objectives

The current study evaluated the feasibility and acceptability of a smartphone app intervention (called Assess, Plan, Track, and Tips [APTT]) for cannabis users wanting to reduce their use.

Method

The current study included 111 cannabis users (68% male, aged 18–50 yrs) who had used cannabis in the past month, were not currently in treatment, and who wanted to reduce/quit their use. Participants were given access to APTT for 1 month. Participants reported on their cannabis use and related problems, confidence in resisting use, severity of dependence, and stage of change at baseline, post-intervention (4 weeks), and at 1-month follow-up. At post-intervention, participants also reported on their usage and satisfaction with the app.

Results

The current study found that APTT was acceptable, with over 40% of participants using the app over 20 times over the course of a month. Participants showed a reduction in dependence and cannabis related problems over the course of the study. Further, participants’ stage of change at baseline predicted changes in cannabis use.

Conclusions/importance

These findings support the feasibility and acceptability of APTT as an engaging app for cannabis users wishing to better manage their use and support the need for future RCTs to assess the efficacy of mobile-based interventions for cannabis users.

Electronic supplementary material

The online version of this article (10.1186/s42238-019-0009-6) contains supplementary material, which is available to authorized users.

Economic demand analysis of within-session dose-reduction during nicotine self-administration

BACKGROUND

This study determined if a within-session dose-reduction design sufficiently captures elasticity of demand for nicotine in male and female rats using environmental enrichment to manipulate demand elasticity.

METHODS

Male and female Sprague-Dawley rats were trained to self-administer nicotine (60 μg/kg/infusion). In Experiment 1, rats began daily dose-reduction for nine sessions following acquisition. Rats then underwent a minimum of five within-session dose-reduction sessions where each dose was available for 10 min. In Experiment 2, rats were reared in isolated, social, or enriched housing followed by acquisition of nicotine self-administration. Rats then underwent within-session dose-reduction. Housing environments were then switched, followed by additional testing sessions. Consumption was calculated for each dose and exponential demand curves were fit.

RESULTS

No sex differences in acquisition of nicotine self-administration were detected for either experiment. In experiment 1, demand intensity (Q₀; estimated intake if nicotine were freely available), was higher with between- compared to within-session dose-reduction, although elasticity of demand (α; rate of decline in nicotine intake as a function of increasing unit price), was lower. In Experiment 2, animals reared in enrichment had fewer infusions during acquisition compared to animals in isolation. Enriched males had reduced demand intensity compared to both isolated and social males, whereas isolated females had reduced intensity compared to enriched females.

CONCLUSIONS

The within-session dose-reduction procedure for nicotine self-administration replicated effects of environmental enrichment on consumption behaviors. Additionally, this procedure captured differences in nicotine demand due to sex, laying important groundwork for future translational research on mechanisms of nicotine dependence.

Support for Patients Who Have Difficulty Quitting Smoking: A Review

Smoking cessation plays a crucial role in reducing preventable morbidity and mortality. However, some smokers find smoking cessation difficult, despite receiving treatment. This includes heavy smokers with chronic obstructive pulmonary disease, smokers with a psychiatric disorder, and female and underage smokers. This review article describes smoking cessation approaches for patients who find it difficult to quit smoking.

Demographic Moderators of the Relationship Between Adverse Childhood Experiences and Cigarette Smoking

Background: Research suggests that there is a dose-response relationship between Adverse Childhood Experiences (ACEs) and cigarette smoking, such that as ACE score increases, so do the odds of smoking behavior, but little is known about what factors moderate this relationship. Objectives: The goal of this study was to examine demographic characteristics as potential moderators of relationship between ACE score and cigarette smoking. Methods: A secondary data analysis was conducted using the 2013 California Behavioral Risk Factor Surveillance System data. The sample included 2,604 U.S. adults (54.8% female; Age: M = 53.3, SD = 8.10). We used multinomial logistic regression to test sex, race, income, and education as moderators of the relationship between ACE score and smoking. Results: ACEs were not significantly associated with smoking behavior. No interactions between ACE score and sex, race, education, or income significantly predicted smoking outcomes. Sex, race, education, and income were significantly and independently associated with smoking outcomes. Men, individuals with lower income and education, and certain ethnic/racial groups reported greater odds of smoking. Conclusions/Importance: Results suggest that there may not be a relationship between ACEs and smoking later in life. Additionally, the relationship between ACEs and smoking in adulthood may not depend on basic demographic features. Knowing which populations are more vulnerable to smoking can help clinicians better assess and tailor interventions to meet the needs of their patients by using culturally sensitive interventions and obtaining resources to help improve treatment access, motivation, and success.

Psychometric Validation of the Short Form of the Smoking Consequences Questionnaire (S-SCQ) for Brazil

Abstract Smoking accounts for 24% of deaths in the general population and is also the factor that explains the biggest amount of years of life lost. It is important to understand the expectations regarding smoking behavior. The present study aimed to validate the Short Form of the Smoking Consequences Questionnaire (S-SCQ) for a Brazilian version. The Researchers did the process of semantic adaptation to language and national context. The S-SCQ was applied in a sample of 129 people. The next step was to perform psychometric analyses for the set of 21 items. Exploratory Factor Analysis, with pairwise treatment for missing cases, was used to achieve construct validity. To carry out Factor Analysis, the method of Principal Component Analysis (PCA) was used initially. Afterwards, Principal Axis Factoring (PAF) using Varimax rotation with Kaiser normalization was applied. The reliability of the total scale (21 items) showed a Cronbach alpha index of 0.851 and a 0.870 Lambda2 of Gutmann. Quite satisfactory rates were also observed in the subscales. Similarly, the item-overall correlation values also confirmed the scale’s good reliability indices.

Prospective associations of breastfeeding and smoking cessation among low-income pregnant women

Although low-income pregnant women have high rates of smoking and low rates of breastfeeding, few studies have examined prospective associations between these risk factors in community samples. Doing so may help improve breast-feeding support programs in this population. We used a secondary analysis of 247 low-income pregnant smokers in Memphis, Tennessee, who were interviewed up to 4 times (twice during pregnancy and twice through 6 months postpartum). Smoking cessation during prepartum and postpartum was defined as a self-report of not smoking for ≥1 week and an expired carbon monoxide level of <10 ppm. Multivariable logistic regression analyses were used to determine whether intent to breastfeed was associated with smoking cessation and whether smoking cessation was associated with actual breastfeeding. Models were adjusted for sociodemographic, pregnancy-related, and smoking-related confounders. Thirty-nine percent of participants intended to breastfeed, and 38% did so. Women who intended to breastfeed were 2 times more likely to quit smoking prepartum (adjusted OR = 1.99, 95% CI [1.06, 3.74]), but not postpartum (adjusted OR = 1.27, 95% CI [0.57, 2.84]). Quitting smoking at baseline and during pregnancy was associated with subsequent breastfeeding (adjusted OR 2.27, 95% CI [1.05, 4.94] and adjusted OR = 2.49, 95% CI [1.21, 5.11]). Low-income women who intended to breastfeed were more likely to quit smoking during pregnancy and those who quit smoking at baseline and prepartum were more likely to breastfeed. Simultaneously supporting breastfeeding and smoking cessation may be very useful to change these important health behaviours among this high-risk population.

Sex differences in nicotine dependency and depressive tendency among smokers

Depressive tendency and nicotine dependency are factors related to the failure of smoking cessation. Women generally have a higher depressive tendency and difficulty in smoking cessation than men. However, the impact of sex differences on the relationship between nicotine dependency and depressive tendency remains unclear. We evaluated 727 patients (496 men and 231 women) who visited our outpatient clinic for smoking cessation therapy and compared various parameters measured between sexes during consultation. Age, duration of smoking, and daily cigarette consumption were significantly higher in men during the first visit. Women had significantly higher self-rating depression scale (SDS) scores and took significantly more antidepressant drugs than men. The SDS score significantly correlated with the Fagerström test for the nicotine dependence score and with daily cigarette consumption in women, but not in men. Thus, the present study demonstrates the differential relationship of depressive tendency with tobacco use or nicotine dependency in men and women, which might reflect sex differences in response to psychological stress.

Sex differences in smoking constructs and abstinence: The explanatory role of smoking outcome expectancies

Scientific evidence suggests women experience more severe problems when attempting to quit smoking relative to men. Yet, little work has examined potential explanatory variables that maintain sex differences in clinically relevant smoking processes. Smoking outcome expectancies have demonstrated sex differences and associative relations with the smoking processes and behavior, including problems when attempting to quit, smoking-specific experiential avoidance, perceived barriers to quitting, and smoking abstinence. Thus, expectancies about the consequences of smoking may explain sex differences across these variables. Accordingly, the current study examined the explanatory role of smoking-outcome expectancies (e.g., long-term negative consequences, immediate negative consequences, sensory satisfaction, negative affect reduction, and appetite weight control) in models of sex differences across cessation-related problems, smoking-specific experiential avoidance, perceived barriers to quitting, and smoking abstinence. Participants included 450 (48.4% female; Mage = 37.45, SD = 13.50) treatment-seeking adult smokers. Results indicated that sex had an indirect effect on problems when attempting to quit smoking through immediate negative consequences and negative affect reduction expectancies; on smoking-specific experiential avoidance through long-term negative consequences, immediate negative consequences, and negative affect reduction expectancies; on barriers to quitting through negative affect reduction expectancies; and on abstinence through appetite weight control expectancies. The current findings suggest that sex differences in negative affect reduction expectancies and negative consequences expectancies may serve to maintain maladaptive smoking processes, whereas appetite weight control expectancies may promote short-term abstinence. These findings provide initial evidence for the conceptual role of smoking expectancies as potential "linking variables" for sex differences in smoking variables. (PsycINFO Database Record

Understanding the link between contingency management and smoking cessation: The roles of sex and self-efficacy

INTRODUCTION

Little is known about the mechanisms linking contingency management (CM) treatment with smoking cessation, and recent research suggests that the CM approach is associated with better smoking cessation outcomes among females than males. The current study investigated self-efficacy as a potential mechanism through which CM treatment influences smoking cessation, and explored whether these relationships differed by sex.

METHODS

Participants (N = 139) were primarily Black (63.3%) and female (57.6%) adults enrolled in a safety-net hospital smoking cessation program. Participants received usual care (UC), which included pharmacotherapy and counseling sessions (n = 66) or a CM intervention (UC + 4 weeks of small, abstinence contingent financial incentives; n = 73). Self-efficacy for quitting was measured on the day after quitting with the Self-Efficacy Scale/Confidence (SESC) questionnaire. Mediation analyses were conducted to evaluate the indirect effects of treatment group on biochemically-verified abstinence (4-weeks post-quit) via self-efficacy, and moderated mediation analyses were conducted to evaluate the moderating role of sex.

RESULTS

Self-efficacy was not found to mediate the relations between CM treatment and smoking cessation in the overall sample. However, analyses indicated a significant moderating effect of sex on the indirect effect of treatment group on smoking cessation through self-efficacy (each of the 3 SESC subscales). Specifically, there was a stronger association between CM and greater self-efficacy among females than males.

CONCLUSION

Findings suggest that CM treatment had a differing impact on self-efficacy among males and females, which in turn influenced the likelihood of smoking cessation.

Trends in self-efficacy to quit and smoking urges among homeless smokers participating in a smoking cessation RCT

INTRODUCTION

In the U.S., approximately 73% of homeless adults smoke cigarettes and they experience difficulty quitting. Homeless smokers report low self-efficacy to quit and that smoking urges are a barrier to quitting. Self-efficacy to quit and smoking urges are dynamic and change throughout smoking cessation treatment. This study examines changes in self-efficacy to quit and smoking urges throughout a smoking cessation intervention among the homeless and identifies predictors of change in these characteristics.

METHODS

Homeless smokers (n=430) participating in a smoking cessation randomized controlled trial in the U.S. completed surveys at baseline, and weeks 1, 2, 4, 6, 8, and 26 on demographic and smoking characteristics (i.e., confidence to quit, self-efficacy to refrain from smoking, and smoking urges). A growth curve analysis was conducted by modeling change in the smoking characteristics over time and examining the variability in the change in smoking characteristics by demographic characteristics and treatment group.

RESULTS

Among the full sample, self-efficacy to refrain from smoking increased linearly over time, confidence to quit increased until the midpoint of treatment but subsequently decreased, and smoking urges decreased until the midpoint of treatment but subsequently increased. There were race differences in these trajectories. Racial minorities experienced significantly greater increases in self-efficacy to refrain from smoking than Whites and Blacks had higher confidence to quit than Whites.

CONCLUSIONS

White participants experienced less increase in self-efficacy to refrain from smoking and lower confidence to quit and therefore may be a good target for efforts to increase self-efficacy to quit as part of homeless-targeted smoking cessation interventions. Sustaining high confidence to quit and low smoking urges throughout treatment could be key to promoting higher cessation rates among the homeless.

Smoking Predicting Physical Activity in an Aging America

OBJECTIVES

Tobacco smoking and physical inactivity are among leading behavioral risk factors for ill health in older adults. This study considers how smoking is associated with physical activity.

DESIGN

Using a Life-Course model, data are analyzed regarding this relationship, controlling for, and interacted with, life-course and other factors. Daily smokers and sometimes smokers were hypothesized to engage in less leisure-time physical activity than those who never smoked, while those who stopped smoking were expected to do more than never smokers. Analyses were performed using SAS-Callable SUDAAN.

SETTING AND PARTICIPANTS

Secondary data from ten years of a national sample of adults aged 18 and over of the National Health Interview Survey, 2001-2010, are used (N = 264,945, missing data excluded, of 282,313 total cases).

MEASUREMENTS

Daily smokers, occasional smokers, and smoking quitters are compared to never smokers with regard to requisite physical activity (150 minutes per week of moderate, 100 of vigorous, and/or 50 of strengthening activity). Life-course measures include birth cohorts, age, and year of survey, as well as gender, race/ethnicity, and education.

RESULTS

Overall, hypotheses are supported regarding daily smokers and quitters; but the hypothesis is strongly rejected among sometimes smokers, who are much more likely to do requisite physical activity. Findings differ by age, sometimes smokers age 65 and over being less likely to do physical activity. Findings among all men are similar to the overall findings, while those among all women are similar to those for older respondents. Associations of smoking status with physical activity vary greatly by race/ethnicity.

CONCLUSIONS

Daily smokers may be most in need of both smoking cessation and leisure-time physical activity interventions. Smoking-cessation efforts may pay greater physical activity benefits among women and the aged, while smoking-reduction efforts may provide better outcomes among men. Smoking reduction efforts may pay more exercise benefits among African-Americans and Hispanics.

Stress and Addiction: When a Robust Stress Response Indicates Resiliency

OBJECTIVE

Stress reactivity research has traditionally focused on the idea that exaggerated responses to stress may have adverse effects on health. Accumulating evidence suggests that attenuated responses to stress and delayed recovery may also be problematic.

METHODS

This review focuses on the role of the stress response of the hypothalamic-pituitary-adrenocortical axis, the endogenous opioid system, and the cardiovascular system in hypertension, pain perception, and addictive behaviors. Results from multiple methods of assessment and stress paradigms conducted in our laboratory over the past two decades are integrated with research from other investigators and with existing theories.

RESULTS

Research indicates that exaggerated biological and physiological responses to stress and attenuated pain perception are associated with hypertension and risk for cardiovascular diseases. This research complements work linking reduced stress responses with enhanced pain sensitivity and discomfort. Multiple studies have also demonstrated that an attenuated stress response is linked to exacerbation of withdrawal symptoms and relapse in nicotine addiction. Evidence indicates important moderators (i.e., sex, personality traits, and early life adversity) and hypothalamic-pituitary-adrenocortical- and endogenous opioid system-related mechanisms in the altered response to stress. I integrate these findings in a conceptual model emphasizing that robust stress responses in the context of addiction and relapse should be considered as a marker of resiliency.

CONCLUSIONS

A blunted stress response may indicate long-term physiological dysregulation that could usher harmful consequences for cardiovascular disease, pain perception, and addictive disorders. The impact of dysregulation is influenced by multiple individual and situational factors that should be considered in evaluating the clinical significance of stress response dysregulation.

Perceived stress and poly-tobacco product use across adolescence: Patterns of association and gender differences

Perceived stress-an endophenotype indicative of the tendency to appraise stress as frequent, unpredictable and unmanageable-is associated with adolescent cigarette smoking. It is unclear whether this association: (1) extends to alternative tobacco products, like electronic cigarettes and hookah (tobacco water pipe), which are increasingly popular among youth, and (2) differs by gender. In this report, data were drawn from a population-based longitudinal cohort of youth in Southern California. Perceived stress was assessed at baseline (7th or 8th grade; 2010). Electronic cigarette, hookah, combustible cigarette, and cigar use were assessed at a 4-year follow-up (11th or 12th grade; 2014). After adjusting for confounders, polytomous logistic regressions showed that a standardized baseline perceived stress score (M = 0, SD = 1) predicted electronic cigarette, hookah, combustible cigarette, and cigar use and a poly-tobacco use index at the 4-year follow-up in the overall sample. Interactions between perceived stress and gender were also observed (Interaction Ps < 0.05), which demonstrated that the association of perceived stress with tobacco product use and poly-use were stronger in females (ORs for current use range: 1.47 to 1.72) than males (ORs range: 0.93 to 1.31). Adjusting for baseline perceived stress, the change in perceived stress from baseline to follow-up was also positively associated with use and poly-use of most tobacco products in females and in males to some extent. In the current era in which teen use of alternative tobacco products is increasingly common, adolescent tobacco use and poly-use research and prevention strategies should address gender-specific origins of tobacco product use risk and consider perceived stress and other emotional endophenotypes in such risk pathways.

Development and evaluation of the See Me Smoke-Free multi-behavioral mHealth app for women smokers

Women face particular challenges when quitting smoking, especially those with weight concerns. A multi-behavioral smoking cessation intervention addressing these concerns and incorporating guided imagery may assist women to engage in healthy lifestyle behaviors. An mHealth app can easily disseminate such an intervention. The goals of this pilot study were to develop and test the feasibility and potential of the See Me Smoke-Free™ mHealth app to address smoking, diet, and physical activity among women smokers. We used pragmatic, direct-to-consumer methods to develop and test program content, functionality, and the user interface and conduct a pre-/post-test, 90-day pilot study. We enrolled 151 participants. Attrition was 52%, leaving 73 participants. At 90 days, 47% of participants reported 7-day abstinence and significant increases in physical activity and fruit consumption. Recruitment methods worked well, but similar to other mHealth studies, we experienced high attrition. This study suggests that a guided imagery mHealth app has the potential to address multiple behaviors. Future research should consider different methods to improve retention and assess efficacy.

Reflections on 15 Years in the Global Tobacco Trenches

This paper is based on my 2017 Research Laureate Presentation at the Annual Scientific Meeting of the American Academy of Health Behavior in Tucson, Arizona. It provides a brief overview of the history of the smoking epidemic, and describes my work in global tobacco control, focusing on my experiences over the last 15 years as a co-founder and intervention director of the Syrian Center for Tobacco Studies (SCTS) in Aleppo, Syria. The SCTS is an NIH-funded research center that draws on a broad range of complementary expertise and resources from developed and developing nations to address the tobacco epidemic in the Arab World. The SCTS strives to serve as a model of scientific excellence and commitment to the health of people in the Middle East and beyond. Major research streams using qualitative, epidemiological, clinical lab, and intervention methodologies are reviewed, along with some of the successes and challenges encountered since the SCTS's founding.

Determinants of Smoking and Cessation Among Latinos: Challenges and Implications for Research

Tobacco is a significant burden to individual and public health, and disparities exist among Latino smokers with respect to use and cessation. Although the prevalence of smoking is lower for Latinos than for non-Latino Whites and the general U.S. population, numerous health disparities exist within the population of Latino smokers. Much is known about determinants of smoking and cessation but the vast majority of this knowledge is based on research with non-Latino White smokers. This results in at least two important challenges in tobacco research among Latino smokers: (i) demonstrating the generalizability of known determinants of smoking and cessation, and; (ii) identifying culturally relevant variables that influence smoking and cessation among Latinos. An argument for increased research in these areas is presented with a review of existing research among Latino smokers that demonstrates these needs. Research is summarized that suggests socioeconomic position, depressive symptomatology, physical dependence, and gender function differently as determinants of smoking and cessation among Latinos compared with the general population of smokers. Research is also reviewed that suggests the promise of acculturation, acculturative stress, and discrimination as culturally relevant determinants of smoking and cessation. Research and practice implications are discussed, and specific areas for future research are offered.

Premenstrual symptoms and smoking-related expectancies

Given that prior research implicates smoking abstinence in increased premenstrual symptoms, tobacco withdrawal, and smoking behaviors, it is possible that women with more severe premenstrual symptoms have stronger expectancies about the effects of smoking and abstaining from smoking on mood and withdrawal. However, such relations have not been previously explored. This study examined relations between premenstrual symptoms experienced in the last month and expectancies that abstaining from smoking results in withdrawal (i.e., smoking abstinence withdrawal expectancies), that smoking is pleasurable (i.e., positive reinforcement smoking expectancies), and smoking relieves negative mood (i.e., negative reinforcement smoking expectancies). In a cross-sectional design, 97 non-treatment seeking women daily smokers completed self-report measures of smoking reinforcement expectancies, smoking abstinence withdrawal expectancies, premenstrual symptoms, mood symptoms, and nicotine dependence. Affect premenstrual symptoms were associated with increased negative reinforcement smoking expectancies, but not over and above covariates. Affect and pain premenstrual symptoms were associated with increased positive reinforcement smoking expectancies, but only affect premenstrual symptoms remained significant in adjusted models. Affect, pain, and water retention premenstrual symptoms were associated with increased smoking abstinence withdrawal expectancies, but only affect premenstrual symptoms remained significant in adjusted models. Findings from this study suggest that addressing concerns about withdrawal and alternatives to smoking may be particularly important in women who experience more severe premenstrual symptoms, especially affect-related changes.

Effects of intimate partner violence, PTSD, and alcohol use on cigarette smoking in a nationally representative sample

BACKGROUND AND OBJECTIVES

Separate literatures indicate that intimate partner violence (IPV), posttraumatic stress disorder (PTSD), and alcohol use are independently associated with increased risk for cigarette smoking. No previous studies have examined the co-occurrence of these problems on smoking quantity and potential gender-specific relationships. This study will address this gap in the literature.

METHODS

Data from Wave 2 of the National Epidemiologic Study on Alcohol and Related Conditions (NESARC) were examined. Variables were assessed during the past year. Individuals (N = 25,604) who reported being married, dating, or involved in a romantic relationship were included.

RESULTS

Among men, PTSD and alcohol use were associated with more cigarettes smoked per day. Among women, PTSD, alcohol use, and IPV victimization were associated with more cigarettes smoked per day. Women who experienced IPV victimization smoked approximately three additional cigarettes per day.

DISCUSSION AND CONCLUSIONS

IPV victimization, PTSD, and alcohol use were associated with cigarettes smoked among women, while IPV experiences were not associated with smoking risk among men.

SCIENTIFIC SIGNIFICANCE

These findings represent an important contribution to the existing literature in that it elucidates the compounding relationship between a common and complex comorbidity and cigarette smoking. Findings indicate a critical need to implement routine smoking screening and intervention in venues where intimate partner violence is commonly encountered, such as advocacy and substance use treatment settings. (Am J Addict 2016;25:283-290).

Influence of menstrual cycle phase on resting-state functional connectivity in naturally cycling, cigarette-dependent women

BACKGROUND

Sex differences in tobacco-related morbidity and mortality exist, with women experiencing more severe health consequences and greater difficulty with smoking cessation than men. One factor that likely contributes to these sex differences is menstrual cycle phase and associated neural and cognitive changes associated with ovarian hormone fluctuations across the menstrual cycle. Previously, we showed that naturally cycling, cigarette-dependent women in the follicular phase of their menstrual cycle showed greater reward-related neural activity and greater craving during smoking cue exposure. To better understand our results and the observed sex differences in smoking behavior and relapse, we explored potential menstrual cycle phase differences in resting-state functional connectivity (rsFC) in naturally cycling, cigarette-dependent women. Understanding how menstrual cycle phase affects neural processes, cognition, and behavior is a critical step in developing more efficacious treatments and in selecting the best treatment option based on a patient's needs.

METHODS

Resting-state functional connectivity analyses were used to examine connectivity strength differences between naturally cycling, premenopausal, cigarette-dependent women who were in the follicular phase (FPs; n = 22) and those in the luteal phase (LPs, n = 16) of their menstrual cycle. We also explored associations between connectivity strength and attentional bias to smoking cues.

RESULTS

Compared with LPs, FPs showed decreased rsFC between the dorsal anterior cingulate cortex (dACC) and the subgenual anterior cingulate cortex, medial orbitofrontal cortex (mOFC), and ventral striatum. Among FPs, rsFC strength between the dACC and the bilateral dorsolateral prefrontal cortex (DLPFC), the bilateral dorsal striatum, and the left temporal gyrus was inversely correlated with attentional bias to smoking cues.

CONCLUSIONS

This is the first study to explore menstrual cycle phase differences in rsFC among cigarette-dependent women, and results suggest that FPs show differences in rsFC underlying cognitive control, which could place them at greater risk for continued smoking and relapse. These findings provide new insights toward individualized treatment strategies.

The role of BMI change on smoking abstinence in a sample of HIV-infected smokers

The prevalence of cigarette smoking among persons living with HIV/AIDS (PLWHA) is approximately 40%, significantly higher than that of the general population. Identifying predictors of successful smoking cessation for PLWHA is necessary to alleviate the morbidity and mortality associated with smoking in this population. Weight gain has been associated with smoking relapse in the general population, but has not been studied among PLWHA. Data from 474 PLWHA enrolled in a smoking cessation randomized clinical trial were analyzed to examine the effect of BMI change, from baseline to 3-month follow-up, on smoking outcomes using multiple logistic regression. The odds of 7-day smoking abstinence at 3-month follow-up were 4.22 (95% CI = 1.65, 10.82) times higher for participants classified as BMI decrease and 4.22 (95% CI = 1.62, 11.01) times higher for participants classified as BMI increase as compared to participants with a minimal increase or decrease in BMI. In this sample, both weight gain and loss following smoking cessation were significantly associated with abstinence at 3-month follow-up among HIV-infected smokers. Further research and a better understanding of predictors of abstinence will encourage more tailored interventions, with the potential to reduce morbidity and mortality.

Social and Environmental Factors Related to Smoking Cessation among Mothers: Findings from the Geographic Research on Wellbeing (GROW) Study

OBJECTIVES

The current study examined associations between race/ethnicity and psychosocial/environmental factors with current smoking status, and whether psychosocial/environmental factors accounted for racial differences in smoking status in a population-based sample of mothers in California.

METHODS

Cross-sectional data from 542 women with a history of smoking were used. Analyses adjusted for age, partner status, and educational attainment.

RESULTS

In models adjusted for sociodemographics, black women had significantly lower odds, and Latina immigrants had significantly higher odds of being a former smoker compared to white women. Persons smoking in the home, having a majority of friends who smoke, having perceptions of their neighborhood as being somewhat or very unsafe, and experiencing food insecurity were associated with decreased odds of being a former smoker. When these variables were entered into a single model, only being a Latina immigrant and having a majority of friends who smoke were significantly associated with smoking status.

CONCLUSIONS

Black women demonstrated a notable disparity compared with white women in smoking status, accounted for by psychosocial/environmental factors. Immigrant Latinas demonstrated notable success in ever quitting smoking. Social networks may be important barriers to smoking cessation among women.

EFFECT OF CYP2A6*4 GENETIC POLYMORPHISMS ON SMOKING BEHAVIORS AND NICOTINE DEPENDENCE IN A GENERAL POPULATION OF JAPANESE MEN

OBJECTIVES

Nicotine in cigarettes is metabolized primarily by CYP2A6-catalyzed oxidation. The CYP2A6*4 allele, in which CYP2A6 is a homozygous whole-deletion variant, completely lacks enzyme activity. The aim of this study was to examine the effects of CYP2A6*4 genetic polymorphism on smoking behavior and nicotine dependence in a general population of Japanese men.

METHODS

The subjects were 124 healthy Japanese men who gave informed consent to give saliva samples. The survey items included general information, smoking behaviors and nicotine dependence. The polymerase chain reaction restriction fragment length polymorphism method was used to analyze the genetic polymorphisms of CYP2A6. The subjects were classified into two groups: Group W (CYP2A6*4 absence: *1A/*1A, *1A/*1B and *1B/*1B) and Group D (CYP2A6*4 presence: *1B/*4A, *4A/*4A, *1A/*4A or *1B/*4D, and *1A/*4D). We analyzed the differences in the survey items between the two groups.

RESULTS

There were no significant differences in smoking behaviors between the two groups. However, Group D tended to have less difficulty in refraining from smoking after waking in the morning compared to Group W (p=0.051).

CONCLUSIONS

CYP2A6*4 genetic polymorphisms may not strongly affect smoking behavior but may possibly have an effect on nicotine dependence.

Increasing progesterone levels are associated with smoking abstinence among free-cycling women smokers who receive brief pharmacotherapy

INTRODUCTION

Preclinical and human laboratory research suggests that (a) progesterone may decrease drug reward, craving, and smoking behavior, and (b) estradiol may enhance drug reward and smoking behavior. A modest majority of treatment research examining the relationship between menstrual cycle phase and outcomes suggests that the luteal menstrual phase, with its uniquely higher progesterone levels, is associated with better cessation outcomes. However, no studies to date have examined the effects of naturally occurring variation in progesterone and estradiol levels on medication-assisted smoking cessation. The present study sought to fill this notable gap in the treatment literature.

METHODS

Weekly plasma progesterone and estradiol levels were obtained from nicotine-dependent female smokers enrolled in a 4-week cessation trial. Participants (N = 108) were randomized to receive a 4-week course of either varenicline (VAR) tablets and placebo patches or placebo tablets and nicotine patches. Plasma samples were obtained 1 week before their cessation attempt and weekly during medication administration. Abstinence was assessed weekly.

RESULTS

Weekly hormone data replicated commonly observed menstrual cycle patterns of progesterone and estradiol levels. Importantly, increases in progesterone level were associated with a 23% increase in the odds for being abstinent within each week of treatment. This effect was driven primarily by nicotine patch-treated versus VAR-treated females.

CONCLUSIONS

This study was the first to identify an association between progesterone level (increasing) and abstinence outcomes in free-cycling women smokers who participated in a medication-based treatment. Furthermore, the potential benefits of progesterone may vary across different pharmacotherapies. Implications of these findings for smoking cessation intervention are discussed.

Gender and stimulus control of smoking behavior

INTRODUCTION

Gender differences in smoking behavior have been proposed to account for poorer outcomes among women attempting to quit. Specifically, it has been suggested that women's smoking behavior is less motivated by nicotine-seeking and more driven by environmental cues. To date, however, few real-world studies have examined the hypothesis that women's smoking is under greater stimulus control.

METHODS

One hundred and ninety four daily smokers (men = 107; women = 87) completed 3 weeks of ecological momentary assessment (EMA) monitoring that provided data on real-world smoking behavior by reporting on situational contexts shown by previous research to influence smoking behavior (including social setting, cigarette availability, alcohol consumption, and mood).

RESULTS

Analyses of particular cues found few gender differences; however, men's smoking increased to a greater extent compared with women's when they were with others who were smoking. Idiographic analyses that allow individual subjects to have different directions of linkage to situational cues also were conducted to assess how predictable subjects' smoking was from a range of contextual characteristics. Compared with women, men's smoking was significantly more closely tied to food/alcohol consumption and tended to be more closely tied to social context. No other gender differences were found.

CONCLUSIONS

EMA analyses suggest that men and women are similarly influenced by cues, including mood. Where there were gender differences, it was men rather than women whose smoking behavior was more influenced by cues. The data contradict the hypothesis that women's smoking is more influenced by cues.

Changes in circulating leptin levels during the initial stage of cessation are associated with smoking relapse

RATIONALE

Leptin has been linked to tobacco craving and withdrawal-related symptoms. Very few studies have examined leptin prospectively in both male and female nonsmokers and smokers.

OBJECTIVES

We examine leptin concentrations prospectively in both male and female nonsmokers and smokers to assess the associations of leptin with psychological symptoms and smoking relapse during ad libitum smoking, the first 48 h post quit, and 4 weeks post-cessation.

METHODS

Self-report psychological, anthropomorphic, and biological measures (cotinine, carbon monoxide, and plasma leptin) were collected before and after 48 h of smoking abstinence. Smokers were stratified at 28 days post quit as abstinent or relapsed if they had smoked daily for seven consecutive days at any point in the 28 days.

RESULTS

Leptin concentration (square root transformed ng/ml) increased over the 48-h abstinence, but only in female abstainers. In contrast, leptin was very stable across time for nonsmokers, relapsers, and males. Cox regression supported that increased leptin was associated with decreased risk of relapse. Leptin was correlated negatively with withdrawal symptoms for abstainers only. Females produce more leptin than males and this level increases from ad libitum smoking to 48-h post quit.

CONCLUSIONS

The current analysis indicates that a leptin increase early in cessation predicts abstinence. The increase in women, but not men, in response to abstinence provides further evidence of important gender differences. The negative correlation between leptin and withdrawal symptoms indicates a possible protective effect of leptin. Further research is ongoing to elucidate the psychological and biological determinants of this effect.

Financial strain and smoking cessation among men and women within a self-guided quit attempt

INTRODUCTION

Financial strain, defined as an unfavorable asset-to-needs ratio, has been associated with reduced odds of smoking cessation in the context of a structured clinical study providing cessation assistance. This study reports on a secondary data analysis that assessed the association of financial strain and biochemically-verified smoking abstinence within a structured clinical study of smokers making a self-guided cessation attempt.

METHODS

Participants (N=58; 65.5% men) were enrolled in a study about anxiety sensitivity and smoking cessation whereby they were instructed to initiate a self-guided quit attempt. Relations between financial strain and biochemically-verified smoking abstinence on the quit day and at Days 3, 7, 14, 28, and 90 post-quit were assessed using generalized estimating equations controlling for age, sex, race, education, partner status, pre-quit cigarettes smoked per day, and time.

RESULTS

Associations between financial strain and abstinence in the whole sample were marginal (aOR=.94, 95% CI=.87-1.01, observations=293; p=.07). However, sex was a significant moderator: greater financial strain was associated with lower odds of abstinence for men (aOR=.90, 95% CI=.80-1.00, observations=201; p=.05), but not women (aOR=1.05, 95% CI=.91-1.21, observations=92; p=.48).

CONCLUSIONS

Results indicated that financial strain was associated with lower odds of cessation among men undergoing a self-guided quit attempt in the context of a structured clinical study. These data suggest that financial strain may be an important socioeconomic determinant of smoking cessation and support its relevance for better understanding socioeconomic-based smoking-related health disparities. Future work may benefit by exploring sex-specific models of financial strain in the context of smoking cessation.

Factors Related to Relapse After 6 Months of Smoking Cessation Among Men in the Republic of Korea: A Cross-Sectional Study

We identified factors associated with relapse after 6 months of smoking cessation (late relapse) among males of the Republic of Korea. Of the 222,707 smokers who visited public health center-based smoking cessation clinics (SCCs) between January 1, 2009 and mid-December 2009, we included 1720 individuals who successfully completed a 6-month smoking cessation program at an SCC. These participants were selected via a random stratified sampling design and completed an SCC user satisfaction survey between December 31, 2009 and January 6, 2010. Multiple logistic regression was used to identify factors associated with late relapse, and path analysis was employed to explore relationships among these factors. The frequency of late relapse was 21.6% (n = 372). Residence in a metropolitan area, low socioeconomic status, and the use of nicotine replacement therapy (NRT) were associated with statistically significant increases in late relapse, whereas greater access to counseling and more satisfaction with the SCC were associated with reduced late relapse. The path analysis showed that a greater number of cigarettes smoked daily and a younger age at smoking initiation exerted significant indirect effects on late relapse when NRT was employed. Residence in a metropolitan area indirectly prevented late relapse as counseling frequency increased. NRT use, counseling frequency, and SCC user satisfaction were affected by both smoking behavior and socioeconomic status. Relapse prevention efforts should concentrate on increasing both counseling frequency and SCC user satisfaction. Future studies should focus on the effect of NRT on the maintenance of long-term cessation at the population level in real-world settings.

Financial incentives for abstinence among socioeconomically disadvantaged individuals in smoking cessation treatment

OBJECTIVES

We evaluated the effectiveness of offering adjunctive financial incentives for abstinence (contingency management [CM]) within a safety net hospital smoking cessation program.

METHODS

We randomized participants (n = 146) from a Dallas County, Texas, Tobacco Cessation Clinic from 2011 to 2013 to usual care (UC; cessation program; n = 71) or CM (UC + 4 weeks of financial incentives; n = 75), and followed from 1 week before the quit date through 4 weeks after the quit date. A subset (n = 128) was asked to attend a visit 12 weeks after the scheduled quit date.

RESULTS

Participants were primarily Black (62.3%) or White (28.1%) and female (57.5%). Most participants were uninsured (52.1%) and had an annual household income of less than $12 000 (55.5%). Abstinence rates were significantly higher for those assigned to CM than UC at all visits following the quit date (all Ps < .05). Point prevalence abstinence rates in the CM and UC groups were 49.3% versus 25.4% at 4 weeks after the quit date and 32.8% versus 14.1% at 12 weeks after the quit date. CM participants earned an average of $63.40 ($150 possible) for abstinence during the first 4 weeks after the scheduled quit date.

CONCLUSIONS

Offering small financial incentives for abstinence might be an effective means to improve abstinence rates among socioeconomically disadvantaged individuals participating in smoking cessation treatment.

A Comprehensive Approach to Tobacco Dependence Interventions

Tobacco smoking remains the leading preventable cause of death and illness in the United States. Smoking cessation is particularly relevant for individuals with chronic obstructive pulmonary disease because it is known from multiple studies that individuals who quit smoking experience an initial improvement in pulmonary function, a decreased rate of normal age-related decline in FEV1, a lower risk of hospital admission, and improved survival. Tobacco dependence must be recognized as a chronic disease, and comprehensive treatment for the tobacco-dependent patient with chronic obstructive pulmonary disease begins with a physician's inquiry into smoking and encouragement to quit, followed by an assessment of the level of dependence and the severity of withdrawal symptoms during previous quit attempts. Combination pharmacotherapy is recommended for the initial treatment of most smokers, especially those with moderate to high baseline levels of tobacco dependence. The patient's history, combined with his or her personal preference, can guide the clinician in initiating an appropriate treatment regimen. Given the chronic nature of tobacco dependence, clinicians must anticipate relapses and the need for recurrent, long-term follow-up. Comprehensive tobacco treatment consultation should be sought whenever possible for patients with high levels of tobacco dependence and multiple relapses or failed quit attempts.

Sex differences in hormonal responses to stress and smoking relapse: a prospective examination

INTRODUCTION

Dysregulation in the hypothalamic-pituitary-adrenal axis has been shown to be associated with smoking relapse. No study has directly examined the role of sex differences in this relationship.

METHODS

Nicotine dependent men (n = 52) and women (n = 46) interested in cessation completed 2 laboratory stress sessions during ad libitum smoking and after 48 hr of abstinence. The laboratory session included baseline, stress, and recovery periods. Blood and saliva samples were collected at the end of each period for the measurement of cortisol and adrenocorticotropic hormone. Self-report measures of craving and withdrawal symptoms were also collected. Participants attended 4 weekly follow-up sessions for counseling where they provided biological samples and self-report measures including smoking status. Relapse was defined by smoking cigarettes for 7 consecutive days post-cessation.

RESULTS

Results showed that 60 participants relapsed during the 4-week period. Cox regression models from the abstinence session showed that cortisol levels regardless of source were predictive of relapse but the direction of prediction was sex dependent (Sex × Hormone, all ps < .05). Follow-up analyses further revealed that lower cortisol levels predicted relapse in men whereas greater cortisol levels predicted relapse in women (ps < .05). Enhanced craving predicted early smoking relapse in men but not in women (ps < .05). Data from the ad libitum session showed no differences in predicting relapse.

CONCLUSION

These findings highlight that sex differences in the hormonal response to stress and subjective craving during nicotine withdrawal are critical predictors of risk for understanding early relapse.

Hemispheric side of damage influences sex-related differences in smoking cessation in neurological patients

Patterns of smoking behavior vary between the sexes. There is evidence that decision making, which is one of the key "executive functions" necessary for making life-style modifications such as smoking cessation, is relatively lateralized to the right hemisphere in males and left hemisphere in females. In the current study, we examined whether the side of brain lesion has a differential effect on smoking behavior between the sexes. We hypothesized sex differences in smoking cessation based on lesion side. Participants were 49 males and 50 females who were smoking at the time of lesion onset. The outcome variable was abstinence from smoking (quit rate) at least one year post lesion. We found that in patients with left-hemisphere damage, quit rates were significantly higher in males than in females; however, in patients with right-hemisphere damage, quit rates were not statistically different. The findings support previous cognitive neuroscience literature showing that components of behavior responsible for maintaining addiction tend to be more strongly lateralized in males, whereas in females there is a more bilateral distribution. Our study provides further evidence for differences in lateralization of complex behavior between the sexes, which has significant implications for differences in treatment strategies between the sexes.

Mood and anxiety regulation by nicotinic acetylcholine receptors: A potential pathway to modulate aggression and related behavioral states

The co-morbidity between smoking and mood disorders is striking. Preclinical and clinical studies of nicotinic effects on mood, anxiety, aggression, and related behaviors, such as irritability and agitation, suggest that smokers may use the nicotine in tobacco products as an attempt to self-medicate symptoms of affective disorders. The role of nicotinic acetylcholine receptors (nAChRs) in circuits regulating mood and anxiety is beginning to be elucidated in animal models, but the mechanisms underlying the effects of nicotine on aggression-related behavioral states (ARBS) are still not understood. Clinical trials of nicotine or nicotinic medications for neurological and psychiatric disorders have often found effects of nicotinic medications on ARBS, but few trials have studied these outcomes systematically. Similarly, the increase in ARBS resulting from smoking cessation can be resolved by nicotinic agents, but the effects of nicotinic medications on these types of mental states and behaviors in non-smokers are less well understood. Here we review the literature on the role of nAChRs in regulating mood and anxiety, and subsequently on the closely related construct of ARBS. We suggest avenues for future study to identify how nAChRs and nicotinic agents may play a role in these clinically important areas. This article is part of the Special Issue entitled 'The Nicotinic Acetylcholine Receptor: From Molecular Biology to Cognition'.

Predictors of smokeless tobacco cessation among telephone quitline participants

BACKGROUND

The prevalence of smokeless tobacco use in the U.S. is increasing and its use is a risk factor for a number of adverse health outcomes. Currently, there is limited evidence on the effectiveness of quitlines for tobacco cessation among smokeless tobacco users.

PURPOSE

To examine factors related to tobacco abstinence among exclusive smokeless tobacco users registering for services with the Oklahoma Tobacco Helpline.

METHODS

Participants included 959 male exclusive smokeless tobacco users registering with the Helpline between 2004 and 2012; a total of 374 completed a follow-up survey 7 months post-registration. Data were collected between 2004 and 2013 and included baseline data at Helpline registration, services received, and 7-month follow-up for 30-day point-prevalence for tobacco abstinence. Univariate and multiple logistic regression examined associations between abstinence and participant characteristics, intensity of Helpline intervention, and behavioral factors. ORs and 95% CIs were reported. Analyses were completed in 2013.

RESULTS

At the 7-month follow-up, 43% of the participants reported 30-day abstinence from tobacco. Each additional completed Helpline call increased the likelihood of tobacco cessation by 20% (OR=1.20, 95% CI=1.05, 1.38). Smokeless tobacco users with higher levels of motivation to quit at baseline were twice as likely to be abstinent than those with low or moderate levels of motivation (OR=2.05, 95% CI=1.25, 3.35). Use of nicotine replacement therapy was not associated with abstinence when adjusted for Helpline calls, income, and level of motivation.

CONCLUSIONS

Tobacco quitlines offer an effective intervention to increase smokeless tobacco abstinence.

Sex differences in smoking cue reactivity: craving, negative affect, and preference for immediate smoking

BACKGROUND AND OBJECTIVES

Female smokers have greater difficulty quitting, possibly due to increased reactivity to smoking-related cues. This study assessed sex differences in craving, affect, and preference for immediate smoking after cue exposure.

METHODS

Regular smokers (n = 60; 50% female) were exposed to smoking and neutral cues in separate, counterbalanced sessions. Outcomes included changes in craving and affect and preference for immediate smoking following cue exposure.

RESULTS

Findings indicated that women exhibited greater preference for immediate smoking (p = .004), and reported greater cue-induced increases in cigarette craving (p = .046) and negative affect (p = .025).

DISCUSSION AND CONCLUSIONS

These data suggest that women may have greater difficulty inhibiting smoking after cue exposure, possibly as a consequence of greater increases in craving and negative affect.

SCIENTIFIC SIGNIFICANCE AND FUTURE DIRECTIONS

Findings suggest a mechanism that may contribute to greater cessation failure among female smokers.

Expectancies for the effectiveness of different tobacco interventions account for racial and gender differences in motivation to quit and abstinence self-efficacy

INTRODUCTION

Racial and gender disparities for smoking cessation might be accounted for by differences in expectancies for tobacco interventions, but few studies have investigated such differences or their relationships with motivation to quit and abstinence self-efficacy.

METHODS

In this cross-sectional study, 673 smokers (African American: n = 443, 65.8%; women: n = 222, 33.0%) under criminal justice supervision who enrolled in a clinical smoking cessation trial in which all received bupropion and half received counseling. All participants completed pretreatment measures of expectancies for different tobacco interventions, motivation to quit, and abstinence self-efficacy. The indirect effects of race and gender on motivation to quit and abstinence self-efficacy through expectancies for different tobacco interventions were evaluated.

RESULTS

African Americans' stronger expectancies that behavioral interventions would be effective accounted for their greater motivation to quit and abstinence self-efficacy. Women's stronger expectancies for the effectiveness of pharmacotherapy accounted for their greater motivation to quit, whereas their stronger expectancies for the effectiveness of behavioral treatments accounted for their greater abstinence self-efficacy.

CONCLUSIONS

Findings point to the mediating role of expectancies for treatment effectiveness and suggest the importance of exploring expectancies among African Americans and women as a way to augment motivation and self-efficacy.

Stability of smoking status in the US population: a longitudinal investigation

AIMS

To determine smoking transitions in a representative sample of US adults.

DESIGN

Longitudinal study using data from the National Epidemiologic Survey on Alcohol and Related Conditions (wave 1, 2001-02; wave 2, 2004-05).

SETTING

The general US adult population.

PARTICIPANTS

A total of 33 309 adults (53.6% female) classified as wave 1 current daily, current non-daily, former daily, former non-daily or never smokers.

MEASUREMENTS

Smoking transitions were determined from waves 1 and 2 data.

FINDINGS

Smoking status remained stable for the majority of current daily (79.8%), former daily (95.8%), former non-daily (96.3%) and never (97.1%) smokers. Among current non-daily smokers, 54.5% quit smoking while 22.5% increased to daily smoking. Current daily smokers who were older [30-44, odds ratio (OR) = 0.62; 95% confidence interval (CI) = 0.49-0.78; 45+, OR = 0.75; 95% CI = 0.61-0.93] and unmarried (OR = 0.80, 95% CI = 0.66-0.96) were less likely to report smoking cessation. Current daily smokers who were Hispanic (OR = 2.15, 95% CI = 1.65-2.81) and college educated (OR = 1.27, 95% CI = 1.05-1.53) were more likely to report smoking cessation. Relapse in former daily smokers was greater in women (OR = 1.44, 95% CI = 1.01-2.06) and lower in older adults (OR = 0.44; 95% CI = 0.27-0.74). Smoking initiation occurred less in women (OR = 0.65; 95% CI = 0.49-0.87) and Hispanic adults (OR = 0.57; 95% CI = 0.36-0.91) and more in unmarried adults (OR = 1.84; 95% CI = 1.37-2.47) and adults with less education (OR = 1.63; 95% CI = 1.09-2.44).

CONCLUSIONS

From 2001 to 2005, smoking status was extremely stable in the US population. Specific gender, race and educational groups need increased prevention and intervention efforts.

The many faces of tobacco use among women

Smoking is still considered to be mainly a male problem. However, it is estimated that there are approximately 250 million women worldwide who smoke cigarettes and millions more women who use smokeless tobacco products. This article addresses the many facets of tobacco use among women. The aim of the paper is to increase recognition among clinicians and researchers of the specific characteristics of female tobacco use. Together with providing epidemiological data on the distribution of tobacco use among women and data from population-based analyses on sociocultural factors that influence it, the article presents tobacco use during pregnancy as a particularly important public health problem. Further, the article points out sex-related differences (ie, physiological, psychological, or behavioral) between male and female tobacco use. A special focus is on the important role of ovarian hormones. Adverse effects of tobacco use to women and their children as well as tobacco-related morbidities and comorbidities are presented, and women's greater susceptibility to tobacco constituents as compared to men is stressed. Awareness of these differences can contribute to improvement of the effectiveness of smoking cessation programs addressed both to the specific female population and to an individual smoking woman.

Pharmacotherapy of smoking cessation

Nicotine in tobacco smoke causes not only pathophysiological changes in the smoker's body, but also develops tolerance to its own action with repeated use. Repeated exposure to nicotine develops neuroadaptation of the receptors, resulting in tolerance to many of the effects of nicotine. Pharmacotherapies for smoking cessation should reduce withdrawal symptoms and block the reinforcing effects of nicotine without causing excessive adverse effects. All forms of nicotine replacement therapy (NRT) - gum, patches and inhaler - and bupropion are safe and effective for increasing smoking cessation rates in the short and long-term use. Combination NRT (more than one therapy) may be indicated in patients who have failed monotherapy.

The potential and peril of health insurance tobacco surcharge programs: evidence from Georgia's State Employees' Health Benefit Plan

INTRODUCTION

A rapidly growing number of U.S. employers are charging health insurance surcharges for tobacco use to their employees. Despite their potential to price-discriminate, little systematic empirical evidence of the impacts of these tobacco surcharges has been published. We attempted to assess the impact of a health insurance surcharge for tobacco use on cessation among enrollees in Georgia's State Health Benefit Plan (GSHBP).

METHODS

We identified a group of enrollees in GSHBP who began paying the tobacco surcharge at the program's inception in July 2005. We examined the proportion of these enrollees who certified themselves and their family members as tobacco-free and no longer paid the surcharge through April 2011, and we defined this as implied cessation. We compared this proportion to a national expected annual 2.6% cessation rate. We also compared our observation group to a comparison group to assess surcharge avoidance.

RESULTS

By April 2011, 45% of enrollees who paid a tobacco surcharge starting in July 2005 had certified themselves as tobacco-free. This proportion exceeded the expected cessation based on 3 times the national rate (p < .001). The length of enrollment was not statistically different between our observation and comparison groups (p = .427).

CONCLUSIONS

The reported rates of tobacco cessation among GSHBP enrollees resulting from a tobacco surcharge substantially exceed national rates. These surcharges appear to be effective, but the value of these results, and the effectiveness of health insurance surcharges in changing behavior, are tempered by the important limitation that enrollees' certification of quitting was self-reported and not subject to additional, clinical verification.

Overcoming limitations in previous research on exercise as a smoking cessation treatment: rationale and design of the "Quit for Health" trial

Aerobic exercise has been proposed as a stand-alone or adjunct smoking cessation treatment, but findings have been mixed. Laboratory studies have shown that individual exercise sessions lead to decreases in withdrawal symptoms and cigarette cravings, but findings are limited by lack of follow-up and artificial settings. On the other hand, smoking cessation treatment RCTs have generally failed to show positive effects of exercise on smoking cessation, but have been plagued by poor and/or unverified compliance with exercise programs. This paper describes the rationale and design for Quit for Health (QFH)--an RCT designed to determine the efficacy of aerobic exercise as an adjunct smoking cessation treatment among women. To overcome limitations of previous research, compliance with the exercise (and wellness contact control) program is incentivized and directly observed, and ecological momentary assessment is used to examine change over time in withdrawal symptoms and cigarette cravings in participants' natural environments.