Incremental validity of anxiety sensitivity in terms of motivation to quit, reasons for quitting, and barriers to quitting among community-recruited daily smokers.

The present investigation examined the relationships between anxiety sensitivity and motivation to quit smoking, barriers to smoking cessation, and reasons for quitting smoking among 329 adult daily smokers (160 females; M (age) = 26.08 years, SD = 10.92). As expected, after covarying for the theoretically relevant variables of negative affectivity, gender, Axis I psychopathology, nonclinical panic attack history, number of cigarettes smoked per day, and current levels of alcohol consumption, we found that anxiety sensitivity was significantly incrementally related to level of motivation to quit smoking as well as current barriers to quitting smoking. Partially consistent with the hypotheses, after accounting for the variance explained by other theoretically relevant variables, we found that anxiety sensitivity was significantly associated with self-control reasons for quitting smoking (intrinsic factors) as well as immediate reinforcement and social influence reasons for quitting (extrinsic factors). Results are discussed in relation to better understanding the role of anxiety sensitivity in psychological processes associated with smoking cessation.     

Psychiatric disorders, familial factors, and cigarette smoking: III. Associations with cessation by young adulthood among daily smokers.

The present study examined whether lifetime psychopathology, regular smoking and psychopathology in family members, and smoking characteristics were associated with successful cessation among daily smokers. A sample of 941 young adults was interviewed for lifetime psychopathology and smoking at three time points; biological parents and siblings were interviewed once for lifetime psychopathology and regular smoking. Within the subset of 242 daily smokers with complete data, most (83%) had tried to quit at least once, although only 22% met our definition of successful cessation (no smoking during the 12 months prior to turning age 25 years). Successful cessation was positively associated with being married and having a higher household income in young adulthood, and negatively associated with lifetime major depressive disorder, elevated antisocial personality disorder symptoms, a family history of drug and alcohol use disorder, and nicotine dependence (for women but not men). Marital status, nicotine dependence (for women but not men), and male gender were significant in multivariate analyses; the effect for major depressive disorder approached significance (p=.052). None of the measures of familial smoking were associated with successful smoking cessation. In conclusion, whereas almost all Axis I disorders in our two previous papers were associated with smoking initiation and progression to daily smoking, major depressive disorder and antisocial personality disorder symptoms were the only psychiatric conditions negatively associated with successful cessation. The causal nature of the significant associations and the degree to which modification of these factors increases the probability of future smoking cessation deserve further attention.     

The effects of household and workplace smoking restrictions on quitting behaviours

OBJECTIVE: To assess the association of household and workplace smoking restrictions with quit attempts, six month cessation, and light smoking. DESIGN: Logistic regressions identified the association of household and workplace smoking restrictions with attempts to quit, six month cessation, and light smoking. SETTING: Large population surveys, United States. SUBJECTS: Respondents (n = 48,584) smoked during the year before interview in 1992-1993, lived with at least one other person, and were either current daily smokers or were former smokers when interviewed. MAIN OUTCOME MEASURES: The outcome measures were an attempt to quit during the last 12 months, cessation for at least six months among those who made an attempt to quit, and light smoking (< 15 cigarettes a day). RESULTS: Smokers who lived (odds ratio (OR) = 3.86; 95% confidence interval (CI) = 3.57 to 4.18) or worked (OR = 1.14; 95% CI = 1.05 to 1.24) under a total smoking ban were more likely to report a quit attempt in the previous year. Among those who made an attempt, those who lived (OR = 1.65, 95% CI = 1.43 to 1.91) or worked (OR = 1.21, 95% CI = 1.003 to 1.45) under a total smoking ban were more likely to be in cessation for at least six months. Current daily smokers who lived (OR = 2.73, 95% CI = 2.46 to 3.04) or worked (OR = 1.53, 95% CI = 1.38 to 1.70) under a total smoking ban were more likely to be light smokers. CONCLUSIONS: Both workplace and household smoking restrictions were associated with higher rates of cessation attempts, lower rates of relapse in smokers who attempt to quit, and higher rates of light smoking among current daily smokers.     

A prospective investigation of the impact of smoking bans on tobacco cessation and relapse

BACKGROUND AND OBJECTIVES: To examine the long term impact of workplace smoking bans on employee smoking cessation and relapse. Over three years we studied a total of 1033 current or former smokers (intervention group) employed in smoke-free hospitals and 816 current or former smokers (comparison group) employed in non-smoke-free workplaces. The design of this natural experiment is a prospective cohort study. We randomly selected both hospitals and employees from 12 strata based on hospital size and state tobacco regulations, and sampled employees in the same communities. Main outcome measures were post-ban quit ratio and relapse rate. RESEARCH DESIGN: Between groups comparisons were conducted using the Cochran-Mantel-Haenszel statistic for general association, stratified Cox proportional hazards models, and the CMH analysis of variance statistic based on ranks. McNemar's test and the sign test were used to test for changes over time within each group. RESULTS: Differences in the post-ban quit ratio were observed between intervention and comparison groups (p < or = 0.02). For employees whose bans were implemented at least seven years before survey, the post-ban quit ratio was estimated at 0.256, compared with 0.142 for employees in non-smoke-free workplaces (p = 0.02). After controlling for a variety of factors, time to quit smoking was shorter for the hospital employees (p < 0.001), with an overall relative risk of quitting of 2.3. Contrary to expectations, relapse rates were similar between the groups. CONCLUSION: Employees in workplaces with smoking bans have higher rates of smoking cessation than employees where smoking is permitted, but relapse is similar between these two groups of employees. The results of this investigation have international applicability for policy makers, clinicians, employers, and employees. Countries should review smoking policies in workplaces in light of their own smoking patterns and efforts to deal with environmental tobacco smoke.     

Ad lib smoking in post-traumatic stress disorder: an electronic diary study

Using ambulatory methods for 1 week of monitoring, this study investigated the association between smoking and situational cues in 22 smokers with post-traumatic stress disorder (PTSD) and 23 smokers without PTSD. Generalized estimating equations contrasted 1,759 smoking and 1,088 nonsmoking situations by group status controlling for multiple covariates. PTSD smokers reported higher stress and PTSD symptoms across daily activities. For all smokers, higher nicotine dependence, craving, food and caffeine consumption, and being outside were related to smoking. PTSD smokers were more likely to smoke when experiencing PTSD symptoms, anxiety, and stress. Following smoking, smokers with PTSD reported a significant reduction in negative affect. These results are consistent with previous ambulatory findings regarding mood in smokers, and underscore that in smokers with PTSD, PTSD symptom variables as well as stress and anxiety are significantly associated with ad lib smoking.     

Ecological momentary assessment of adolescent smoking cessation: a feasibility study.

Attempts to quit smoking by adolescents typically fail, even when aided by psychosocial and pharmacological treatments. Gaining a better understanding of the process of smoking cessation and relapse in this population could lead to improved treatments and increases in cessation rates. Ecological momentary assessment (EMA) has been used to describe the relapse process among adults, but not among adolescents. This study examined the feasibility of using EMA to examine relapse among adolescent smokers. Participants (N = 13) used a hand-held computer for 3 weeks to report on their smoking behavior, affect state, and exposure to smoking cues during a quit attempt (7 days prequit, 14 days postquit). All of the participants recorded a quit attempt and at least one lapse during the monitoring interval. Compliance with the protocol was generally high but decreased slightly over time. As with adults, evidence indicated that lapses were associated with craving, negative affect, and smoking cues. These data support the feasibility and potential value of using EMA with adolescent smokers.     

Tobacco craving predicts lapse to smoking among adolescent smokers in cessation treatment.

Previous research indicates that tobacco craving predicts relapse to smoking among adult smokers attempting to quit. We hypothesized a similar relationship between craving and lapse (any smoking following a period of abstinence) among adolescent smokers during the treatment phase of a clinical trial. A visit was considered a lapse visit if the participant reported smoking or had a carbon monoxide level of 7 ppm or greater subsequent to an abstinent visit. A total of 34 participants (mean age = 14.9 years [SD = 1.3]; mean cigarettes/day = 18.0 [SD = 7.6]; mean Fagerstr?m Test for Nicotine Dependence score = 6.8 [SD = 1.34]; 65% female), were included in the present analysis of 167 treatment visits. Logistic regression analyses showed a positive relationship between degree of craving, measured by the Questionnaire on Smoking Urges, and lapse during smoking cessation treatment (p = .013). Additionally, linear regression analyses demonstrated a strong positive association between cigarettes smoked per day and craving scores (p<.001). Taken together with other data, these findings suggest that degree of craving might influence tobacco abstinence for adolescent smokers. Thus monitoring and addressing craving appears useful to increase the success of adolescent smoking cessation.     

Post-traumatic stress disorder and smoking: a systematic review.

We conducted a systematic review of what is known about the relationship between post-traumatic stress disorder (PTSD) and smoking to guide research on underlying mechanisms and to facilitate the development of evidence-based tobacco treatments for this population of smokers. We searched Medline, PsychINFO, and the Cochrane Central Register of Controlled Trials and identified 45 studies for review that presented primary data on PTSD and smoking. Smoking rates were high among clinical samples with PTSD (40%-86%) as well as nonclinical populations with PTSD (34%-61%). Most studies showed a positive relationship between PTSD and smoking and nicotine dependence, with odds ratios ranging between 2.04 and 4.52. Findings also suggest that PTSD, rather than trauma exposure itself, is more influential for increasing risk of smoking. A small but growing literature has examined psychological factors related to smoking initiation and maintenance and the overlapping neurobiology of PTSD and nicotine dependence. Observational studies indicate that smokers with PTSD have lower quit rates than do smokers without PTSD. Yet a few tobacco cessation treatment trials in smokers with PTSD have achieved quit rates comparable with controlled trials of smokers without mental disorders. In conclusion, the evidence points to a causal relationship between PTSD and smoking that may be bidirectional. Specific PTSD symptoms may contribute to smoking and disrupt cessation attempts. Intervention studies that test behavioral and pharmacological interventions designed specifically for use in patients with PTSD are needed to reduce morbidity and mortality in this population.     

Preliminary examination of tobacco withdrawal in adolescent smokers during smoking cessation treatment

Tobacco withdrawal symptoms have been shown to play a significant role in mediating relapse to smoking in adult smokers; however, few prospective studies have examined the course of tobacco withdrawal symptoms over time and their connection to lapse in adolescent smokers. Withdrawal symptoms were assessed weekly for 4 weeks in a sample of adolescent smokers participating in a pilot cessation intervention. Adolescent smokers experienced an exacerbation in overall withdrawal symptoms, particularly of cravings and restlessness, although symptoms were generally mild. The course of symptoms was different for boys and girls: Girls generally experienced a peak and subsequent decline in symptoms early in the establishment of abstinence, whereas boys experienced a constant level of symptoms that did not decline over the 4 weeks. Finally, withdrawal symptoms experienced on quit day were not related to lapse to smoking during the course of treatment for either boys or girls. These results suggest that although withdrawal symptoms may be uncomfortable, they may not be the most salient to a lapse to smoking for adolescent smokers attempting to quit. These findings have direct implications for the design and implementation of treatment of nicotine dependence in adolescent smokers.     

The role of impulsivity on smoking maintenance.

In order to better understand why those higher in impulsivity experience more difficulties during smoking abstinence, the current study examined the possible mechanisms contributing to cigarette smoking relapse. Fifty dependent cigarette smokers completed measures designed to assess craving, tobacco withdrawal severity, and negative affect during 48 hours of nicotine abstinence. Using a series of multilevel models (SAS Proc Mixed Procedure), significant impulsivity x time analyses revealed differences in craving, F(2, 96) = 3.74, p<.05, and anxiety, F(2, 96) = 3.23, p<.05. Simple slopes analyses indicated that heightened trait-impulsivity predicted greater increases in craving and anxiety during a 48-hour abstinence period. These findings suggest that smokers with higher levels of impulsivity may lack the ability to find an accessible and comparable substitute for cigarette smoking during a cessation attempt. This study also highlights the importance of considering individual differences when treating those who wish to quit smoking.     

Anxiety sensitivity and smoking motives and outcome expectancies among adult daily smokers: replication and extension.

The present investigation examined the incremental validity of anxiety sensitivity in the context of distress intolerance in terms of predicting smoking motives and outcome expectancies. Participants were a community sample of 144 daily smokers (85 women, M (age) = 29.72 years, SD = 11.96). Results indicated that above and beyond discomfort intolerance, Axis I diagnoses, gender, volume of alcohol consumption, and average number of cigarettes smoked per day, anxiety sensitivity significantly incrementally predicted habitual, addictive, and negative affect reduction motives to smoke, as well as negative reinforcement outcome expectancies. No such incremental effects were similarly evident for distress intolerance. Findings are discussed in relation to the role of anxiety sensitivity in smoking motives and outcome expectancies.     

The return to smoking: 1-year relapse trajectories among female smokers.

Research has demonstrated that a lapse in cigarette abstinence often leads smokers to fully relapse (i.e., return to daily smoking). However, patterns of smoking resumption beyond the point at which relapse occurs have not been examined in systematic follow-up studies. Daily cigarette intake data for 108 female adult smokers who participated in a smoking cessation trial were recorded at several points during the 365 days following the participants' quit date. SAS Proc Traj, a group-based mixture modeling procedure, was used to determine cigarette-use trajectories over time (i.e., patterns of smoking resumption). Over the 365 days, 27% of the sample maintained abstinence. Among the 73% who relapsed, four distinct trajectories emerged: low-level users (8% of the overall sample), moderate users (17%), slow-returners (15%), and quick-returners (33%). A few individual characteristics differentiated these groups. Overall, the findings illustrate that, after relapsing, smokers do not follow a unitary course of smoking resumption; rather, they exhibit more variable resumption patterns than previously assumed.     

Tobacco use and readiness to quit smoking in low-income HIV-infected persons.

The study aim was to identify covariates of smoking status and readiness to quit that encompassed key sociodemographic and health status variables, health-related quality of life, drug use and unprotected sex, and tobacco use variables in a cohort of low-income persons living with HIV. We also examined the impact of HIV diagnosis on smoking cessation. The sample (N = 428) was mostly male (59%) and Black (53%) or Hispanic (30%), and had a high school education or less (87%). Mean age was 40 years. Two-thirds of participants were current smokers, 19% former smokers, and 16% never smokers. Current smokers smoked a mean of 16 cigarettes/day for 22 years; 42% were in the precontemplation stage of readiness to quit smoking, 40% were contemplators, and 18% were in preparation. Most current smokers (81%) reported receiving medical advice to quit smoking. Multivariate logistic regression analyses indicated that current smokers, compared with former smokers, were more likely to use illicit drugs, perceive a lower health risk for continued smoking, and report less pain. Current smokers, compared with nonsmokers (former and never smokers), were more likely to report greater illicit drug use in their lifetime, current illicit drug use, and less pain. A multiple linear regression indicated that greater current illicit drug use, greater emotional distress, and a lower number of quit attempts were associated with lower stage of readiness to quit smoking. These findings confirm a high prevalence of smoking among HIV-infected persons and suggest a complex interplay among drug use, pain, and emotional distress that impact smoking status and, among smokers, readiness to quit. Tobacco control programs for HIV-infected persons should build motivation to quit smoking and address salient barriers to cessation--such as comorbid drug use, emotional distress, pain, and access to and coverage for treatment--and should educate smokers regarding the HIV-specific health benefits of cessation.     

Association of post-treatment smoking change with future smoking and cessation efforts among adolescents with psychiatric comorbidity.

Little is known about how initial change following a smoking intervention relates to longer-term smoking outcomes among adolescent smokers with psychiatric comorbidity. The present study investigated this relationship among psychiatrically hospitalized adolescents (N = 183) who participated in a controlled trial comparing motivational interviewing to brief advice. Quit attempters (n = 37), reducers (n = 45), and maintainers (n = 101) were assembled based on, respectively, having made a quit attempt, having reduced smoking by at least 50%, and having reduced smoking by less than 50% in the first week after hospital discharge. Hierarchical linear models and generalized estimating equations were conducted to test group differences in average number of cigarettes per smoking day and odds of making a quit attempt during subsequent weeks of a 12-month continuous follow-up, and in cotinine-verified abstinence rates at 1, 6, and 12 months posthospitalization. Baseline smoking levels and presence of a substance use disorder or anxiety disorder were predictive of outcomes. After controlling for covariates, we found that quit attempters smoked less during follow-up than did the other change groups and that reducers smoked less than maintainers. Quit attempters evidenced a higher percentage of quit attempts during follow-up than did the other change groups. Reducers had a greater average percentage of quit attempts during follow-up than did maintainers. However, groups did not differ on cotinine-verified abstinence rates across the follow-up period. Findings have implications for initial post-treatment change as it relates to subsequent smoking and cessation outcomes among adolescent smokers at especially high risk for smoking persistence.     

The impact of carotid plaque screening on motivation for smoking cessation.

Showing smokers their own atherosclerotic plaques might increase motivation for smoking cessation, since they underestimate their own risk for smoking-related diseases. To assess the feasibility and optimal processes of studying the impact of carotid atherosclerotic plaque screening in smokers, we enrolled 30 daily cigarette smokers, aged 40-70 years, in an observational pre-post pilot study. All smokers underwent smoking cessation counseling, nicotine replacement therapy, a carotid ultrasound, an educational tutorial on atherosclerosis, baseline and 2-month motivation to change assessment, and assessment of smoking cessation at 2 months. Participants had a mean smoking duration of 34 years (SD = 7). Carotid plaques were present in 22 smokers (73%). Between baseline and 2 months after plaque screening, motivation for smoking cessation increased from 7.4 to 8.4 out of 10 (p = .02), particularly in those with plaques (7.2 to 8.7, p = .008). At 2 months, the smoking quit rate was 63%, with a quit rate of 73% in those with plaques vs. 38% in those without plaques (p = .10). Perceived stress, anxiety, and depression did not increase after screening. 96% of respondents answered correctly at least 80% of questions regarding atherosclerosis knowledge at baseline and after 2 months. In conclusion, studying the process of screening for carotid plaques for the purpose of increasing motivation for smoking cessation, in addition to counseling and drug therapy for smoking cessation in long-term smokers, appears feasible. The impact of carotid plaque screening on smoking cessation should be examined in larger randomized controlled trials with sufficient power to assess the impact on long-term smoking cessation rates.     

Efficacy of the nicotine inhaler in smoking reduction: A double-blind, randomized trial.

Many smokers are not ready to quit but are interested in changing their smoking behavior, particularly if such a change is associated with a reduction in health risk. The present study evaluated the efficacy of the nicotine inhaler in reducing smoking. Exploratory studies assessed whether reduction in smoking was associated with reduction in markers of disease risk. A total of 429 healthy smokers (smoking at least 20 cigarettes/day) were randomly assigned to either nicotine-containing or placebo inhalers, which subjects were allowed to use ad libitum for up to 1 year. The nicotine inhaler was significantly superior to placebo in achieving reduction in daily cigarette consumption by at least 50% after 4 months, compared with baseline (18% vs. 8%, p = .004). Active treatment promoted smoking cessation: 8% of subjects in the nicotine group and 1% in the placebo group were abstinent at month 15. Throughout the study, smoking reduction, per se, independent of treatment group, was associated with a statistically significant decrease in exhaled carbon monoxide and serum cotinine and thiocyanate. Smoking reduction also improved established risk markers for cardiovascular disease over 4 months. The incidence of adverse events did not differ significantly between the active and placebo groups. The most common treatment-related adverse events were throat irritation and cough. In conclusion, the nicotine inhaler can help smokers who are unable or unwilling to quit to reduce daily cigarette consumption, which may be a health benefit on its own and may further promote quitting.     

Is the association of smoking and depression a recent phenomenon?

Part of the hardening hypothesis to explain the persistence of smoking-despite powerful antismoking forces-links smoking with psychopathology, especially depression. It has been proposed that the association between depression and smoking has emerged in more recent cohorts as smoking rates declined, disproportionately leaving among current smokers those who found it more difficult to quit because of their psychopathology. We examined the association of regular smoking and depression in a cohort who began smoking prior to the decline in smoking rates in the United States and assessed a corollary hypothesis that smokers with depression were more likely to persist in smoking than were those without depression. Data were from the Wisconsin Longitudinal Study of a random sample of high school graduates from the class of 1957. In the 1992 follow-up, a subset of these 53-54-year-olds were assessed for lifetime and current depression and smoking (n = 4,858). A modest association between regular smoking and depression was found (OR = 1.4, 95% CI = 1.2-1.6); persistence of smoking (current smoking among ever regular smokers) was unrelated to single-episode or recurrent depression (OR = 1.1, 95% CI = 0.8-1.5). The results do not support the proposition that the association between smoking and depression emerged when smoking rates declined, or that self-medication of depression through smoking is a likely mechanism for the persistence of smoking.     

Effect of an eight week smoking ban on women at US navy recruit training command

OBJECTIVE: To examine the effect of a unique organisational smoking ban on female United States Navy recruits, a population with historically high smoking rates. SETTING AND DESIGN: Study participants were female recruits (n = 5503) entering the Navy recruit training command between March 1996 and March 1997 (12 consecutive months). Participants completed smoking surveys at entry to recruit training (baseline) and again at graduation from training after exposure to an eight week, 24 hour a day smoking ban. Effects of the ban on baseline to graduation changes in perceptions of being a smoker were examined, and relapse rates among baseline ever smokers was assessed three months after leaving recruit training. RESULTS: Among all recruits, 41.4% reported being smokers at entry (that is, reported any smoking in the 30 days before entering recruit training). As a result of the ban, there was a significant reduction (from about 41% to 25%, p < 0.001) in the percentage of all women recruits who reported themselves as smokers, a much larger change than expected had no ban been in place. Relapse at the three month follow up varied according to the type of smoker at entry into the Navy, with rates ranging from 89% relapse among baseline daily smokers to 31% among baseline experimenters. CONCLUSIONS: Findings suggest that the ban provides some smokers who desire to quit with an external impetus and support to do so. However, high relapse rates indicate that more than an organisationally mandated smoking ban during recruit training is needed to help younger smokers, more regular smokers, and those who intend to continue smoking to quit after joining the Navy.     

Use of the current population survey to characterize subpopulations of continued smokers: a national perspective on the "hardcore" smoker phenomenon.

The existence of "hardcore" smokers, those most likely to have substantial difficulty quitting, may have far reaching impact on how to best allocate cessation resources. It has been suggested that hardcore smokers make up only a small fraction of current smokers and therefore do not represent a significant public health problem. However, little is known about the prevalence and nature of this subgroup of smokers in the United States. Based on a national sample, the 1998-1999 Tobacco Use Supplement to the Current Population Survey, we categorized, based on smoking pattern, groups of current smokers who were over age 25 years (N=33,568). We compared hardcore smokers with other groups of current smokers on demographic, environmental, and smoking variables to assess whether hardcore smokers represent a unique group. Hardcore smokers were defined as established daily smokers, consuming 15 or more cigarettes per day with no reported history of quit attempts. Hardcore smokers represent 13.7% of all current smokers and 17.6% of all established smokers. They are more likely to be male, unmarried, not in the work force, and have lower education. They also are more likely to have started smoking at a younger age, smoke more, and are less likely to report contact with smoking restrictions. This analysis suggests that hardcore smokers are distinct from other groups of smokers. These results also indicate that hardcore smokers account for a substantial proportion of smokers and as such may represent a significant public health challenge that needs to be addressed.     

Prevalence of smoking and its relationship with carotid atherosclerosis in Alaskan Eskimos of the Norton Sound region: the GOCADAN study.

Since 2000, the Genetics of Coronary Artery Disease in Alaska Natives (GOCADAN) study has been collecting information on cardiovascular disease (CVD) and its risk factors from 1,214 Alaska Natives of the Norton Sound region, a population with increasing rates of heart disease and stroke. Because smoking was reported in a large proportion of the participants, this analysis was undertaken to evaluate smoking patterns and their relation to other risk factors and to CVD. The relationships among smoking habits and demographic factors, body mass index, plasma fibrinogen, prevalent hypertension, and carotid plaque were evaluated. Eighty percent of participants had smoked 100+ cigarettes in their lifetime. Fifty-seven percent of women and 63% of men (p = .12) were current smokers: one in four smokers had quit. Current smokers (OR = 2.1; 95% CI = 1.1-3.8) and those who had quit <5 years ago (OR = 1.6; 95% CI = 1.1-2.2) were more likely than non-smokers to have carotid plaque. Pack-years smoked also were correlated with carotid plaque. The high prevalence of smoking and low rates of cessation in this population demonstrate an urgent need for smoking prevention and cessation programs among Alaskan Eskimos of the Norton Sound region and other Alaska Native groups.