The California Tobacco Control Program's effect on adult smokers: (1) Smoking cessation

Cigarette Prices and Disparities in Smoking Cessation in the United States

INTRODUCTION

Achieving cessation in people with established smoking patterns remains a challenge. Increasing cigarette prices has been one of the most successful strategies for lowering smoking rates. The extent to which it has remained effective in encouraging cessation among adults in recent years and how the effectiveness has varied by sociodemographic characteristics is unclear.

AIMS AND METHODS

Using repeated cross-sectional data collected by the Tobacco Use Supplement of the Current Population Survey, we investigate the relationship between cigarette prices and cessation from 2003 to 2019 in adults at least 25 years old. We examine the associations between price and cessation in the population overall and by sex, race and ethnicity, and socioeconomic status.

RESULTS

We found mixed support for associations between greater local prices and cessation. Unadjusted models showed that greater local prices were associated with greater odds of cessation, but the associations did not persist after controlling for sociodemographic characteristics. The associations did not significantly differ by respondent characteristics. Sensitivity analysis using alternative specifications and retail state price as the main predictor showed similar results. Sensitivity analysis with controls for e-cigarette use in the 2014-2019 period showed that greater local price was associated with cessation among adults with less than a high school degree. When stratified by year of data collection, results show that greater local prices were associated with cessation after 2009.

CONCLUSIONS

Overall, the study adds to the conflicting evidence on the effectiveness of increasing prices on smoking cessation among adults with established smoking patterns.

IMPLICATIONS

Higher cigarette prices have been one of the most successful tools for lowering smoking prevalence. It remains unclear how effective they have been in recent years in encouraging adults with established smoking patterns to quit. The study's results show that greater local prices were associated with higher odds of cessation, but the association did not persist after sociodemographic adjustment. In a sensitivity analysis, greater local price was associated with cessation among people with less than a high school degree in models controlling for e-cigarette use. We also found evidence that greater local price was associated with cessation after 2009. More comprehensive smoke-free coverage was also associated with greater odds of cessation. The study's results highlight that encouraging cessation among adults with an established smoking pattern remains a challenging policy problem even when cigarette prices rise.

Pre- and Postnatal Exposures to Tobacco Smoking and Survival of Childhood Acute Lymphoblastic and Myeloid Leukemias in California, United States

BACKGROUND

Tobacco smoke adversely affects the prognosis of adult cancers including myeloid leukemia, but less is known in children.

METHODS

We evaluated whether pre- and postnatal exposures to tobacco smoke decrease 5-year survival of 1,235 childhood acute lymphoblastic leukemia (ALL) and 188 childhood acute myeloid leukemia (AML) cases derived from a population-based case-control study in California. Cases were diagnosed between 1995 and 2015 (median follow-up time of 13.2 years overall). We obtained data on tobacco smoking (before conception, during pregnancy, after birth), parental education and income, clinical features, and vital status through 2020. Cox proportional hazards regression was used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for mortality associated with smoking, adjusting for sociodemographic characteristics and risk group (ALL only).

RESULTS

About 23% of mothers and 39% of fathers reported smoking and 130 children with ALL and 52 with AML died within 5 years. For AML, increased risks of death were observed among children whose fathers smoked before conception compared with nonsmoking fathers [HR = 1.41; 95% confidence interval (CI), 0.95-3.44 and 3.47; 95% CI, 1.37-8.81, respectively for <20 vs. ≥20 cigarettes per day; Ptrend = 0.01]. HR for child's passive smoking was 1.74, 95% CI, 0.81-3.73. Paternal preconception smoking may also reduce 5-year survival among ALL with favorable prognostic molecular subtypes (high hyperdiploidy and absence of IKZF1 gene deletion), although the associations did not reach statistical significance (Pheterogeneity = 0.07).

CONCLUSIONS

Paternal preconception smoking decreased 5-year survival of childhood AML.

IMPACT

Knowledge of exposure to tobacco smoking should be integrated in the treatment plan of childhood leukemias.

Clinical Implication of Smoking-Related Aryl-Hydrocarbon Receptor Repressor (AHRR) Hypomethylation in Japanese Adults

BACKGROUND

Tobacco smoking is a leading preventable cause of morbidity and mortality worldwide; still, the success rate of smoking cessation is low in general. From the viewpoint of public health and clinical care, an objective biomarker of long-term smoking behavior is sought.Methods and Results:This study assessed DNA methylation as a biomarker of smoking in a hospital setting through a combination of molecular approaches including genetic, DNA methylation and mRNA expression analyses. First, in an epigenome-wide association study involving Japanese individuals with chronic cardiovascular disease (n=94), genome-wide significant smoking association was identified at 2 CpG sites on chromosome 5, with the strongest signal at cg05575921 located in intron 3 of the aryl-hydrocarbon receptor repressor (AHRR) gene. Highly significant (P<1×10^-27) smoking-cg05575921 association was validated in 2 additional panels (n=339 and n=300). For the relationship of cg05575921 methylation extent with time after smoking cessation and cumulative cigarette consumption among former smokers, smoking-related hypomethylation was found to remain for ≥20 years after smoking cessation and to be affected by multiple factors, such ascis-interaction of genetic variation. There was a significant inverse correlation (P=0.0005) between cg05575921 methylation extent andAHRRmRNA expression.

CONCLUSIONS

The present study results support that reversion of AHRR hypomethylation can be a quantifiable biomarker for progress in and observance of smoking cessation, although some methodological points need to be considered.

Incidence of Cigarette Smoking Relapse Among Individuals Who Switched to e-Cigarettes or Other Tobacco Products

IMPORTANCE

Although e-cigarettes are not approved as a cessation device, many who smoke believe that e-cigarettes will help them quit cigarette smoking successfully.

OBJECTIVE

To assess whether people who recently quit smoking and who had switched to e-cigarettes or another tobacco product were less likely to relapse to cigarette smoking compared with those who remained tobacco free.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed a nationally representative sample of US households that participated in 4 waves of the Population Assessment of Tobacco and Health Study (conducted 2013 through 2017), combining 2 independent cohorts each with 3 annual surveys. Eligible participants were individuals who smoked at baseline, had recently quit at the first follow-up, and completed the second follow-up survey.

EXPOSURES

Use of e-cigarettes or alternate tobacco products at follow-up 1 after recently quitting smoking.

MAIN OUTCOMES AND MEASURES

Weighted percentage of participants with over 12 months abstinence by follow-up 2.

RESULTS

Of a total of 13 604 participants who smoked cigarettes at baseline, 9.4% (95% CI, 8.7%-10.0%) recently had quit smoking (mean age, 41.9; 95% CI, 39.7-46.6 years; 641 [43.2%] women) Of these, 22.8% (95% CI, 19.7%-26.0%) had switched to e-cigarettes, with 17.6% (95% CI, 14.8%-20.5%) using them daily. A total of 37.1% (95% CI, 33.7%-40.4%) used a noncigarette tobacco product and 62.9% (95% CI, 59.6%-66.3%) were tobacco free. Rates of switching to e-cigarettes were highest for those who were in the top tertile of tobacco dependence (31.3%; 95% CI, 25.0%-37.7%), were non-Hispanic White (26.4%; 95% CI, 22.3%-30.4%), and had higher incomes (annual income ≥$35 000, 27.5%; 95% CI, 22.5%-32.4% vs <$35 000, 19.3%; 95% CI, 16.3%-22.3%). At follow-up 2, unadjusted relapse rates were similar among those who switched to different tobacco products (for any tobacco product: successfully quit, 41.5%; 95% CI, 36.2%-46.9%; relapsed with significant requit, 17.0%; 95% CI, 12.4%-21.6%; currently smoking, 36.2%; 95% CI, 30.9%-41.4%). Controlled for potential confounders, switching to any tobacco product was associated with higher relapse rate than being tobacco free (adjusted risk difference, 8.5%; 95% CI, 0.3%-16.6%). Estimates for those who switched to e-cigarettes, whether daily or not, were not significant. While individuals who switched from cigarettes to e-cigarettes were more likely to relapse, they appeared more likely to requit and be abstinent for 3 months at follow-up 2 (17.0%; 95% CI, 12.4%-21.6% vs 10.4%; 95% CI, 8.0%-12.9%).

CONCLUSIONS AND RELEVANCE

This large US nationally representative study does not support the hypothesis that switching to e-cigarettes will prevent relapse to cigarette smoking.

Effects of Cigarette Prices on Intention to Quit, Quit Attempts, and Successful Cessation Among African American Smokers

INTRODUCTION

This study examined the effects of cigarette price on intention to quit, quit attempts, and successful cessation among African American smokers in the United States and explored whether price effects differed by income level and menthol use status. Price effects were further compared to White counterparts.

METHODS

We used pooled cross-sectional data from 2006 to 2007 and 2010 to 2011 Tobacco Use Supplements to the Current Population Survey to analyze 4213 African American recent active smokers. Three dependent variables were examined: any quit attempts in the past 12 months, successful cessation for at least 3 months, and intention to quit in the next 6 months. For each dependent variable, separate multiple logistic regression models were estimated to determine the impact of cigarette prices.

RESULTS

There was no indication that price was associated with quit attempts or successful cessation, but price was positively associated with increased odds of intending to quit among African American smokers (p < .001). In contrast, prices were positively associated with intention to quit and quit attempts for White smokers. The association between price and intention to quit was significantly positive for African American low-income and menthol smokers but was not statistically significant for African American high-income and non-menthol smokers. There was no evidence of a price effect on quit attempts and successful cessation for each subgroup of African Americans.

CONCLUSIONS

Tobacco tax policy alone may not be enough to increase quit attempts or successful cessation among African Americans. Community-based cessation programs tailored toward African American smokers, especially low-income menthol smokers, are needed.

IMPLICATIONS

The results revealed that, among African American smokers, particularly among low-income and menthol smoking African American smokers, price appears to be positively associated with intention to quit; nevertheless, this deterrent effect does not appear to translate to actualized quit attempts or successful cessation. Increasing cigarette prices as a standalone policy may not be independently effective in increasing quit attempts and successful cessation within the African American community. Community-based cessation interventions tailored for African Americans are needed to help further translate desired cessation into actualized quit attempts.

A Computational Model for Assessing the Population Health Impact of Introducing a Modified Risk Claim on an Existing Smokeless Tobacco Product

Computational models are valuable tools for predicting the population effects prior to Food and Drug Administration (FDA) authorization of a modified risk claim on a tobacco product. We have developed and validated a population model using best modeling practices. Our model consists of a Markov compartmental model based on cohorts starting at a defined age and followed up to a specific age accounting for 29 tobacco-use states based on a cohort members transition pathway. The Markov model is coupled with statistical mortality models and excess relative risk ratio estimates to determine survival probabilities from use of smokeless tobacco. Our model estimates the difference in premature deaths prevented by comparing Base Case ("world-as-is") and Modified Case (the most likely outcome given that a modified risk claim is authorized) scenarios. Nationally representative transition probabilities were used for the Base Case. Probabilities of key transitions for the Modified Case were estimated based on a behavioral intentions study in users and nonusers. Our model predicts an estimated 93,000 premature deaths would be avoided over a 60-year period upon authorization of a modified risk claim. Our sensitivity analyses using various reasonable ranges of input parameters do not indicate any scenario under which the net benefit could be offset entirely.

An Update on Hardening: A Qualitative Review

Introduction

This review examines the evidence for the hardening hypothesis; that is, the prevalence of (1) becoming a former smoker is decreasing over time due to (2) decreased quit attempts, or (3) decreased success on a given quit attempt.

Methods

PubMed, EMBASE, PsychINFO, trial registries, and other databases were searched for population-based surveys that reported whether one of the aforementioned three outcomes decreased over time.

Results

None of the 26 studies found that conversion from current to former smoking, number of quit attempts, or success on a given quit attempt decreased over time and several found these increased over time. These results appeared to be similar across survey dates, duration of time examined, number of data points, data source, outcome definitions, and nationality.

Conclusions

These results convincingly indicate hardening is not occurring in the general population of smokers. On the other hand, the prevalence of smoking is declining less among older and women smokers, and smokers with low education, low income, psychological problems, alcohol or drug abuse, medical problems, and greater nicotine dependence, than among those without these characteristics, presumably due to less quitting. Why this has not lead to decreased success in stopping smoking in the general population is unclear.

Implications

Some have argued that a greater emphasis on harm reduction and more intensive or dependence-based treatments are needed because remaining smokers are those who are less likely to stop with current methods. This review finds no or little evidence for this assumption. Psychosocial factors, such as low education and psychiatric problems, predict less ability to quit and appear to becoming more prevalent among smokers. Why this is not leading to decreased quitting in the general population is an anomaly that may be worth trying to understand.

Tobacco screening and cessation efforts by dental providers: A quality measure evaluation

OBJECTIVES

The purpose of this study was to adapt, test, and evaluate the implementation of a primary care "Preventive care and Screening" meaningful use quality measure for tobacco use, in dental institutions. We determined the percentage of dental patients screened for tobacco use, and the percentage of tobacco users who received cessation counseling.

METHODS

We implemented the dental quality measure (DQM), in three dental schools and a large dental accountable care organization. An automated electronic health record (EHR) query identified patients 18 years and older who were screened for tobacco use one or more times within 24 months, and who received cessation counseling intervention if identified as a tobacco user. We evaluated EHR query performance with a manual review of a subsample of charts.

RESULTS

Across all four sites, in the reporting calendar year of 2015, a total of 143,675 patients met the inclusion criteria for the study. Within 24 months, including 2014 and 2015 calendar years, percentages of tobacco screening ranged from 79.7 to 99.9 percent, while cessation intervention percentages varied from 1 to 81 percent among sites. By employing DQM research methodology, we identified intervention gaps in clinical practice.

CONCLUSIONS

We demonstrated the successful implementation of a DQM to evaluate screening rates for tobacco use and cessation intervention. There is substantial variation in the cessation intervention rates across sites, and these results are a call for action for the dental profession to employ tobacco evidence-based cessation strategies to improve oral health and general health outcomes.

Facebook recruitment of smokers: comparing gain- and loss-framed ads for the purposes of an Internet-based smoking cessation intervention

Abstract: Gain- and loss-framed messages about smoking behavior have commonly been used to promote cessation. However, there are still no clear conclusions as to what kind of message is more effective for motivating smokers to quit. This study compared the effectiveness of loss- and gain-framed messages in the online recruitment of smokers via Facebook Advertising. Loss- and gain-framed messages about smoking were created and released as Facebook ads. Users who clicked on the ads were automatically redirected to the “Live Without Tobacco” intervention (http://www.vivasemtabaco.com.br). The amount spent on the ads was BRL 647.64. Data were collected from the Facebook Ads platform and from a relational database. Analyses were performed on the 6,350 users who clicked on one of the ads and 1,731 who were successfully redirected to the intervention. Gain-framed ads reached 174,029 people and loss-framed ads reached 180,527. The former received 2,688 clicks, while the latter received 3,662. The cost of the click was BRL 0.12 per gain-framed ad and BRL 0.09 per loss-framed ad. Loss-framed ads reached more users, got more clicks (and website accesses), and led to more accounts and quit plans being created. Loss-framed messages about smoking appear to be more cost-effective for both initial recruitment and intervention engagement. Facebook has proven to be a good outreach and recruitment tool and can be a solution for the difficulty in reaching smokers for cessation interventions.

Smoking Among Hispanic/Latino Nationality Groups and Whites, Comparisons Between California and the United States

Introduction

Although California is home to the largest Hispanic/Latino population, few studies have compared smoking behavior trends of Hispanic/Latino nationality groups in California to the remaining United States, which may identify the impact of the states antitobacco efforts on these groups. This study compared smoking status, frequency, and intensity among Mexican Americans, Central/South Americans, and non-Hispanic Whites in California to the remaining United States in the 1990s and 2000s.

Methods

Data were analyzed using the 1992-2011 Current Population Survey Tobacco Use Supplement to report the estimated prevalence of smoking status, frequency, and intensity by decade, race/ethnicity, and state residence. Weighted logistic regression explored sociodemographic factors associated with never and heavy smoking (≥20 cigarettes per day).

Results

There were absolute overall increases from 6.8% to 9.6% in never smoking across all groups. Compared to the remaining United States, there was a greater decrease in heavy smoking among Mexican American current smokers in California (5.1%) and a greater increase in light and intermittent smokers among Central/South American current smokers in California (9.3%) between decades. Compared to those living in the remaining United States, smokers living in California had lower odds of heavy smoking (1990s: odds ratio [OR] = 0.64, 95% confidence interval [CI] = 0.62, 0.66; 2000s: 0.54, 95% CI = 0.52, 0.55).

Conclusions

California state residence significantly impacted smoking behaviors as indicated by significant differences in smoking intensity between California and the remaining United States among Hispanic/Latino nationality groups. Understanding smoking behaviors across Hispanic/Latino nationality groups in California and the United States can inform tobacco control and smoking prevention strategies for these groups.

Implications

The present study explored the differences in smoking behaviors between Whites, Mexican Americans, and Central South/Americans living in California versus the rest of the United States in the 1990s and the 2000s. The results contribute to our current knowledge as there have been minimal efforts to provide disaggregated cigarette consumption information among Hispanic/Latino nationality groups. Additionally, by comparing cigarette consumption between those in California and the remaining United States, our data may provide insight into the impact of California's antitobacco efforts in reaching Hispanic/Latino subpopulations relative to the remaining US states, many of which have had less tobacco control policy implementation.

A Mobile Game to Support Smoking Cessation: Prototype Assessment

Background

Cigarette smoking results in an estimated seven million deaths annually. Almost half of all smokers attempt to quit each year, yet only approximately 6% are successful. Although there are multiple effective interventions that can increase these odds, substantial room remains for improvement. One effective approach to helping smokers quit is contingency management, where quitting is incentivized with the delivery of monetary rewards in exchange for objective evidence (eg, exhaled carbon monoxide levels) of abstinence.

Objective

We assessed the feasibility and promise of Inspired, a contingency management mobile app for smoking cessation that uses game-based rewards to incentivize abstinence from smoking instead of the monetary (or material) rewards typically used. We sought participant feedback and limited objective data on: the features and design of Inspired, interest in using Inspired when it becomes available, the likelihood of Inspired being an effective cessation aid, and the rank order preference of Inspired relative to other familiar smoking cessation aids.

Methods

Twenty-eight treatment-seeking smokers participated in this study. Participants attended a single one-hour session in which they received an overview of the goals of the Inspired mobile game, practiced submitting breath carbon monoxide (CO) samples, and played representative levels of the game. Participants were then told that they could play an extra level, or they could stop, complete an outcome survey, receive payment, and be dismissed. A sign-up sheet requesting personal contact information was available for those who wished to be notified when the full version of Inspired becomes available.

Results

Using binary criteria for endorsement, participants indicated that, assuming it was currently available and fully developed, they would be more likely to use Inspired than: any other smoking cessation aid (21/28, 75%), the nicotine patch (23/28, 82%), a drug designed to reduce smoking cravings (23/28, 82%), or a program involving attendance in training sessions or support group meetings (27/28, 96%). In the questionnaire, participants indicated that both the Inspired program (26/28, 93%) and the Inspired game would be “Fun” (28/28, 100%), and 71% (20/28) reported that the program would help them personally quit smoking. Fifty-eight percent of participants (15/26) chose to continue playing the game rather than immediately collecting payment for participation and leaving. Eighty-two percent of participants (23/28) signed up to be notified when the full version of Inspired becomes available.

Conclusions

This was the first study to evaluate a game-based contingency management app that uses game-based virtual goods as rewards for smoking abstinence. The outcomes suggest that the completed app has potential to be an effective smoking cessation aid that would be widely adopted by smokers wishing to quit.

Associations of Bar and Restaurant Smoking Bans With Smoking Behavior in the CARDIA Study: A 25-Year Study

Indoor smoking bans have often been associated with reductions in smoking prevalence. However, few studies have evaluated their association with within-person changes in smoking behaviors. We linked longitudinal data from 5,105 adults aged 18-30 years at baseline from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1985-2011) to state, county, and local policies mandating 100% smoke-free bars and restaurants by census tract. We used fixed-effects models to examine the association of smoking bans with within-person change in current smoking risk, smoking intensity (smoking ≥10 cigarettes/day on average vs. <10 cigarettes/day), and quitting attempts, using both linear and nonlinear adjustment for secular trends. In models assuming a linear secular trend, smoking bans were associated with a decline in current smoking risk and smoking intensity and an increased likelihood of a quitting attempt. The association with current smoking was greatest among participants with a bachelor's degree or higher. In models with a nonlinear secular trend, pooled results were attenuated (confidence intervals included the null), but effect modification results were largely unchanged. Findings suggest that smoking ban associations may be difficult to disentangle from other tobacco control interventions and emphasize the importance of evaluating equity throughout policy implementation.

Outcomes for a Public Hospital Tobacco Cessation Program: The Cook County Health and Hospitals System Experience

The objective of this study is to determine the rate and predictors of sustained smoking cessation for a cohort of smokers exposed to a guideline-based health education program delivered during routine clinical care at an urban public hospital. This is a retrospective analysis of 755 public hospital system patients who had at least two health educator contacts embedded in routine clinical care, with the latter contact 12-18 months after the baseline. The education occurred during visits to primary care, specialty clinics, urgent/episodic care, or during hospitalization. The assessment of smoking status is determined by the health educators as part of their routine assessment and recorded in the program's database. The primary outcomes are self-reported 12-month sustained smoking cessation at the 12-18 month contact and predictors of cessation. The cohort is predominantly minority smokers (African American 69 % and Latino 15 %) and uninsured (70 %) or on Medicaid (13 %). The sustained cessation rate was 9.3 %. Latino ethnicity, smoking 1-9 cigarettes/day at baseline, reporting smoke-free home, and additional educator contact in the year after the baseline were independent predictors of sustained cessation in the multivariate analysis. Smokers with multiple risks for poor cessation outcomes exposed to a guideline-based program of health education during routine healthcare encounters had sustained smoking cessation rates that compare favorably with published National Health Interview Study population cessation rates. An additional educator contact after the baseline was a predictor of cessation. The findings support development of cessation programs in which health educators are integrated into clinical care settings.

Exploring Impacts of Taxes and Hospitality Bans on Cigarette Prices and Smoking Prevalence Using a Large Dataset of Cigarette Prices at Stores 2001-2011, USA

In the USA, little is known about local variation in retail cigarette prices; price variation explained by taxes, bans, and area-level socio-demographics, and whether taxes and hospitality bans have synergistic effects on smoking prevalence. Cigarette prices 2001–2011 from chain supermarkets and drug stores (n = 2973) were linked to state taxes (n = 41), state and county bar/restaurant smoking bans, and census block group socio-demographics. Hierarchical models explored effects of taxes and bans on retail cigarette prices as well as county smoking prevalence (daily, non-daily). There was wide variation in store-level cigarette prices in part due to differences in state excise taxes. Excise taxes were only partially passed onto consumers (after adjustment, $1 tax associated with $0.90 increase in price, p < 0.0001) and the pass-through was slightly higher in areas that had bans but did not differ by area-level socio-demographics. Bans were associated with a slight increase in cigarette price (after adjustment, $0.09 per-pack, p < 0.0001). Taxes and bans were associated with reduction in smoking prevalence and taxes had a stronger association when combined with bans, suggesting a synergistic effect. Given wide variation in store-level prices, and uneven state/county implementation of taxes and bans, more federal policies should be considered.

E-cigarette use and smoking reduction or cessation in the 2010/2011 TUS-CPS longitudinal cohort

Background

Electronic cigarettes (e-cigarettes) are heavily marketed and widely perceived as helpful for quitting or reducing smoking intensity. We test whether ever-use of e-cigarettes among early adopters was associated with: 1) increased cigarette smoking cessation; and 2) reduced cigarette consumption.

Methods

A representative cohort of U.S. smokers (N = 2454) from the 2010 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) was re-interviewed 1 year later. Outcomes were smoking cessation for 30+ days and change in cigarette consumption at follow-up. E-cigarettes use was categorized as for cessation purposes or for another reason. Multivariate regression was used to adjust for demographics and baseline cigarette dependence level.

Results

In 2011, an estimated 12 % of adult U.S. smokers had ever used e-cigarettes, and 41 % of these reported use to help quit smoking. Smokers who had used e-cigarettes for cessation were less likely to be quit for 30+ days at follow-up, compared to never-users who tried to quit (11.1 % vs 21.6 %; ORadj = 0.44, 95 % CI = 0.2–0.8). Among heavier smokers at baseline (15+ cigarettes per day (CPD)), ever-use of e-cigarettes was not associated with change in smoking consumption. Lighter smokers (<15 CPD) who had ever used e-cigarettes for quitting had stable consumption, while increased consumption was observed among all other lighter smokers, although this difference was not statistically significant.

Conclusions

Among early adopters, ever-use of first generation e-cigarettes to aid quitting cigarette smoking was not associated with improved cessation or with reduced consumption, even among heavier smokers.

Tobacco use disparities by racial/ethnic groups: California compared to the United States

Racial/ethnic disparities in cigarette use and cessation persist. This study compared cigarette consumption and former smoking trends in California (CA) with the rest of the United States (US) by racial/ethnic categories of non-Hispanic White, Black, Hispanic/Latino, and Asian/Pacific Islander groups. Data were analyzed from the 1992 to 2011 Tobacco Use Supplement to the Current Population Survey. Consumption levels across decades were examined and adjusted logistic regression models were fit to compare across CA and US. Results indicated steady declines in ever smoking prevalence for all groups with much lower magnitudes of change among US Blacks and Whites compared to their CA counterparts. After controlling for age, gender, and education, CA had significantly fewer heavy smokers (OR=0.45, 95% CI:0.38-0.54), more light and intermittent smokers (LITS; OR=1.68, 95%CI: 1.45-1.93), and a greater proportion of former smokers (OR=1.35, 95%CI: 1.24-1.48) than the rest of US. Data were stratified by race/ethnicity and the patterns shown were mostly consistent with CA performing statistically better than their US counterparts with the exception of Black LITS and Asian/Pacific Islander former smokers. California's success in reducing tobacco use disparities may serve as a prime example of tobacco control policy for the country. CA and the US will need to continue to address tobacco use and cessation in the context of the growing diversity of the population.

Achieving the tobacco endgame: evidence on the hardening hypothesis from repeated cross-sectional studies in New Zealand 2008-2014

INTRODUCTION

The hardening hypothesis proposes that as smoking prevalence declines the proportion of 'hardcore' or 'hardened' smokers will increase. The possible constructs of hardening include reduced motivation to quit, increased levels of addiction, increased levels of disadvantage and reduced quit rates among continuing smokers. Most previous studies have investigated only a single facet of the hypothesis. We used data from a national population monitor to test the hypothesis using measures across all four hardening constructs.

METHODS

We analysed data from a biennial population-based survey of New Zealand adults (aged 15 years+) from 2008 to 2014. Data were collected through face-to-face computer-assisted personal interviews.

RESULTS

During a period of reducing smoking prevalence, there were no statistically significant changes in indicators of hardening including the proportion of smokers who were unmotivated to quit, unable to quit despite repeated attempts or receiving state benefits or on a low income. Quit rates did not change significantly over the study period. For 2014 versus 2008, the OR for recent (within last 1-12 months) quitting was 1.14 (95% CI 0.53 to 2.46) and for sustained (within previous 13-24 months) quitting was 1.88 (95% CI 0.78 to 4.54).

CONCLUSIONS

This study provides evidence that robust tobacco control strategies that result in substantial declines in smoking prevalence are not accompanied by the hypothesised increase in 'hardcore' or 'hardened' smokers who are more addicted and less motivated and able to quit. The findings suggest that there is no need for substantial change in approach to achieve New Zealand's Smokefree 2025 goal on the grounds that the smoker population is becoming increasingly hardened.

Associations Between Cigarette Print Advertising and Smoking Initiation Among African Americans

OBJECTIVES

The objective of this study was to examine changes in the annual number of cigarette advertisements in magazines with a predominantly African-American audience following the broadcast ban on tobacco, and whether fluctuations in cigarette print advertising targeting African Americans during the late-1970s until the mid-1980s were associated with declines in smoking initiation.

DESIGN

We tabulated the annual number of cigarette advertisements from magazines with large African-American readerships (Ebony, Essence, and Jet) from 1960 to 1990. Advertisements were coded depending on whether they featured African-American models. We calculated the incidence rate of regular smoking initiation from 1975 to 1990 for African-American 14-25 years old using data from the 1992-1993, 1995-1996, 1998-1999, and 2001-2002 Tobacco Use Supplements of the Current Population Survey. We examined whether trends in smoking initiation coincided with trends in cigarette advertising practices among African Americans.

RESULTS

The annual aggregated number of printed cigarette advertisements in Ebony, Essence, and Jet magazines increased at least five-fold starting in 1971, following the broadcast ban on cigarette advertising. A decrease in the percentage of ads by Brown & Williamson that showed African-American models was positively correlated (r = 0.30) with declines in the incidence rate of smoking initiation among African Americans from the late-1970s to the mid-1980s.

CONCLUSION

The tobacco industry adapted quickly following the broadcast ban on cigarettes by increasing print advertising in African-American magazines. However, changes in print advertising practices by were associated with declines in smoking initiation among African Americans from the late-1970s to mid-1980s.

Implementing Tobacco Control Programs in Homeless Shelters

Background. Tobacco-related chronic diseases contribute significantly to the increased morbidity and mortality observed in the homeless population. Few homeless service settings address tobacco use among their clients. Method. Directors and staff from emergency and transitional shelters in San Diego County completed a questionnaire on no-smoking policies and smoking cessation services and participated in in-depth, semistructured interviews to examine the barriers to and facilitators of implementing smoke-free policies and cessation services in their facilities. Results. Facilities differed in outdoor restrictions around smoking: 61.5% reported having an outdoor designated smoking zone, and 25% reported having a campus-wide ban on smoking. About one-third of the facilities offered on-site resources for smoking cessation. Although directors and staff supported smoke-free policies, they reported that the increased resources needed to “police” the policy created barriers to implementation. Almost all directors and staff expressed interest in developing an on-site tobacco control program, but they reported that lack of expertise among staff posed challenges to implementing such a program. Conclusion. Our findings suggest that for a tobacco control program to be effective in homeless shelters, it should include training and incentives for staff to implement smoke-free policies and cessation services.

Cigarette smoking cessation attempts among current US smokers who also use smokeless tobacco

INTRODUCTION

Concurrent use of cigarettes and smokeless tobacco is common, but little is known regarding the association of smokeless tobacco use with cigarette smoking cessation. Dual users may have lower cigarette consumption levels, which may also play a role in smoking cessation.

METHODS

The 2010-2011 Tobacco Use Supplement to the Current Population Survey included 26,760 current cigarette smokers, of which 675 concurrently used smokeless tobacco. We compared characteristics of the most recent cigarette smoking quit attempt of the past year between dual users and exclusive smokers, using multivariate regression.

RESULTS

Dual users (45%) were more likely than exclusive smokers (37%) to have made a cigarette smoking quit attempt during the previous year (p<0.01), even after adjusting for demographic differences and cigarette dependence levels (ORadj 1.33, 95% CI 1.15-1.53). Half (48%) of dual users who made a quit attempt tried to quit "by switching to smokeless tobacco". However, once in a quit attempt, dual users relapsed more quickly than exclusive smokers (Cox regression HRadj 1.13, 95% CI 1.02-1.26). There was no difference in 30-day abstinence rates on the most recent quit attempt (ORadj 1.09, 95% CI 0.88-1.37). For both groups, the best predictor of past 30-day abstinence was cigarette consumption level.

CONCLUSIONS

Current cigarette smokers who also use smokeless tobacco are more likely to have tried to quit, but relapse more quickly than exclusive smokers, and are not more likely to have attained 30day smoking cessation. Prospective studies at the population level are needed.

Association of Cigarette Prices with the Prevalence of Smoking in Korean University Students: Analysis of Effects of the Tobacco Control Policy

BACKGROUND

Increased pricing of cigarettes might be one of the most effective approaches for reducing the prevalence of smoking. This study aimed to investigate the effects of increasing cigarette prices through taxation by a tobacco intervention policy on the changes in smoking prevalence in Korean university students.

MATERIALS AND METHODS

The participants in this study were 23,047 healthy university students aged 18-29 years from a health examination in 2011-2015. We investigated the adjusted prevalence of daily and occasional smoking before and after increasing cigarette prices through taxation.

RESULTS

The prevalence of occasional smoking was significantly decreased in 2015 from 2014 in both male (from 10.7% in 2014 to 5.4%) and female (from 3.6% to 1.1%) students, but the prevalence of daily smoking did not decrease significantly. The frequency of individuals who had attempted smoking cessation during the past year was significantly higher among occasional smokers in male students (90.2%) compared with daily smokers (64.9%). For female students, there were no differences in experience of smoking cessation, willingness for smoking cessation, or E-cigarette experience between daily and occasional smokers.

CONCLUSIONS

We found that a policy of increasing cigarette prices through taxation is associated with decreases in the prevalence of occasional smokers, who have relatively lower nicotine dependence compared with individuals who smoke daily. The results of our study suggest that social support and direct intervention for smoking cessation at the community level are needed for university students alongside the pricing policy.

Light and intermittent smoking among California Black, Hispanic/Latino, and non-Hispanic White men and women

INTRODUCTION

The prevalence of light and intermittent smoking (LITS) is increasing as the prevalence of heavier smoking continues to fall. The purpose of this study was to examine changes in LITS over time among Blacks, Hispanic/Latinos (Latinos) and non-Hispanic Whites (Whites).

METHODS

Data from the California Tobacco Surveys from 1990, 1992, and 1996 (Time 1 [T1]) were combined and compared to combined data from 1999, 2002, 2005, and 2008 (Time 2 [T2]). T1 participants (N = 50,424) included Blacks (n = 3,029), Latinos (n = 7,910), and Whites (n = 39,485). T2 participants (N = 53,005) included Blacks (n = 5,460), Latinos (n = 14,273), and Whites (n = 33,246).

RESULTS

LITS increased by a factor of 12.9% to a rate of 79.6% (76.0-83.2) among Latinos, by 19.4% to a rate of 74.4% (70.9-77.9) among Blacks, and by 51.7% to a rate of 48.9% (47.5-50.3) among Whites. In unadjusted analyses at T1, females were more likely to be LITS than males across ethnic groups. At T2, this sex difference was maintained among Whites, but not Blacks and Latinos. Females were significantly more likely to be LITS than males when controlling for demographic variables.

CONCLUSIONS

The present study found that LITS rates increased over time for male and female Black, Latino and White adults. There is a need for increased tobacco control attention to LITS across all ethnic groups, but with additional focus on Blacks, Latinos, and women who have the highest rates of LITS.

The effect of tobacco control policy on smoking cessation in relation to gender, age and education in Lithuania, 1994-2010

BACKGROUND

This study aimed to evaluate the association between tobacco control policies and trends in smoking cessation according to gender, age and educational level in Lithuania in 1994-2010.

METHODS

The data were obtained from nine cross-sectional postal surveys conducted biennially within the framework of Finbalt Health Monitor project during 1994-2010. Each survey was based on a nationally representative random sample drawn from the National population register. The sample consisted of 3000 citizens aged 20-64 in 1994-2008 surveys and 4000 in the 2010 survey. In total, 17161 individuals participated in all surveys. The development of tobacco control policy in Lithuania was assessed using the Tobacco Control Scale (TCS). The association of the TCS scores with short-term and long-term quitting according to gender, age and education was examined using logistic regression analysis with control for secular trends.

RESULTS

Over the last two decades, a large improvement in the development of tobacco control policy has been achieved in Lithuania. At the same time, this progress was associated with the increase in smoking cessation. A significant increase in both short-term and long-term quit ratios was found among people aged 20-44. An increase by 10 points on the TCS was associated with 17% increase in the odds of short-term quitting and with 15% increase in the odds of long-term quitting. The association between tobacco control policies and long-term quitting was stronger among younger than older people. No differential effect of tobacco control policies on smoking cessation was found in relation to gender and educational level.

CONCLUSIONS

The improvement in Lithuanian tobacco control policies was associated with an increase in smoking cessation in long-term perspective. These policies have not only benefitted highly educated groups, but lower educated groups as well. Nonetheless, further development of comprehensive tobacco control policies is needed in order to decrease social inequalities in smoking cessation.

The role of betel-quid chewing in smoking cessation among workers in Taiwan

BACKGROUND

Current smokers exhibit a higher rate of betel-quid chewing than non-smokers. However, little is known regarding the extent to which betel-quid chewing may affect attempts to quit smoking and smoking cessation. The aim of the present study is to examine the association between betel-quid chewing and patterns of quitting smoking. Specifically, we explore whether betel-quid chewing is associated with (1) current smokers who have never attempted to quit versus those who have attempted to quit and have failed, those who are in the process of quitting, and successful cessation smokers, and (2) current smokers who have attempted to quit and have failed versus those who have successfully quit smoking.

METHODS

A telephone survey of 7,215 workers was conducted and obtained an 88.6% response rate. In the survey, the respondents' smoking and betel-quid chewing statuses were recorded and a list of covariates was assessed.

RESULTS

After controlling for the effect of the covariates, betel-quid chewing was found to be more highly associated with current smokers who have never attempted to quit, compared to current smokers who are in the process of quitting (OR = 12.72; 95% CI = 1.05-154.26), successful cessation smokers (OR = 3.62; 95% CI = 2.32-5.65), and smokers who have attempted to quit and have failed (OR = 1.37; 95% CI = 1.06-1.77), respectively. In addition, betel-quid chewing is more highly associated with a failure to quit smoking than with successfully quitting smoking (OR = 3.46; 95% CI = 2.17-5.51).

CONCLUSION

The findings support four plausible reasons why betel-quid chewing may dissuade smokers from quitting. These reasons highlight additional avenues for potentially reducing the smoking population in workplaces, such as considering work contexts and social norms, and product sales in smoking-cessation campaigns.

Assessment of health impacts of decreased smoking prevalence in Copenhagen: Application of the DYNAMO-HIA model

Aims: Tobacco smoking is among the leading risk factors for chronic disease and early death in developed countries, including Denmark, where smoking causes 14% of the disease burden. In Denmark, many public health interventions, including smoking prevention, are undertaken by the municipalities, but models to estimate potential health effects of local interventions are lacking. The aim of the current study was to model the effects of decreased smoking prevalence in Copenhagen, Denmark. Methods: The DYNAMO-HIA model was applied to the population of Copenhagen, by using health survey data and data from Danish population registers. We modelled the effects of four intervention scenarios aimed at different target groups, compared to a reference scenario. The potential effects of each scenario were modelled until 2040. Results: A combined scenario affecting both initiation rates among youth, and cessation and re-initiation rates among adults, which reduced the smoking prevalence to 4% by 2025, would have large beneficial effects on incidence and prevalence of smoking-related diseases and mortality. Health benefits could also be obtained through interventions targeting only cessation or re-initiation rates, whereas an intervention targeting only initiation among youth had marginal effects on morbidity and mortality within the modelled time frame. Conclusions: By modifying the DYNAMO-HIA model, we were able to estimate the potential health effects of four interventions to reduce smoking prevalence in the population of Copenhagen. The effect of the interventions on future public health depended on population subgroup(s) targeted, duration of implementation and intervention reach.

Smoking ban policies and their influence on smoking behaviors among current California smokers: a population-based study

OBJECTIVE

To assess whether smoking ban policies are associated with smoking reduction and quit attempts among California smokers.

METHODS

Data were examined for 1718 current smokers from follow-up telephone interviews conducted in 2011 of persons previously identified as smokers in a representative sample of the adult population of California. Population weighted logistic regressions controlling for demographic and other variables were used to evaluate the association between smoking ban policies (home, work, and town) and changes in tobacco use (past year quit attempt or reduction in smoking rate).

RESULTS

Living in a home with a total ban was significantly associated with smoking reduction (adjusted odds ratio, AOR: 2.4, 95% CI: 1.4-4.2) and making a quit attempt (AOR: 2.3, 95% CI: 1.3-3.9) compared to living in a home with no home ban. Self-reported perception of an outdoor ban in one's city/town was associated with smoking reduction (AOR: 1.7, 95% CI: 1.02-2.7) and making a quit attempt (AOR: 1.8, 95% CI: 1.05-2.9).

CONCLUSION

These results indicate that smoking bans not only protect nonsmokers from the harms of secondhand smoke, but are also associated with smoking reduction and cessation.

Impact of the 2009 Taiwan tobacco hazards prevention act on smoking cessation

AIMS

In January 2009, the government of Taiwan amended the 1997 Tobacco Hazards Prevention Act by extending smoke-free areas to include almost all enclosed work-places and public places, adding graphic health warnings to cigarette packages, totally banning tobacco advertisements, promotion and sponsorship and increasing tobacco taxes. This study examined the impact of the 2009 amended Act on smoking cessation in Taiwan.

DESIGN

Taiwan Adult Tobacco Surveys 2007 and 2010, each with a nationally representative sample of adults aged 18 years and older (n = 16 588, and n = 16 295, respectively).

PARTICIPANTS

All recent active smokers (current smokers plus former smokers who quit smoking within the past 12 months) were used for the analyses (n = 3783 in 2007, and n = 2777 in 2010).

MEASUREMENTS

Quit attempt rate and annual cessation rate (defined as having succeeded in quitting for at least 3 months) among recent active smokers were compared between the pre-Act (2007) and post-Act (2010) periods.

FINDINGS

The quit attempt rate increased significantly from 39.4% in 2007 to 42.9% in 2010. The annual cessation rate increased significantly from 7.1 to 8.9%. A multivariate analysis, controlling for demographic characteristics, showed that the implementation of the 2009 Act was associated with an increase in the quit attempt rate [odds ratio (OR) = 1.14; 95% confidence interval (CI) = 1.03-1.25] and the annual cessation rate (OR = 1.28; 95% CI = 1.08-1.53).

CONCLUSIONS

The comprehensive tobacco control programme introduced in 2009 in Taiwan, which combined smoke-free legislation with a tobacco tax increase, graphic health warning labels and a total ban on tobacco advertisements, was associated with increases in quit attempt rate and annual cessation rate.

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 effectiveness of cigarette price and smoke-free homes on low-income smokers in the United States

OBJECTIVES

We examined the effectiveness of state cigarette price and smoke-free homes on smoking behaviors of low-income and high-income populations in the United States.

METHODS

We used the 2006-2007 Tobacco Use Supplement to the Current Population Survey. The primary outcomes were average daily cigarette consumption and successful quitting. We used multivariable regression to examine the association of cigarette price and smoke-free home policies on these outcomes.

RESULTS

High state cigarette price (pack price ≥ $4.50) was associated with lower consumption across all income levels. Although low-income individuals were least likely to adopt smoke-free homes, those who adopted them had consumption levels and successful quit rates that were similar to those among higher-income individuals. In multivariable analysis, both policies were independently associated with lower consumption, but only smoke-free homes were associated with sustained cessation at 90 days.

CONCLUSIONS

High cigarette prices and especially smoke-free homes have the potential to reduce smoking behaviors among low-income individuals. Interventions are needed to increase adoption of smoke-free homes among low-income populations to increase cessation rates and prevent relapse.

How does rate of smoking cessation vary by age, gender and social grade? Findings from a population survey in England

AIMS

To assess the incidence of long-term smoking cessation as a function of age, gender, social grade and their interactions.

DESIGN AND SETTING

Cross-sectional surveys of population representative samples of smokers in England.

PARTICIPANTS

A total of 24 094 ever smokers (≥21 and ≤60 years of age) participating in household surveys between November 2006 and February 2011.

MEASUREMENTS

The ratio of long-term (>1 year) ex-smokers to ever-smokers was calculated for each age. Regression analyses were used to model the association between age and quit ratio, with the change in quit ratio by year of age n years versus all years up to n-1 years, yielding an estimate of the quitting incidence at that age. Analyses were conducted for the entire sample and then for the sample stratified by gender and social grade, and interactions assessed between these variables.

FINDINGS

A cubic trend was needed to fit the data. The estimated quitting incidence between ages 21 and 30 was 1.5% (95% CI: 1.0%-2.0%), between 31 and 50 it was 0.3% (95% CI: 0.2%-0.5%) and between 51 and 60 it was 1.2% (95% CI: 0.7%-1.7%). Age interacted with gender and social grade: women and smokers from higher social grades had a higher incidence of quitting than men and those from lower social grades specifically in young adulthood. CONCLUSIONS : The incidence of smoking cessation in England appears to be greater in young and old adults compared with those in middle age. Women and higher social grade smokers show a greater incidence of quitting than men and those from lower social grades specifically in young adulthood.

A dynamic population model for estimating all-cause mortality due to lifetime exposure history

We developed a comprehensive, flexible dynamic model that estimates all-cause mortality for a hypothetical cohort. All model input is user-specified. In the base case, members of the cohort may be exposed to a high risk product as they age. The counterfactual scenario includes exposure to both a high risk and a lower risk product. The model sorts the population into age and exposure categories, and applies the appropriate mortality rates to each category. The model tracks individual exposure histories, and estimates, at the end of each modeled age category, the number of survivors in the two exposure scenarios (base case and counterfactual), and the difference between them. Markov Chain Monte Carlo techniques are used to estimate the variability of the results. Model output was compared against US and Swedish life tables using population-specific tobacco exposure transition probabilities derived from the literature, and it produced similar survival estimates.

Tobacco smoking, quitting, and relapsing among adult males in Mainland China: the China Seven Cities Study

INTRODUCTION

Despite an estimated 1 million tobacco-related deaths annually in China, public health officials face overwhelming barriers to implementing effective tobacco control policies and programs. Models of effective tobacco control can be adapted for Chinese tobacco use and culture based on reliable and valid data regarding predictors of smoking and abstaining.

METHODS

As part of the China Seven Cities Study to assess the role of rapid social, economic, and cultural change on tobacco use and related health practices and outcomes, 4,072 adult male smokers provided data in 3 annual waves. Measures included current smoking, nicotine dependence, readiness for quitting, perceived stress, hostility, depressive symptoms, as well as covariates (e.g., age, marital status, educational attainment, and family income).

RESULTS

Odds of being abstinent at Wave 3 were increased by: lower nicotine dependence at Wave 1 and becoming less dependent between Waves 1 and 3; progressing beyond the contemplation stage between Waves 1 and 3; perceiving less stress, whether initially at Wave 1 or over time from Wave 1 to Wave 3; and lower hostility scores at Wave 1 and decreased hostility from Wave 1 to Wave 3. Among those who quit, odds of remaining abstinent rather than relapsing by Wave 3 were higher among those who were less dependent at Wave 1 and who became less dependent from Wave 1 to Wave 3; and those who showed decreases in hostility from Wave 1 to Wave 3.

CONCLUSIONS

The public health challenge posed by very high prevalence of male smoking in China can be met by policies and programs that lead to successful long-term cessation. This can only be done successfully by designing interventions based on knowledge of the country's smokers and the current study suggests several elements.

Increasing lung cancer death rates among young women in southern and midwestern States

PURPOSE

Previous studies reported that declines in age-specific lung cancer death rates among women in the United States abruptly slowed in women younger than age 50 years (ie, women born after the 1950s). However, in view of substantial geographic differences in antitobacco measures and sociodemographic factors that affect smoking prevalence, it is unknown whether this change in the trend was similar across all states.

METHODS

We examined female age-specific lung cancer death rates (1973 through 2007) by year of death and birth in each state by using age-period-cohort models. Cohort relative risks adjusted for age and period effects were used to compare the lung cancer death rate for a given birth cohort to a referent birth cohort (ie, the 1933 cohort herein).

RESULTS

Age-specific lung cancer death rates declined continuously in white women in California, but the rates declined less quickly or even increased in the remaining states among women younger than age 50 years and women born after the 1950s, especially in several southern and midwestern states. For example, in some southern states (eg, Alabama), lung cancer death rates among women born in the 1960s were approximately double those of women born in the 1930s.

CONCLUSION

The unfavorable lung cancer trend in white women born after circa 1950 in southern and midwestern states underscores the need for additional interventions to promote smoking cessation in these high-risk populations, which could lead to more favorable future mortality trends for lung cancer and other smoking-related diseases.

A pragmatic trial in the Rio de Janeiro subway to capture smokers for a quitline: methodological challenges and opportunities

According to the World Health Organization, smoking is an important cause of death worldwide. To encourage smoking cessation, persuasive messages can be used to raise smokers' risk perception. This article discusses challenges and solutions in designing a study to evaluate the effect of two different communication strategies ("gains from quitting" vs. "losses from continuing smoking") in encouraging calls to a quitline. The authors conducted an intervention study in two subway stations for 4 weeks, considering only 1 strategy per station. Large posters containing non-age-specific images and texts, on the basis of the theme"shortness of breath," were displayed on central dividing columns on the boarding platforms. Call rates from the selected stations, and respective rate ratios, overall and per study week, were calculated. Passengers who were smokers, exposed to the positive-content message, called on average 1.7 times more often than did those exposed to the negative-content message (p = .01). Moreover, call rate ratios did not decline over the 4 weeks of the study (p = .40). The effectiveness findings suggest that antismoking campaigns could use positive-content messages in order to recruit a larger smoker population. The proposed methodology can also be used to evaluate effectiveness of messages for "capturing" individuals with other health problems (e.g., alcohol abuse), thereby increasing its potential impact.

Prevalence of video game use, cigarette smoking, and acceptability of a video game-based smoking cessation intervention among online adults

INTRODUCTION

Video games may serve as an ideal platform for developing and implementing technology-based contingency management (CM) interventions for smoking cessation as they can be used to address a number of barriers to the utilization of CM (e.g., replacing monetary rewards with virtual game-based rewards). However, little is known about the relationship between video game playing and cigarette smoking. The current study determined the prevalence of video game use, video game practices, and the acceptability of a video game-based CM intervention for smoking cessation among adult smokers and nonsmokers, including health care professionals.

METHODS

In an online survey, participants (N = 499) answered questions regarding their cigarette smoking and video game playing practices. Participants also reported if they believed a video game-based CM intervention could motivate smokers to quit and if they would recommend such an intervention.

RESULTS

Nearly half of the participants surveyed reported smoking cigarettes, and among smokers, 74.5% reported playing video games. Video game playing was more prevalent in smokers than nonsmokers, and smokers reported playing more recently, for longer durations each week, and were more likely to play social games than nonsmokers. Most participants (63.7%), including those who worked as health care professionals, believed that a video game-based CM intervention would motivate smokers to quit and would recommend such an intervention to someone trying to quit (67.9%).

CONCLUSIONS

Our findings suggest that delivering technology-based smoking cessation interventions via video games has the potential to reach substantial numbers of smokers and that most smokers, nonsmokers, and health care professionals endorsed this approach.

Estimating the probabilities of making a smoking quit attempt in Italy: stall in smoking cessation levels, 1986-2009

Background

No data on annual smoking cessation probability (i.e., the probability of successfully quit in a given year) are available for Italy at a population level. Mathematical models typically used to estimate smoking cessation probabilities do not account for smoking relapse. In this paper, we developed a mathematical model to estimate annual quitting probabilities, taking into account smoking relapse and time since cessation.

Methods

We developed a dynamic model describing the evolution of current, former, and never smokers. We estimated probabilities of smoking cessation by fitting the model with observed smoking prevalence in Italy, 1986-2009.

Results

Annual cessation probabilities were higher than 5% only in elderly persons and in women aged < 30 years, while in adults aged 30-49 and 50-59 cessations were about 2% and 3-5%, respectively. Most of quit probabilities stalled from 1986 to 2009.

Conclusions

Over the last 20 years, cessation probabilities among Italian smokers, particularly for those aged 30-59 years, have been very low and stalled. Quitting in Italy is considered as a practicable strategy only by women in the age of pregnancy and by elderly persons, when it’s likely that symptoms of tobacco-related diseases have already appeared. In order to increase cessation probabilities, smoking cessation treatment policies (introducing total reimbursement of cessation treatments, with a further development of quitlines and smoking cessation services) should be empowered and a country-wide mass media campaign targeting smokers aged 30-59 years and focusing on promotion of quitting should be implemented.

Reimbursing dentists for smoking cessation treatment: views from dental insurers

INTRODUCTION

Screening and delivery of evidence-based interventions by dentists is an effective way to reduce tobacco use. However, dental visits remain an underutilized opportunity for the treatment of tobacco dependence. This is, in part, because the current reimbursement structure does not support expansion of dental providers' role in this arena. The purpose of this study was to interview dental insurers to assess attitudes toward tobacco use treatment in dental practice, pros and cons of offering dental provider reimbursement, and barriers to instituting a tobacco use treatment-related payment policy for dental providers.

METHODS

Semi-structured interviews were conducted with 11 dental insurance company executives. Participants were identified using a targeted sampling method and represented viewpoints from a significant share of companies within the dental insurance industry.

RESULTS

All insurers believed that screening and intervention for tobacco use was an appropriate part of routine care during a dental visit. Several indicated a need for more evidence of clinical and cost-effectiveness before reimbursement for these services could be actualized. Lack of purchaser demand, questionable returns on investment, and segregation of the medical and dental insurance markets were cited as additional barriers to coverage.

CONCLUSIONS

Dissemination of findings on efficacy and additional research on financial returns could help to promote uptake of coverage by insurers. Wider issues of integration between dental and medical care and payment systems must be addressed in order to expand opportunities for preventive services in dental care settings.

Smoking cessation treatment preferences, intentions, and behaviors among a large sample of Colorado gay, lesbian, bisexual, and transgendered smokers

INTRODUCTION

Little is known about preferences, intentions, and behaviors regarding evidence-based cessation treatment for smoking cessation among gay, lesbian, bisexual, and transgendered (GLBT) adults.

METHODS

We obtained and analyzed questionnaire responses from GLBT smokers (n= 1,633) surveyed in 129 GLBT-identified Colorado venues and online during 2007.

RESULTS

Most respondents (80.4%) smoked daily. Nearly one-third smoked 20 or more cigarettes/day. Fewer than half (47.2%) had attempted quitting in the previous year, and only 8.5% were preparing to quit in the next month. More than one-fourth (28.2%) of quit attempters had used nicotine replacement therapy (NRT), and a similar proportion said they intended to use NRT in their next quit attempt. Lesbians were significantly less likely than gay men to have used or intend to use NRT. One-fourth of respondents said they were uncomfortable talking to their doctor about quitting smoking. Four factors (daily smoking, ever having used NRT, a smoke-free home rule, and comfort asking one's doctor for cessation advice) were associated with preparation to quit smoking.

CONCLUSIONS

GLBT self-identification was not associated with lower than average acceptance of evidence-based smoking cessation strategies, especially NRT, but a large minority of GLBT smokers were unlikely to seek cessation assistance through clinical encounters. Public health campaigns should focus on supporting motivation to quit and providing nonclinical access to evidence-based treatments.

Impact of Scottish smoke-free legislation on smoking quit attempts and prevalence

Objectives

In Scotland, legislation was implemented in March 2006 prohibiting smoking in all wholly or partially enclosed public spaces. We investigated the impact on attempts to quit smoking and smoking prevalence.

Methods

We performed time series models using Box-Jenkins autoregressive integrated moving averages (ARIMA) on monthly data on the gross ingredient cost of all nicotine replacement therapy (NRT) prescribed in Scotland in 2003–2009, and quarterly data on self-reported smoking prevalence between January 1999 and September 2010 from the Scottish Household Survey.

Results

NRT prescription costs were significantly higher than expected over the three months prior to implementation of the legislation. Prescription costs peaked at £1.3 million in March 2006; £292,005.9 (95% CI £260,402.3, £323,609, p<0.001) higher than the monthly norm. Following implementation of the legislation, costs fell exponentially by around 26% per month (95% CI 17%, 35%, p<0.001). Twelve months following implementation, the costs were not significantly different to monthly norms. Smoking prevalence fell by 8.0% overall, from 31.3% in January 1999 to 23.7% in July–September 2010. In the quarter prior to implementation of the legislation, smoking prevalence fell by 1.7% (95% CI 2.4%, 1.0%, p<0.001) more than expected from the underlying trend.

Conclusions

Quit attempts increased in the three months leading up to Scotland's smoke-free legislation, resulting in a fall in smoking prevalence. However, neither has been sustained suggesting the need for additional tobacco control measures and ongoing support.

Health psychology: where are we and where do we go from here?

Human behaviour plays a significant role in most of the leading causes of death. Psychological science has the potential to enhance health outcomes through a better understanding of health promoting and health damaging behaviours. Health psychology and the related field of behavioural medicine focus on the interplay among biological dispositions, behaviour, and social context. The field might advance by building better collaboration with other fields of medicine, sharing expertise on technical aspects of psychometric outcomes assessment, identifying behavioural interventions to reduce health disparities, and creating an infrastructure that fosters multidisciplinary research.

Association of BDNF and COMT genotypes with cognitive processing of anti-smoking PSAs

Anti-smoking public service announcements (PSAs) often use persuasive arguments to attempt to influence attitudes about smoking. The persuasiveness of a PSA has previously been associated with factors that influence the cognitive processing of its message. Genetic factors that influence cognitive processing might thus affect individuals' responses to the persuasive arguments presented in PSAs. In the present study, we examined polymorphisms in the genes encoding brain-derived neurotrophic factor (BDNF Val66Met) and catechol-O-methyltransferase (COMT Val158Met), which affect cognitive processing in the prefrontal cortex, to identify genetic factors associated with self-reported outcomes of message processing, perceived effectiveness and quitting intentions among smokers viewing PSAs. A total of 120 smokers viewed sets of four PSAs that varied with respect to features of argument strength (AS) and message sensation value. We observed significant associations of BDNF genotype with central processing, narrative processing, perceived effectiveness of the anti-smoking PSAs and participant quitting intentions; the BDNF Met allele was associated with lower scores on all these measures. Central processing acted as a mediator of the association of genotype with quitting intentions and perceived effectiveness. There was a significant interaction of COMT genotype by AS in the model of narrative processing, such that individuals homozygous for the COMT Val allele reported higher narrative processing in the high-AS condition but not in the low-AS condition. To our knowledge, this is the first study to identify genetic factors associated with cognitive processing of anti-smoking PSAs.

Effects of tobacco-related media campaigns on smoking among 20-30-year-old adults: longitudinal data from the USA

OBJECTIVE

Young adults in the USA have one of the highest smoking prevalence rates of any age group, and young adulthood is a critical time period of targeting by the tobacco industry. The authors examined relationships between potential exposure to tobacco-related media campaigns from a variety of sponsors and 2-year smoking change measures among a longitudinal sample of US adults aged 20-30 years from 2001 to 2008.

METHODS

Self-report data were collected from a longitudinal sample of 12,931 US young adults from age 20 to 30. These data were merged with tobacco-related advertising exposure data from Nielsen Media Research. Two-year measures of change in smoking were regressed on advertising exposures.

RESULTS

Two-year smoking uptake was unrelated to advertising exposure. The odds of quitting among all smokers and reduction among daily smokers in the 2 years between the prior and current survey were positively related to anti-tobacco advertising, especially potential exposure levels of 104-155 ads over the past 24 months. Tobacco company advertising (including corporate image and anti-smoking) and pharmaceutical industry advertising were unrelated to quitting or reduction.

CONCLUSION

Continued support for sustained, public health-based well-funded anti-tobacco media campaigns may help reduce tobacco use among young adults.

Emergency department-initiated tobacco dependence treatment

OBJECTIVE

To examine the feasibility of a fax referral program to increase enrollment in tobacco dependence treatment in emergency department (ED) patients.

METHODS

The control group received quit advice and printed information; the intervention group also received a faxed referral that generated telephone contacts.

RESULTS

Treatment enrollment was higher in the intervention group (13.5% vs 2.7%). Only the faxed referral was associated with treatment enrollment.

CONCLUSIONS

An ED intervention is feasible. Faxed referral resulted in a 5-fold increase in tobacco treatment enrollment. The ED may be an opportune setting to facilitate smoking-cessation behavior change among lower income, underserved patients.