Strategies for Management of Antiretroviral Therapy (SMART) Study Group, El-Sadr WM, Lundgren JD, Neaton JD, Gordin F, Abrams D, Arduino RC, Babiker A, Burman W, Clumeck N, Cohen CJ, Cohn D, Cooper D, Darbyshire J, Emery S, Fätkenheuer G, Gazzard B, Grund B, Hoy J, Klingman K, Losso M, Markowitz N, Neuhaus J, Phillips A, Rappoport C. CD4+ count-guided interruption of antiretroviral treatment

BACKGROUND

Despite declines in morbidity and mortality with the use of combination antiretroviral therapy, its effectiveness is limited by adverse events, problems with adherence, and resistance of the human immunodeficiency virus (HIV).

METHODS

We randomly assigned persons infected with HIV who had a CD4+ cell count of more than 350 per cubic millimeter to the continuous use of antiretroviral therapy (the viral suppression group) or the episodic use of antiretroviral therapy (the drug conservation group). Episodic use involved the deferral of therapy until the CD4+ count decreased to less than 250 per cubic millimeter and then the use of therapy until the CD4+ count increased to more than 350 per cubic millimeter. The primary end point was the development of an opportunistic disease or death from any cause. An important secondary end point was major cardiovascular, renal, or hepatic disease.

RESULTS

A total of 5472 participants (2720 assigned to drug conservation and 2752 to viral suppression) were followed for an average of 16 months before the protocol was modified for the drug conservation group. At baseline, the median and nadir CD4+ counts were 597 per cubic millimeter and 250 per cubic millimeter, respectively, and 71.7% of participants had plasma HIV RNA levels of 400 copies or less per milliliter. Opportunistic disease or death from any cause occurred in 120 participants (3.3 events per 100 person-years) in the drug conservation group and 47 participants (1.3 per 100 person-years) in the viral suppression group (hazard ratio for the drug conservation group vs. the viral suppression group, 2.6; 95% confidence interval [CI], 1.9 to 3.7; P<0.001). Hazard ratios for death from any cause and for major cardiovascular, renal, and hepatic disease were 1.8 (95% CI, 1.2 to 2.9; P=0.007) and 1.7 (95% CI, 1.1 to 2.5; P=0.009), respectively. Adjustment for the latest CD4+ count and HIV RNA level (as time-updated covariates) reduced the hazard ratio for the primary end point from 2.6 to 1.5 (95% CI, 1.0 to 2.1).

CONCLUSIONS

Episodic antiretroviral therapy guided by the CD4+ count, as used in our study, significantly increased the risk of opportunistic disease or death from any cause, as compared with continuous antiretroviral therapy, largely as a consequence of lowering the CD4+ cell count and increasing the viral load. Episodic antiretroviral therapy does not reduce the risk of adverse events that have been associated with antiretroviral therapy. (ClinicalTrials.gov number, NCT00027352 [ClinicalTrials.gov].).

The Contemplation Ladder: Validation of a measure of readiness to consider smoking cessation

Presents evidence for the validity of the Contemplation Ladder, a measure of readiness to consider smoking cessation. Analyses of data collected from more than 400 smokers at two worksites before and during a 10-month intervention indicate that Ladder scores were significantly associated with reported intention to quit, number of previous quit attempts, perceived co-worker encouragement to quit, and socioeconomic status. Ladder scores predicted subsequent participation in programs designed to educate workers about their smoking habit and its contingent risks. The Ladder did not predict biochemically validated abstinence of 24 hr or more. To assess its ability to distinguish between groups known a priori to differ in readiness, we administered the Ladder to 36 participants in a clinic-based smoking cessation program. As predicted, clinic patients scored significantly higher than the workers on the Ladder. The importance of distinguishing between smokers at the lowest stages of readiness to quit is discussed.

Design and methods of the Population Assessment of Tobacco and Health (PATH) Study

BACKGROUND

This paper describes the methods and conceptual framework for Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study data collection. The National Institutes of Health, through the National Institute on Drug Abuse, is partnering with the Food and Drug Administration's (FDA) Center for Tobacco Products to conduct the PATH Study under a contract with Westat.

METHODS

The PATH Study is a nationally representative, longitudinal cohort study of 45 971 adults and youth in the USA, aged 12 years and older. Wave 1 was conducted from 12 September 2013 to 15 December 2014 using Audio Computer-Assisted Self-Interviewing to collect information on tobacco-use patterns, risk perceptions and attitudes towards current and newly emerging tobacco products, tobacco initiation, cessation, relapse behaviours and health outcomes. The PATH Study's design allows for the longitudinal assessment of patterns of use of a spectrum of tobacco products, including initiation, cessation, relapse and transitions between products, as well as factors associated with use patterns. Additionally, the PATH Study collects biospecimens from consenting adults aged 18 years and older and measures biomarkers of exposure and potential harm related to tobacco use.

CONCLUSIONS

The cumulative, population-based data generated over time by the PATH Study will contribute to the evidence base to inform FDA's regulatory mission under the Family Smoking Prevention and Tobacco Control Act and efforts to reduce the Nation's burden of tobacco-related death and disease.

Beyond prejudice as simple antipathy: hostile and benevolent sexism across cultures

The authors argue that complementary hostile and benevolent components of sexism exist across cultures. Male dominance creates hostile sexism (HS), but men's dependence on women fosters benevolent sexism (BS)--subjectively positive attitudes that put women on a pedestal but reinforce their subordination. Research with 15,000 men and women in 19 nations showed that (a) HS and BS are coherent constructs that correlate positively across nations, but (b) HS predicts the ascription of negative and BS the ascription of positive traits to women, (c) relative to men, women are more likely to reject HS than BS, especially when overall levels of sexism in a culture are high, and (d) national averages on BS and HS predict gender inequality across nations. These results challenge prevailing notions of prejudice as an antipathy in that BS (an affectionate, patronizing ideology) reflects inequality and is a cross-culturally pervasive complement to HS.

e-Cigarette awareness, use, and harm perceptions in US adults

OBJECTIVES

We estimated e-cigarette (electronic nicotine delivery system) awareness, use, and harm perceptions among US adults.

METHODS

We drew data from 2 surveys conducted in 2010: a national online study (n = 2649) and the Legacy Longitudinal Smoker Cohort (n = 3658). We used multivariable models to examine e-cigarette awareness, use, and harm perceptions.

RESULTS

In the online survey, 40.2% (95% confidence interval [CI] = 37.3, 43.1) had heard of e-cigarettes, with awareness highest among current smokers. Utilization was higher among current smokers (11.4%; 95% CI = 9.3, 14.0) than in the total population (3.4%; 95% CI = 2.6, 4.2), with 2.0% (95% CI = 1.0, 3.8) of former smokers and 0.8% (95% CI = 0.35, 1.7) of never-smokers ever using e-cigarettes. In both surveys, non-Hispanic Whites, current smokers, young adults, and those with at least a high-school diploma were most likely to perceive e-cigarettes as less harmful than regular cigarettes.

CONCLUSIONS

Awareness of e-cigarettes is high, and use among current and former smokers is evident. We recommend product regulation and careful surveillance to monitor public health impact and emerging utilization patterns, and to ascertain why, how, and under what conditions e-cigarettes are being used.

Self-efficacy in weight management

Self-efficacy is an important mediating mechanism in advancing understanding of the treatment of obesity. This study developed and validated the Weight Efficacy Life-Style Questionnaire (WEL), improving on previous studies by the use of clinical populations, cross-validation of the initial factor analysis, exploration of the best fitting theoretical model of self-efficacy, and examination of change in treatment. The resulting 20-item WEL consists of five situational factors: Negative Emotions, Availability, Social Pressure, Physical Discomfort, and Positive Activities. A hierarchical model was found to provide the best fit to the data. Results from two separate clinical treatment studies (total N = 382) show that the WEL is sensitive to changes in global scores as well as to a subset of the five situational factor scores. Treatment programs may be incomplete if they change only a subset of the situational dimensions of self-efficacy. Theoretical and clinical implications are discussed.

The stages and processes of exercise adoption and maintenance in a worksite sample

We applied the model of the stages and processes of change to exercise adoption and maintenance. This model has shown promise in advancing theory and treatment of the addictions and other negative health behaviors, but there have been few systematic attempts to apply the model to positive health behaviors, such as exercise adoption. Questionnaires dealing with the stages and processes of exercise change were developed and administered to a sample of 1,172 participants in a worksite health promotion project. The sample was split randomly into halves for (a) initial model development and testing and (b) confirmatory measurement model testing. Additional model confirmation was obtained by examining the hierarchical structure of the processes of change and by conducting Stage x Process analyses. Results suggest that the underlying constructs derived from smoking cessation and other addictive behaviors can be generalized to exercise behavior. Understanding the stages and processes of exercise behavior change may yield important information for enhancing exercise adoption, adherence, and relapse prevention at both individual and public health levels.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

Distribution of smokers by stage in three representative samples

OBJECTIVES

A key variable for the design of individual and public health interventions for smoking cessation is Stage of Change, a variable which employs past behavior and behavioral intention to characterize an individual's readiness to change. Reactively recruited samples distort estimates of the stage distribution in the population because such samples attract a disproportionate number of late-stage participants. Three representative samples are described which provide accurate estimates of the stage distribution in the population. These samples are of adequate size to permit within-sample comparisons with respect to sex, age, Hispanic or non-Hispanic origin, race, and education level. The implications of using stage distribution as a tool for planning intervention is discussed.

METHOD

The first sample of 4,144 smokers was from the state of Rhode Island and involved a random-digit-dial survey. The second sample of 9,534 smokers was from the state of California and involved a stratified random-digit-dial survey. The third sample of 4,785 smokers was from a total of 114 worksites located in four different geographic locations.

RESULTS

The stage distributions were approximately identical across the three samples, with approximately 40% of the sample in Precontemplation, 40% in Contemplation, and 20% in Preparation. The stage distribution was generally stable across age groups with the exception of the 65 years and older group. Education level did affect the stage distribution with the proportion of the sample in Precontemplation decreasing as education level increased. In all three samples, minor differences in stage distribution were related to Hispanic origin and race, but the pattern was not consistent across the samples.

CONCLUSIONS

The pattern of stage distribution has important implications for the design of interventions. Existing interventions are most appropriate for the Preparation stage, but the majority of the three samples were in the first two stages, resulting in a likely mismatch between the smoker and the intervention. The stability of distribution across age suggests that interventions that are appropriately matched to stage can be applied across all age groups. The differences found with respect to education, Hispanic origin, and race can serve as a guide to the tailoring of intervention materials.

Interleukin-2 therapy in patients with HIV infection

BACKGROUND

Used in combination with antiretroviral therapy, subcutaneous recombinant interleukin-2 raises CD4+ cell counts more than does antiretroviral therapy alone. The clinical implication of these increases is not known.

METHODS

We conducted two trials: the Subcutaneous Recombinant, Human Interleukin-2 in HIV-Infected Patients with Low CD4+ Counts under Active Antiretroviral Therapy (SILCAAT) study and the Evaluation of Subcutaneous Proleukin in a Randomized International Trial (ESPRIT). In each, patients infected with the human immunodeficiency virus (HIV) who had CD4+ cell counts of either 50 to 299 per cubic millimeter (SILCAAT) or 300 or more per cubic millimeter (ESPRIT) were randomly assigned to receive interleukin-2 plus antiretroviral therapy or antiretroviral therapy alone. The interleukin-2 regimen consisted of cycles of 5 consecutive days each, administered at 8-week intervals. The SILCAAT study involved six cycles and a dose of 4.5 million IU of interleukin-2 twice daily; ESPRIT involved three cycles and a dose of 7.5 million IU twice daily. Additional cycles were recommended to maintain the CD4+ cell count above predefined target levels. The primary end point of both studies was opportunistic disease or death from any cause.

RESULTS

In the SILCAAT study, 1695 patients (849 receiving interleukin-2 plus antiretroviral therapy and 846 receiving antiretroviral therapy alone) who had a median CD4+ cell count of 202 cells per cubic millimeter were enrolled; in ESPRIT, 4111 patients (2071 receiving interleukin-2 plus antiretroviral therapy and 2040 receiving antiretroviral therapy alone) who had a median CD4+ cell count of 457 cells per cubic millimeter were enrolled. Over a median follow-up period of 7 to 8 years, the CD4+ cell count was higher in the interleukin-2 group than in the group receiving antiretroviral therapy alone--by 53 and 159 cells per cubic millimeter, on average, in the SILCAAT study and ESPRIT, respectively. Hazard ratios for opportunistic disease or death from any cause with interleukin-2 plus antiretroviral therapy (vs. antiretroviral therapy alone) were 0.91 (95% confidence interval [CI], 0.70 to 1.18; P=0.47) in the SILCAAT study and 0.94 (95% CI, 0.75 to 1.16; P=0.55) in ESPRIT. The hazard ratios for death from any cause and for grade 4 clinical events were 1.06 (P=0.73) and 1.10 (P=0.35), respectively, in the SILCAAT study and 0.90 (P=0.42) and 1.23 (P=0.003), respectively, in ESPRIT.

CONCLUSIONS

Despite a substantial and sustained increase in the CD4+ cell count, as compared with antiretroviral therapy alone, interleukin-2 plus antiretroviral therapy yielded no clinical benefit in either study. (ClinicalTrials.gov numbers, NCT00004978 [ESPRIT] and NCT00013611 [SILCAAT study].)

Parental smoking and adolescent smoking initiation: an intergenerational perspective on tobacco control

OBJECTIVE

Adolescence is an important period of risk for the development of lifelong smoking behaviors. Compelling, although inconsistent, evidence suggests a relationship between parental smoking and the risk of smoking initiation during adolescence. This study investigates unresolved issues concerning the strength and nature of the association between parent smoking and offspring smoking initiation.

METHODS

We enrolled 564 adolescents aged 12 to 17, along with 1 of their parents, into the New England Family Study between 2001 and 2004. Lifetime smoking histories were obtained from parents and their adolescent offspring. Discrete-time survival analysis was used to investigate the influence of parental smoking histories on the risk of adolescent smoking initiation.

RESULTS

Parental smoking was associated with a significantly higher risk of smoking initiation in adolescent offspring. In addition, the likelihood of offspring smoking initiation increased with the number of smoking parents and the duration of exposure to parental smoking, suggesting a dose-response relationship between parental smoking and offspring smoking. Offspring of parents who had quit smoking were no more likely to smoke than offspring of parents who had never smoked. The effects of parental smoking on offspring initiation differed by sex (with a stronger effect of fathers' smoking on boys than girls), developmental period (with a stronger effect of parental smoking before the adolescent was age 13 than afterward), and residence of parents (with effects of fathers' smoking being dependent on living in the same household as the adolescent). Parental smoking was also associated with stronger negative reactions to adolescents' first cigarette, a potential marker of the risk of progression to higher levels of use.

CONCLUSIONS

Parental smoking is an important source of vulnerability to smoking initiation among adolescents, and parental smoking cessation might attenuate this vulnerability.

The efficacy of exercise as an aid for smoking cessation in women: a randomized controlled trial

BACKGROUND

Smoking prevalence rates among women are declining at a slower rate than among men.

OBJECTIVE

To determine if exercise, a healthful alternative to smoking, enhances the achievement and maintenance of smoking cessation.

METHODS

Two hundred eighty-one healthy, sedentary female smokers were randomly assigned to either a cognitive-behavioral smoking cessation program with vigorous exercise (exercise) or to the same program with equal staff contact time (control). Subjects participated in a 12-session, group-based smoking cessation program. Additionally, exercise subjects were required to attend 3 supervised exercise sessions per week and control subjects were required to participate in 3 supervised health education lectures per week. Abstinence from smoking was based on self-report, was verified by saliva cotinine level, and was measured at 1 week after quit day (week 5), end of treatment (week 12), and 3 and 12 months later (20 and 60 weeks after quit day, respectively).

RESULTS

Compared with control subjects (n = 147), exercise subjects (n = 134) achieved significantly higher levels of continuous abstinence at the end of treatment (19.4% vs 10.2%, P = .03) and 3 months (16.4% vs 8.2%, P=.03) and 12 months (11.9% vs 5.4%, P=.05) following treatment. Exercise subjects had significantly increased functional capacity (estimated VO2 peak, 25+/-6 to 28+/-6, P<.01) and had gained less weight by the end of treatment (3.05 vs 5.40 kg, P = .03).

CONCLUSIONS

Vigorous exercise facilitates short- and longer-term smoking cessation in women when combined with a cognitive-behavioral smoking cessation program. Vigorous exercise improves exercise capacity and delays weight gain following smoking cessation.

Using the stages of change model to increase the adoption of physical activity among community participants

PURPOSE

This study examined the use of the stages of change model to design an exercise intervention for community volunteers.

DESIGN

The "Imagine Action" campaign was a community-wide event incorporating the involvement of local worksites and community agencies. Community members registering for the campaign were enrolled in a six-week intervention program designed to encourage participation in physical activity.

SUBJECTS

Six hundred and ten adults aged 18 to 82 years old enrolled in the program. Seventy-seven percent of the participants were female and the average age was 41.8 years (SD = 13.8).

SETTING

The campaign was conducted in a city with a population of approximately 72,000 and was promoted throughout community worksites, area schools, organizations, and local media channels.

MEASURES

One question designed to assess current stage of exercise adoption was included on the campaign registration form as were questions about subject name, address, telephone number, birthdate, and gender.

INTERVENTION

The intervention included written materials designed to encourage participants to initiate or increase physical activity, a resource manual describing activity options in the community, and weekly "fun walks" and "activity nights."

RESULTS

A Stuart-Maxwell test for correlated proportions revealed that subjects were significantly more active after the six-week intervention. Sixty-two percent of participants in Contemplation became more active while 61% in Preparation became more active.

CONCLUSIONS

Most participants increased their stage of exercise adoption during the six-week intervention. This study provides preliminary support for use of the stages of change model in designing exercise interventions.

Knowing what to think by knowing who you are: self-categorization and the nature of norm formation, conformity and group polarization

We contrast two theoretical approaches to social influence, one stressing interpersonal dependence, conceptualized as normative and informational influence (Deutsch & Gerard, 1955), and the other stressing group membership, conceptualized as self-categorization and referent informational influence (Turner, Hogg, Oakes, Reicher & Wetherell, 1987). We argue that both social comparisons to reduce uncertainty and the existence of normative pressure to comply depend on perceiving the source of influence as belonging to one's own category. This study tested these two approaches using three influence paradigms. First we demonstrate that, in Sherif's (1936) autokinetic effect paradigm, the impact of confederates on the formation of a norm decreases as their membership of a different category is made more salient to subjects. Second, in the Asch (1956) conformity paradigm, surveillance effectively exerts normative pressure if done by an in-group but not by an out-group. In-group influence decreases and out-group influence increases when subjects respond privately. Self-report data indicate that in-group confederates create more subjective uncertainty than out-group confederates and public responding seems to increase cohesiveness with in-group - but decrease it with out-group - sources of influence. In our third experiment we use the group polarization paradigm (e.g. Burnstein & Vinokur, 1973) to demonstrate that, when categorical differences between two subgroups within a discussion group are made salient, convergence of opinion between the subgroups is inhibited. Taken together the experiments show that self-categorization can be a crucial determining factor in social influence.

Socioeconomic status over the life course and stages of cigarette use: initiation, regular use, and cessation

STUDY OBJECTIVE

To investigate the association between multiple indicators of socioeconomic status (SES) over the life course and three stages of cigarette use: initiation, regular use, and cessation.

DESIGN

Prospective birth cohort study.

SETTING

Providence, Rhode Island.

PARTICIPANTS

Subjects (n=657) aged 30 to 39 were offspring of participants in the Brown University cohort of the United States National Collaborative Perinatal Project started in 1959.

MAIN RESULTS

A significantly increased risk of smoking initiation was observed among people from lower socioeconomic backgrounds. Low SES in childhood also increased the risk for progression to regular smoking, and was associated with a reduced likelihood of smoking cessation. Progression to regular smoking and smoking persistence were also associated with lower adult SES.

CONCLUSIONS

Socioeconomic conditions over the life course accumulate to produce increased rates of smoking uptake and reduced rates of cessation among lower SES people. Addressing SES gradients in smoking will require persistent and extended intervention over multiple life stages.

High-level expression of a recombinant antibody from myeloma cells using a glutamine synthetase gene as an amplifiable selectable marker

We report a method for introducing a glutamine synthetase (GS) selectable marker into myeloma cells in which transfectants are selected by growth in a glutamine-free medium. Vector amplification can subsequently be selected using the specific inhibitor of GS, methionine sulphoximine (MSX). Using this system, DNA sequences encoding a chimeric B72.3 IgG4 antibody were expressed from hCMV-MIE promoters in NSO myeloma cells. A cell line was isolated after a single round of selection for vector amplification which contains approximately 4 copies of the vector, secretes 10-15 pg/cell/day cB72.3 antibody during exponential growth and can accumulate 560 mg/l antibody in a fed-batch air-lift fermentation system. Productivity is stable in the absence of MSX selection.

Being better by being right: subjective group dynamics and derogation of in-group deviants when generic norms are undermined

The authors predicted that derogation of group deviants depends on the extent to which in-group norms or values are validated or undermined in a social context. In Experiment 1 participants were less tolerant and derogated in-group deviants more when other in-group members opposed the norm. In Experiment 2 participants derogated in-group deviants more than out-group deviants and than noncategorized individuals, but only when normative in-group members lacked uniformity. In Experiment 3 participants derogated in-group deviants more when there was uncertainty about in-group superiority. These results are consistent with previous research on the black sheep effect (J. M. Marques, V. Y. Yzerbyt, & J. -P. Leyens, 1988) and with the model of subjective group dynamics (D. Abrams, J. M. Marques, N. J. Bown, & M. Henson, 2000; J. M. Marques, D. Abrams, D. Paez, & C. Martinez-Taboada, 1998).

Harm Minimization and Tobacco Control: Reframing Societal Views of Nicotine Use to Rapidly Save Lives

Inhalation of the toxic smoke produced by combusting tobacco products, primarily cigarettes, is the overwhelming cause of tobacco-related disease and death in the United States and globally. A diverse class of alternative nicotine delivery systems (ANDS) has recently been developed that do not combust tobacco and are substantially less harmful than cigarettes. ANDS have the potential to disrupt the 120-year dominance of the cigarette and challenge the field on how the tobacco pandemic could be reversed if nicotine is decoupled from lethal inhaled smoke. ANDS may provide a means to compete with, and even replace, combusted cigarette use, saving more lives more rapidly than previously possible. On the basis of the scientific evidence on ANDS, we explore benefits and harms to public health to guide practice, policy, and regulation. A reframing of societal nicotine use through the lens of harm minimization is an extraordinary opportunity to enhance the impact of tobacco control efforts.

Debunking myths about self-quitting: Evidence from 10 prospective studies of persons who attempt to quit smoking by themselves

This article examines data from 10 longterm prospective studies (N greater than 5,000) in relation to key issues about the self-quitting of smoking, especially those discussed by Schachter. When a single attempt to quit was evaluated, self-quitters' success rates were no better than those reported for formal treatment programs. Light smokers (20 or less cigarettes per day) were 2.2 times more likely to quit than heavy smokers. The cyclical nature of quitting was also examined. There was a moderate rate (mdn = 2.7%) of long-term quitting initiated after the early months (expected quitting window) of these studies, but also a high rate (mdn = 24%) of relapsing for persons abstinent for six months. The number of previous unsuccessful quit attempts was unrelated to success in quitting. Finally, there were few occasional smokers (slips) among successful long-term quitters. We argue that quitting smoking is a dynamic process, not a discrete event.

The Contemplation Ladder: validation of a measure of readiness to consider smoking cessation

Presents evidence for the validity of the Contemplation Ladder, a measure of readiness to consider smoking cessation. Analyses of data collected from more than 400 smokers at two worksites before and during a 10-month intervention indicate that Ladder scores were significantly associated with reported intention to quit, number of previous quit attempts, perceived co-worker encouragement to quit, and socioeconomic status. Ladder scores predicted subsequent participation in programs designed to educate workers about their smoking habit and its contingent risks. The Ladder did not predict biochemically validated abstinence of 24 hr or more. To assess its ability to distinguish between groups known a priori to differ in readiness, we administered the Ladder to 36 participants in a clinic-based smoking cessation program. As predicted, clinic patients scored significantly higher than the workers on the Ladder. The importance of distinguishing between smokers at the lowest stages of readiness to quit is discussed.

Patterns of Electronic Cigarette Use Among Adults in the United States

INTRODUCTION

Amid increasing rates of electronic cigarette (e-cigarette) use in the United States, there is an urgent need to monitor patterns of use at the population level in order to inform practice, policy and regulation. This article examines how patterns of e-cigarette use among adults differ between users and nonusers of cigarettes using the most current national data.

METHODS

We analyzed data from the 2014 National Health Interview Survey. We estimated prevalence of ever, current, and daily e-cigarette use and examined how use patterns differed by demographic subgroups and measures of cigarette smoking status that accounted for the recent availability of e-cigarettes in the US marketplace.

RESULTS

Current e-cigarette use is extremely low among never cigarette smokers (0.4%) and former smokers who quit cigarettes 4 or more years ago (0.8%). Although e-cigarette experimentation is most common among current cigarette smokers and young adults, daily use is highest among former smokers who quit in the past year (13.0%) and older adults. Compared to daily cigarette smokers, recently quit smokers were more than four times as likely to be daily users of e-cigarettes (AOR: 4.33 [95% CI: 3.08-6.09]).

CONCLUSIONS

Extremely low e-cigarette use among never-smokers and longer term former smokers suggest that e-cigarettes neither promote widespread initiation nor relapse among adults. Recognition of the heterogeneity of smokers, including the time since quitting, is critical to draw accurate conclusions about patterns of e-cigarette use at the population level and its potential for public health benefit or harm.

IMPLICATIONS

Data from 2014 National Health Interview Survey indicate that e-cigarettes have not been attracting adult non-smokers or promoting relapse in longer term former smokers. Moreover, the data are suggestive that some recent quitters may have done so with the assistance of e-cigarettes. Creating measures of smoking status that treat former smokers as a homogenous group is insufficient to assess the epidemiology of e-cigarette use and the potential impact on public health.

Patterns of tobacco use and dual use in US young adults: the missing link between youth prevention and adult cessation

Few studies address the developmental transition from youth tobacco use uptake to regular adulthood use, especially for noncigarette tobacco products. The current study uses online panel data from the Legacy Young Adult Cohort Study to describe the prevalence of cigarette, other tobacco product, and dual use in a nationally representative sample of young adults aged 18-34 (N = 4,201). Of the 23% of young adults who were current tobacco users, 30% reported dual use. Ever use, first product used, and current use were highest for cigarettes, cigars, little cigars, and hookah. Thirty-two percent of ever tobacco users reported tobacco product initiation after the age of 18 and 39% of regular users reported progressing to regular use during young adulthood. This study highlights the need for improved monitoring of polytobacco use across the life course and developing tailored efforts for young adults to prevent progression and further reduce overall population prevalence.

Educational attainment and cigarette smoking: a causal association?

BACKGROUND

Despite abundant evidence that lower education is associated with a higher risk of smoking, whether the association is causal has not been convincingly established.

METHODS

We investigated the association between education and lifetime smoking patterns in a birth cohort established in 1959 and followed through adulthood (n = 1311). We controlled for a wide range of potential confounders that were measured prior to school entry, and also estimated sibling fixed effects models to control for unmeasured familial vulnerability to smoking.

RESULTS

In the full sample of participants, regression analyses adjusting for multiple childhood factors (including socioeconomic status, IQ, behavioural problems, and medical conditions) indicated that the number of pack-years smoked was higher among individuals with less than high school education [rate ratio (RR) = 1.58, confidence interval (CI) = 1.31, 1.91]. However, in the sibling fixed effects analysis the RR was 1.23 (CI = 0.80, 1.93). Similarly, adjusted models estimated in the full sample showed that individuals with less than high school education had fewer short-term (RR = 0.40; CI = 0.23, 0.69) and long-term (RR = 0.59; CI = 0.42, 0.83) quit attempts, and were less likely to quit smoking (odds ratio = 0.34; CI = 0.19, 0.62). The effects of education on quitting smoking were attenuated in the sibling fixed effects models that controlled for familial vulnerability to smoking.

CONCLUSIONS

A substantial portion of the education differential in smoking that has been repeatedly observed is attributable to factors shared by siblings that contribute to shortened educational careers and to lifetime smoking trajectories. Reducing disparities in cigarette smoking, including educational disparities, may therefore require approaches that focus on factors early in life that influence smoking risk over the adult life span.