Observed smoking in cars: a method and differences by socioeconomic area

Objectives

To establish a reproducible method to estimate he point prevalence of smoking and second‐hand smoke (SHS) exposure in cars, and to compare this prevalence between two areas of contrasting socioeconomic status.

Method

A method involving two teams of observers was developed and evaluated. It involved observing 16 055 cars in Wellington, New Zealand. Two of the observation sites represented a high and a low area of deprivation (based on a neighbourhood deprivation index) and three were in the central city.

Results

A 4.1% point prevalence of smoking in cars was observed (95% confidence interval (CI) 3.8% to 4.4%). There was a higher prevalence of smoking in cars in the high deprivation area relative to the other sites, and particularly compared to the low deprivation area (rate ratio relative to the latter 3.2, 95% CI 2.6 to 4.0). Of cars with smoking, 23.7% had other occupants being exposed to SHS. Cars with smoking and other occupants were significantly more likely to have a window open (especially if the smoker was not the driver). The observation method developed was practical, and inter‐observer agreement was high (κ value for the “smoking seen in car” category 0.95).

Conclusions

Observational studies can be an effective way of investigating smoking in cars. The data from this survey suggest that smoking in cars occurs at a higher rate in relatively deprived populations and hence may contribute to health inequalities. Fortunately, there are a number of policy options for reducing SHS exposure in cars including mass media campaigns and laws for smoke‐free cars.     

Instructed smoking expectancy modulates cue-elicited neural activity: a preliminary study.

In recent years, research applying functional neuroimaging to the study of cue-elicited drug craving has emerged. This research has begun to identify a distributed system of brain activity during drug craving. A review of this literature suggested that expectations regarding the opportunity to use a drug affected the pattern of neural responses elicited by drug cues. Using functional magnetic resonance imaging (fMRI), we examined the effects of smoking expectancy on the neural response to neutral (e.g., roll of tape) and smoking-related (a cigarette) stimuli in male cigarette smokers deprived of nicotine for 8 hr. As predicted, several brain regions (e.g., the anterior cingulate cortex) exhibited differential activation during cigarette versus neutral cue exposure. Moreover, we found that subregions of the prefrontal cortex (i.e., ventromedial, ventrolateral, and dorsolateral prefrontal cortices) showed cue-elicited activation that was modulated by smoking expectancy. These results highlight the importance of perceived drug use opportunity in the neurobiological response to drug cues.     

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.     

Mortality attributable to cigarette smoking in Taiwan: a 12-year follow-up study

BACKGROUND—Assessment of the impact of cigarette smoking on mortality helps to indicate the importance of tobacco control in a given country.
OBJECTIVES—To examine the relative risk of dying from various diseases for cigarette smoking and to estimate annual mortality attributable to cigarette smoking in Taiwan.
DESIGN—Prospective cohort study.
SUBJECTS AND SETTING—A cohort of 14 397 male and female residents aged 40 years or older recruited from 12 townships and precincts in Taiwan from 1982 to 1986. Information on cigarette smoking was collected from each subject at local health centres through a standardised personal interview based on a structured questionnaire. They were followed up regularly to determine their vital status until 1994.
MAIN OUTCOME MEASURES—Cox's proportional hazards regression models were used to derive relative risks of cause-specific mortality for current cigarette smokers compared with never-smokers, and to examine dose-response relationships between mortality from various causes and several measures of cigarette smoking (daily consumption, duration, age of initiation, and cumulative smoking in pack-years).
RESULTS—A total of 2552 persons died during the study period. Among men, cigarette smoking was significantly associated with an increased risk of dying from all causes combined (relative risk (RR) = 1.3); cancer of all sites combined (RR = 1.5); cancers of the stomach (RR = 1.9), liver (RR = 2.2), and lung (RR = 3.7); ischaemic heart disease (RR = 1.8); other heart diseases (RR = 1.4); and chronic obstructive pulmonary disease (RR = 1.9). Among women, cigarette smoking was significantly associated with an increased risk of dying from all causes combined (RR = 1.8), cancer of the lung (RR = 3.6), and peptic ulcer (RR = 17.8). The estimated number of deaths attributable to cigarette smoking in Taiwan in 1994 was 8161 (13.9% of total deaths) for men and 1216 (3.3% of total deaths) for women. In the same year cigarette smoking caused 21.3% and 2.9% of cancer deaths in men and women, respectively, in Taiwan.
CONCLUSIONS—Cigarette smoking has a striking impact on overall mortality and deaths from various causes in the Taiwanese population. Tobacco control should be established as the top priority in public health programmes in Taiwan.


Keywords: mortality; smoking-attributable diseases; Taiwan     

Parental smoking cessation and children's smoking: mediation by antismoking actions.

The present study investigated whether parents' antismoking actions mediated the prospective relationship between parental smoking cessation and children's smoking. Smoking status of parents (predictor) was assessed when their children were in 3rd grade, parental antismoking actions (mediators) were assessed when their children were in 11th grade, and children's smoking status (outcome) was assessed when they were in 12th grade. In 20 Washington state school districts, data were collected from 1,600 children (49% female, 91% White) and from their parents. Results showed that children's odds of daily smoking were reduced by 39% (95% CI = 24%-51%) for those whose parents had quit smoking, compared with those whose parents were current smokers. Asking to sit in nonsmoking sections of public establishments was a significant (p<.01) mediator that explained 64% of the association between parental smoking cessation and children's smoking. However, not allowing smoking in the home and asking others not to smoke around them were not significant mediators (p = .10, and p = .06, respectively). In conclusion, asking to sit in a nonsmoking section of a public establishment substantially mediates the relationship between parental smoking cessation and children's smoking.     

Personality and smoking status: a meta-analysis.

We used meta-analytic techniques in an attempt to clarify the strength and direction of the association between smoking status and personality, which narrative reviews have indicated remains a largely inconsistent literature. Included were cross-sectional studies that reported personality data for healthy, adult smokers and nonsmokers using measures of personality traits derived from Eysenck's tripartite taxonomy of human personality. Of the 25 studies that contributed to the meta-analysis, 22 reported data on smoking status and extraversion and 22 reported data on smoking status and neuroticism. Meta-analysis using a fixed-effects framework indicated a significant difference between smokers and nonsmokers on both extraversion (p<.001) and neuroticism (p<.001) traits, which remained significant when a random-effects framework was used to accommodate significant between-study heterogeneity. These data from cross-sectional observational studies published between 1972 and 2001 indicate that both increased extraversion and increased neuroticism are associated with an increased likelihood of being a smoker rather than a nonsmoker, although in both cases the effect sizes indicated by the meta-analysis were small. We found no evidence that the strength of these associations varied with year of publication.     

Nortriptyline for smoking cessation: a review.

This article reviews the efficacy of nortriptyline for smoking cessation based on a meta-analysis of the Cochrane Library. Six placebo-controlled trials have shown nortriptyline (75-100 mg) doubles quit rates (OR = 2.1). Between 4% and 12% of smokers dropped out because of adverse events, but no serious adverse events occurred. The efficacy of nortriptyline did not appear to be related to its antidepressant actions. Nortriptyline is an efficacious aid to smoking cessation with a magnitude of effect similar to that for bupropion and nicotine replacement therapies. Whether nortriptyline produces serious side effects at these doses in healthy, nondepressed smokers remains unclear because it has been tested in only 500 smokers. The finding that nortriptyline and bupropion are effective for smoking cessation but that selective serotonin-reuptake inhibitors are not suggests that dopaminergic or adrenergic, but not serotonergic, activity is important for cessation efficacy. Until further studies can verify a low incidence of significant adverse events, nortriptyline should be a second-line treatment for smoking cessation.     

Rural adolescent attitudes toward smoking and weight loss: relationship to smoking status.

Perceptions that smoking contributes to weight loss are widespread among youth. We examined the association between weight loss and smoking to determine whether supportive attitudes were associated with smoking status and whether this is a particular problem in rural areas. High school students (N=730) completed a survey assessing smoking-related characteristics and behaviors. Attitudes assessed included perceptions of whether weight concerns were the reasons others smoke and personal beliefs about tobacco's effect on weight gain. Smoking status was categorized as never (44%), experimental (42%), and current (14%). Multinomial logistic regressions investigated relationships between attitudes and smoking, adjusting for weight goals, gender, ethnicity, parent/peer smoking, and body mass index. Both attitudinal measures were associated with smoking (p< .05). Nonsmokers and experimental smokers were more likely than current smokers to believe that people smoke to lose weight. Although current smokers were less likely to report that others smoke for weight control, they believed they would gain weight if they quit. Conversely, nonsmokers and experimental smokers were less likely to believe they would gain weight if they do not smoke compared with current smokers. Thus personal attitudes differ from attitudes toward others with respect to weight loss and smoking. Moreover, endorsement of these attitudes can reliably distinguish current versus experimental smokers and may help better clarify the transition to current smoker. Because weight concerns are a significant factor in youth smoking, these issues should be included in intervention efforts, particularly in rural communities where smoking rates are higher and age at initiation is earlier.     

Reconsidering stress and smoking: a qualitative study among college students

Background

Although it is widely acknowledged among adult smokers that increases in smoking are often precipitated by stressful events, far less attention has been given to smoking during times of stress among youth.

Aims

To address this gap by drawing attention to the social utility of smoking in contexts associated with stress among college students.

Design

Face‐to‐face semistructured interviews with college freshmen at a large midwestern university in the US.

Participants

Male and female low‐level smokers (n = 24), defined as those who reported regular weekday smoking (typically 3–4 cigarettes a day) and smoking at parties on weekends, were interviewed once in person. In addition, 40 brief interviews with smokers were conducted during final examination.

Measurements

Interviews focused on a range of issues including current smoking behaviour and reasons for smoking. As part of the interview, students were given a deck of cards that listed a range of reasons for smoking. Participants were asked to select cards that described their smoking experience in the past 2 weeks. Those who selected cards that indicated smoking when stressed were asked to explain the reasons why they did so.

Results

A review of qualitative responses reveals that smoking served multiple functions during times of stress for college students. Cigarettes are a consumption event that facilitates a brief social interaction during study times when students feel isolated from their friends. Cigarettes also serve as an idiom of distress, signalling non‐verbally to others that they were stressed. Students described smoking to manage their own stress and also to help manage “second‐hand stress” from their friends and classmates.

Conclusions

Moving away from an individual‐focused analysis of stress to a broader assessment of the social contexts of smoking provides a more nuanced account of the multifunctionalilty of cigarettes in students'' lives. Qualitative research draws attention to issues including the need for smoking and socialising during examination time, smoking as a way to take a break and refocus, notions of second‐hand stress and smoking to manage social relationships.In the past decade, several US‐based studies have reported significant levels of smoking among college students, with approximately 30% of college students reporting having smoked in the past 30 days, and 40% reporting having smoked in the past year.^1,2 Studies have found that a majority of college students who smoke are social smokers, meaning that they smoke more often with others than when alone, particularly when drinking, and that they smoke at low levels.^3,4 To understand better the patterns of low‐level tobacco use, qualitative research was conducted to examine closely the contexts in which students smoked. It has been suggested that a better understanding of the social context of smoking may help enhance tobacco control research and practice.⁵ Two broad contexts that begged consideration were positive social contexts in which tobacco use occurred (such as parties where alcohol was consumed), and contexts associated with stress, be this stressful life events (such as the taking of exams) or stressful events related to the management of social relationships and shifts in identity at this time of transition in life.This article highlights major findings of qualitative research on smoking in contexts associated with stress among college students. It is well established in the general population that increases in smoking are often precipitated by stressful events.^6,7 We draw attention to the social utility of smoking in contexts associated with stress, acknowledging that tobacco use also has psychological and physiological effects when used as a form of stress management and self‐medication.Three major issues guided the research: (1) to explore the extent to which students use smoking as a multifunctional tool for stress management; (2) to determine whether students use smoking as an idiom of distress and a means of showing empathy when a friend is under stress; and (3) to provide details on the complex of motivations that lead students to smoke during examination time.     

The effectiveness of smoking cessation interventions prior to surgery: a systematic review.

The objective of this review was to evaluate the effectiveness of smoking cessation interventions prior to surgery and examine smoking cessation rates at 6 months follow-up. The Cochrane Library Database, PsycINFO, EMBASE, Medline, and Cinahl databases were searched using the terms: smok$, smoking cessation, tobacco, cigar$, preop$, operati$, surg$, randomi*ed control$ trial, intervention, program$, cessation, abstinen$, quit. Further articles were obtained from reference lists. The search was limited to articles on adults, written in English and published up to December 2006. Only randomized control trials (RCTs) that incorporated smoking cessation interventions to patients awaiting elective surgery were included. Seven studies met the inclusion criteria. Methodological quality was assessed by all the authors. The findings revealed that short-term quit rates (or a reduction by more than half of normal daily rate) ranged from 18% to 93% in patients receiving a smoking intervention (mean 55%), compared with a range of 2%-65% of controls (mean = 27.7%). Two studies examined smoking status at 6 months but these revealed no significant difference in abstinence rates between patients who had received an intervention and those that had not. Studies that incorporated counseling in addition to nicotine replacement therapy appeared to show greater benefits. It is concluded that smoking cessation interventions prior to surgery are effective in helping patients to quit smoking. However, such effects appear to be short-lived. Future research needs to examine intervention and patient factors to see whether tailoring the smoking cessation intervention specifically to the patient improves overall abstinence rates.     

Personality and smoking status: a longitudinal analysis.

We attempted to clarify the strength and nature of the association between personality and smoking status in early and middle adulthood, using a longitudinal study design. Data from the Medical Research Council National Survey of Health and Development, based on a stratified sample of all single, legitimate births occurring in England, Wales, and Scotland in one week of March 1946 (N = 5,362), were analyzed using generalized estimating equations methods to account for the correlation between the smoking status variables for the same individual over time. The unadjusted estimates indicated that the odds of being a current smoker increased with higher personality score for both extraversion (p<.0001) and neuroticism (p<.0001) traits. Sex was significantly associated with being a current smoker (p<.0001), with males more likely than females to be current smokers. Current smoking decreased with increasing age (p<.0001). These relationships were maintained in the fully adjusted model. These data indicate that both higher levels of extraversion and higher levels of neuroticism, as measured at age 16, are independently associated with an increased likelihood of subsequently being a current smoker rather than a nonsmoker at all time points, although the observed effect sizes were small. Males also were more likely than females to be current smokers, and increasing age reduced the likelihood of being a current smoker, which is consistent with an attempt by a subset of smokers in the cohort to subsequently stop smoking.     

Efficacy of naltrexone in smoking cessation: a preliminary study and an examination of sex differences.

This double-blinded, placebo-controlled trial evaluated the efficacy of naltrexone as an adjunct to standard smoking cessation treatment. Participants (N = 110) were adult male and female nicotine-dependent smokers who expressed interest in quitting smoking. All subjects received six sessions of behavioral counseling (1 hr/session for 6 weeks), and 1 month of the nicotine patch (21 mg for the first 2 weeks, 14 mg the third week, 7 mg the fourth week). Subjects were randomly assigned to the naltrexone or placebo group. The naltrexone group started at 25 mg daily for 3 days prior to the quit date, and increased to 50 mg/day on the quit date and following 8 weeks. At the end of medication treatment, the naltrexone group had better quit rates versus the placebo group (48% quit on naltrexone vs. 41% on placebo), but this difference was not statistically significant. However, men and women differed on several measures: in the placebo group, women had significantly lower quit rates than men (39% vs. 67%, p<.05), but in the naltrexone group, women had quit rates comparable with those of men (58% vs. 62%, p = ns). Further examination revealed that naltrexone significantly reduced men's and women's cessation-related weight gain and selectively reduced women's urge to smoke to relieve negative affect and withdrawal. The results suggest continued examination of naltrexone as an adjunct in smoking cessation, particularly in female smokers, who have historically shown worse outcomes with traditional treatment methods.     

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.     

Ethnic differences in predictors of adolescent smoking onset and escalation: a longitudinal study from 7th to 12th grade.

The present study sought to determine whether risk factors for cigarette smoking onset have a stronger influence on Black versus White children, and whether those patterns differ for nonsmokers versus experimental smokers. As part of a larger study, 5,213 seventh graders were surveyed annually for 5 years. The survey instrument assessed cigarette smoking, along with a variety of background variables thought to influence smoking. Results indicated that rebelliousness predicted smoking onset for Black nonsmokers; peer modeling was more influential for Whites. For both ethnicities, socially isolated children were at increased risk. The variables that predicted the shift from experimental to regular smoking were for the most part different from those that predicted smoking onset. Specifically, youths who lived with smokers, viewed smoking as a means to a goal, and experienced few adverse physiological effects of smoking were more likely to increase their cigarette consumption. Overall, we found that, contrary to previous research, risk factors for smoking differed across ethnicity. Further, smoking onset appears to be shaped by forces different from those that accelerate consumption.     

Getting young adults to quit smoking: a formative evaluation of the X-Pack Program.

The lack of promising smoking cessation interventions targeting young adults is a recognized public health problem. This study was designed to determine the feasibility of a young-adult-oriented program, the X-Pack Program, when administered to college student smokers, and to estimate its effect on smoking cessation. Participants (N = 83) were randomized after enrollment to receive either a moderately intensive, E-mail-based, young-adult intervention (the X-Pack group) or a less-intensive program aimed at a general adult audience (the Clearing the Air group). Participants were assessed at baseline and at 3 and 6 months after enrollment. Participants in the X-Pack group rated their treatment more favorably overall, were more engaged in program activities, and quit for more consecutive days at the 3- and 6-month follow-ups, compared with the Clearing the Air group. Differences in quit rates favored the X-Pack group at the two follow-ups, but the differences were not significant. These findings offer some support for the X-Pack Program when administered to college smokers.