Brief report: pain and readiness to quit smoking cigarettes.

This study explored the relationship between smoking and significant pain. It was hypothesized that readiness to quit smoking would be negatively affected by pain issues. A cross-sectional design was used in this phone-based survey with randomly selected adult smokers. A total of 307 adult participants in the control group from a larger Quit and Win Study participated in the interview. Participants were contacted at home and completed a 20-min phone survey including measures of pain, stress, depressive symptoms, social support, tobacco use status, and readiness to quit smoking. A total of 28% reported significant pain in the past week. Participants who experienced significant pain smoked more cigarettes per day than those who did not report significant pain. However, pain was not associated with readiness to quit. More than half (58%) of those with significant pain were in the contemplation stage of change or higher. The fact that smokers with pain were just as likely as those without significant pain to be ready to quit demands that each individual patient with pain be assessed for readiness to quit so that a tailored approach can be adopted either to motivate the patient to quit or to assist the patient with evidence-based tobacco dependence treatment strategies if he or she wants such treatment. Placing formal tobacco dependence treatment programs within pain clinics and addressing pain in smoking cessation programs is recommended.     

Depression predicts smoking early but not late in a quit attempt.

This study examined the relationship between depression history and smoking after a quit attempt. A total of 677 smokers participating in a randomized smoking cessation trial (Smith et al., 2001) provided data on current depression, depression history, and depression-related measures and smoking at 1 week and 6 months after a quit date. Depression history predicted smoking at 1 week postquit but not at 6 months postquit. Smoking during the first week was not predictive of smoking at 6 months in those with a history of depression but was predictive among those with no history of depression. Prediction models including depression history and depression-related measures (e.g., negative affect, negative cognitive style) showed that depression history was a powerful predictor of smoking early in the quit attempt.     

Mentholated cigarettes and smoking cessation: findings from COMMIT. Community Intervention Trial for Smoking Cessation

OBJECTIVE: To examine the association between the use of menthol cigarettes and smoking cessation, amount smoked, and time to first cigarette in the morning. BACKGROUND: The majority of African American smokers smoke mentholated cigarettes. Some evidence suggests that African Americans may be more nicotine dependent than whites. One theory is that menthol in cigarettes is responsible for enhancing the dependence producing capacity of cigarettes; however, few studies have prospectively examined the association between menthol use and indicators of nicotine dependence. METHODS: Baseline smokers from the Community Intervention Trial for Smoking Cessation (COMMIT) completed a telephone tobacco use survey in 1988 and were re-interviewed in 1993. Use of mentholated cigarettes was assessed by self report at baseline. Indicators of dependence examined were six month cessation in 1993, amount smoked among continuing smokers in 1993, and time to first cigarette in the morning in 1988. Multivariate regression techniques were used to assess the association of baseline menthol use with these outcomes while controlling for other factors related to dependence. RESULTS: Overall, 24% of the sample smoked a mentholated brand in 1988. No consistent associations were observed for menthol use and indicators of dependence in both overall and race specific analyses. Factors significantly associated with increased menthol use were female sex, age 25-34 years, African American and Asian race/ethnicity, greater education, greater than 60 minutes to the first cigarette in the morning, two or more past quit attempts, and use of premium brand cigarettes. Canadian respondents and those who smoked 15-24 cigarettes per day had lower rates of menthol use. Use of mentholated cigarettes was not associated with quitting, amount smoked, or time to first cigarette in the morning. CONCLUSION: Future work is needed to clarify the physiological and sociocultural mechanisms involved in mentholated cigarette smoking.     

Menthol cigarettes and health risks in Lung Health Study data.

Whether menthol cigarettes confer a higher risk of death than plain cigarettes is not known. The Lung Health Study (LHS) enrolled 5,887 adult smokers in a clinical trial of smoking cessation and ipratropium in the prevention of chronic obstructive pulmonary disease. LHS participants have been subjected to surveillance for mortality from all causes for 14 years. We examined these data for differences between self-reported smokers of menthol cigarettes versus plain cigarettes. Using proportional hazards regression methods, we found no differences in hazard ratios for coronary heart disease, cardiovascular disease, lung cancer, or death from any cause. Contrary to expectations about nicotine dependence, we found that users of menthol cigarettes had smoked fewer pack-years at baseline. We found no difference in success at smoking cessation with or without menthol. We conclude that our data contain no evidence that mentholation of cigarettes increases the hazards of smoking.     

Impact of Posttraumatic Stress Disorder on early smoking lapse and relapse during a self-guided quit attempt among community-recruited daily smokers

The present investigation examined whether daily smokers with posttraumatic stress disorder (PTSD), as compared to daily smokers with either anxiety psychopathology or no current Axis I psychopathology, have decreased success in the early phases of a self-guided smoking quit attempt. Participants were 140 daily smokers (81 women; M (age) = 29.5; SD = 11.9; range = 18-65 years); approximately one-third of the sample met criteria for current PTSD (n = 47), one-third met criteria for other current anxiety disorders (without PTSD; n = 33), and one-third did not meet criteria for any current Axis I disorder (n = 60). Consistent with prediction, membership in the PTSD group, compared to membership in the other anxiety disorders group and the group with no current Axis I psychopathology, was associated with increased risk of lapse during the first week following quit day. Additionally, daily smokers with PTSD and other anxiety disorders were at significantly increased risk of relapse during the first week post-cessation compared to persons without Axis I psychopathology. However, the PTSD group and the other anxiety disorders group did not differ from one another in terms of relapse. Results suggest that PTSD is associated with increased risk of smoking lapse and relapse compared to smokers with no current Axis I psychiatric problems, and increased risk of early smoking lapse but not relapse, as compared to those with other anxiety disorders. Findings provide novel evidence that PTSD, and perhaps anxiety disorders more generally, may be important factors in reducing the odds of successful unaided quit attempts in the early phases of cessation.     

Does a failed quit attempt reduce cigarette consumption following resumption of smoking? The effects of time and quit attempts on the longitudinal analysis of self-reported cigarette smoking intensity.

California Tobacco Survey respondents were asked the intensity of their cigarette smoking 1 year previously and at the time of the survey. Respondents reported a generally lower smoking intensity at survey time compared with 1 year previously. Multivariable statistical models on the change in smoking intensity in the past year were fitted to assess the effects of low-tar cigarette use, a quit attempt in the past year, smoking intensity 1 year previously, and demographic variables (age, education, income, and race). The most important predictor of change in intensity was the intensity 1 year previously. The next most important predictor was whether a quit attempt had been made in the previous year. The demographic variables also were found to have a significant effect, although their effects were of smaller magnitude. Low-tar cigarette use was not a significant predictor of change in intensity in multivariable analysis. The effect of a quit attempt on the reduction in intensity of smoking suggests that periods of cessation may reduce the intensity of smoking and the level of addiction for several months following relapse. Consequently, it may be important to control for cessation activity in studies comparing exposures from conventional tobacco products to exposures from new products that purport to offer lower harm.     

A randomized trial of nicotine replacement therapy in combination with reduced-nicotine cigarettes for smoking cessation

A randomized double-blind, active controlled, parallel group, multi-center phase II clinical trial was conducted to evaluate the efficacy of reduced-nicotine cigarettes as a novel smoking cessation treatment (under Investigational Device Exemption 69,185). The concept for a reduced-nicotine cigarette designed to progressively wean smokers from the smoking habit is based on research demonstrating that successful smoking cessation is not only dependent on withdrawal of nicotine, but also on weaning from the habitual sensory and behavioral reinforcement of smoking. Treatment consisted of Quest brand of cigarettes (Quest 1, 2, and 3), which respectively deliver 0.59+/-0.06, 0.3+/-0.05, and less than 0.05 mg nicotine, either alone or in combination with nicotine replacement therapy (NRT). The primary endpoint was 4 weeks of continuous abstinence (Weeks 7-10), with additional follow-up at 3 and 6 months. Adult men and women smokers (N = 346), motivated to quit, were randomized to one of three treatment groups: Quest plus NRT (NRT pretreatment 2 weeks before, and NRT after the quit date), Quest plus placebo patch, or active control plus NRT (conventional cigarette, followed by NRT after quit date). Results showed that Quest plus NRT was more effective than active control plus NRT in achieving 4 weeks of continuous abstinence (32.8% vs. 21.9%). Quest plus placebo patch yielded an abstinence rate similar to that of the active control plus NRT (16.4% vs. 21.9%). No serious adverse events were attributable to the investigational product. Quest plus NRT offers promise as a new smoking cessation treatment.     

Socioeconomic disparity in provider-delivered assistance to quit smoking.

The U.S. Public Health Service smoking cessation clinical practice guideline is the accepted gold standard for smoking cessation treatment. It offers evidence-based treatment recommendations for all clinicians to deliver to all patients at each visit. Despite the release of the guideline and the publication of Healthy People 2010, health care providers still may not appropriately counsel patients to quit smoking. Furthermore, disparities may exist among smokers who are assisted to quit smoking by their health care providers. The present study tested for an association between selected sociodemographic and tobacco-related factors and assistance to quit smoking. This 2001 National Health Interview Survey secondary analysis included a U.S. civilian, noninstitutionalized population. Participants were self-reported current smokers who visited a health care provider in the past 12 months and were at least 25 years old. The outcome measure was smokers' self-report of whether assistance to quit smoking was given by a health care provider. Of smokers who received advice (N = 3,046), only 38% received assistance to quit smoking. Smokers were less likely to report assistance to quit smoking if they were younger or Black, or if they had a high or middle level of socioeconomic disadvantage. In the final logistic regression model, being married, attempting to quit in the past 12 months, and consuming more tobacco were associated with receiving assistance to quit smoking. Increased age also was associated with receiving assistance, as was greater socioeconomic advantage (higher education, higher income, health insurance). The mechanisms responsible for the disparities in delivery of tobacco dependence treatment must be investigated further.     

Dimensions of depressive symptoms and smoking cessation.

Because different psychopathologic components of depressive symptoms may have distinct etiologies, examining their differential effects on smoking cessation may elucidate mechanisms underlying the smoking-depression relationship. Negative affect (NA), somatic features (SF), low positive affect/anhedonia (PA), and interpersonal disturbance (IP) have been identified as unique dimensions of depression that can be measured using the Center for Epidemiologic Studies Depression Scale (CESD). This study examined common and unique associations between CESD subscales and baseline smoking characteristics, nicotine withdrawal, and relapse in 157 participants enrolled in a smoking cessation trial for heavy social drinkers. Each dimension was univariately associated with negative and positive reinforcement smoking motives. Only SF had unique relations with tolerance smoking motives and univariate associations with nicotine dependence severity. Only PA predicted cessation-related changes in withdrawal symptoms on quit day. Analyses predicting abstinence at 8, 16, and 26 weeks post quit date showed that NA, SF, and PA each univariately predicted relapse, ps< or =.0083. Only low PA predicted poorer outcomes incrementally to the other dimensions, even when controlling for level of nicotine dependence, smoking frequency, and history of major depression, p = .0018. Interventions targeting anhedonia and low positive affect may be useful for smokers trying to quit.     

Recruitment of physician offices for an office-based adolescent smoking cessation study.

Physician office settings play an important role in tobacco cessation intervention. However, few tobacco cessation trials are conducted at these sites, in part because of the many challenges associated with recruiting community physician offices into research. The present study identified and implemented strategies for recruiting physician offices into a randomized clinical trial of tobacco screening and cessation interventions with adolescent patients. A total of 30 community physicians participated in focus groups to elicit their perceptions of facilitators of and barriers to initial engagement of physician practices and the subsequent enrollment of the practices in long-term research projects. Physicians identified facilitators such as (a) the involvement of office staff in the recruitment process and (b) on-site presentations of the study's background and aims. Some of the barriers identified were time commitment concerns and the lack of incentives in exchange for participation. These focus group findings were then integrated with theory-based and empirically driven recruitment strategies for a 12-month randomized tobacco intervention trial with adolescent patients. Of 185 office practices approached to participate (screened from a pool of 273 practices), 103 agreed to on-site presentations of the study. Subsequently, almost all of the practices (101) that received the presentation agreed to enroll in the study. Conclusions are that (a) recruitment is a multicomponent process, (b) the processes of communication, engagement, and enrollment must be carefully planned and implemented to achieve maximal results, and (c) the development of effective strategies for recruiting health care provider practices presents an important infrastructure for testing adolescent smoking cessation interventions.     

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.     

The relationship between smoking cessation and mouth ulcers.

Patients who stop smoking often complain of aphthous (mouth) ulcers. This symptom is sometimes attributed to the use of smoking cessation medications, but little is known about it. We investigated the incidence, severity, and time course of mouth ulcers in abstaining smokers and the effect of different smoking cessation medications on the symptom. The sample consisted of 1234 smokers who sought treatment at a large smoking cessation clinic, maintained at least 1 week of continuous biochemically validated abstinence, and provided usable data. Participants assessed their mouth ulcers by rating a mouth ulcer item added to the Mood and Physical Symptoms Scale. Subjects made ratings weekly on three occasions while still smoking and over 4 weeks following smoking cessation. After stopping smoking, some 40% of patients developed mouth ulcers, mostly in the first 2 weeks. The problem was generally mild, but 8% reported severe ulceration. The ulcers resolved within 4 weeks in 60% of patients affected. The ulcer ratings in patients using oral nicotine replacement products were higher than in those using patch, nasal spray or bupropion in the first week of abstinence but not afterward. Mouth ulcers were more prevalent in more dependent smokers, and the occurrence of ulcers correlated with other tobacco withdrawal symptoms. Our results confirm that mouth ulcers are a common result of stopping smoking, affecting two in five quitters. Patients should be reassured that the lesions are a result of stopping smoking and not a side-effect of smoking cessation medication.