Distributions of smokers by stage: international comparison and association with smoking prevalence

Risk factors for subclinical carotid atherosclerosis among current smokers

This study characterized the determinants of carotid atherosclerosis in a large contemporary sample of current smokers. Associations between risk factors, carotid intima-media thickness (CIMT), and carotid plaque presence were determined by multivariable regression. Participants included 1504 current smokers (58% female) who were a median (interquartile range) of 44.7 (38-53) years old and smoked 25 (15-40) pack-years; 55% had plaque. Pack-years, age, male sex, nonwhite race, body mass index, systolic blood pressure, small low-density lipoproteins (LDLs), and total high-density lipoproteins were independently associated with CIMT (model R(2) =0.434, P<.001). Pack-years (odds ratio [OR], 1.14 per 10 pack-years; P=.001), age (OR, 1.75 per 10 years; P<.001), body mass index (OR, 0.91 per 5 kg/m(2) ; P=.035), and small LDLs (OR, 1.11 per 100 nmol/L; P<.001) were independently associated with carotid plaque presence (model χ(2) =210.7, P<.001). The association between pack-years and carotid plaque was stronger in women (OR, 1.09 per 10 pack-years, P(interaction) =.018).

Comparing computer-tailored, internet-based smoking cessation counseling reports with generic, untailored reports: a randomized trial

To assess and compare the impact on quit attempts of online computer-tailored smoking cessation counseling reports and untailored reports, we performed a randomized controlled trial on a smoking cessation website in 2007-2008. After answering a questionnaire, current and former smokers were randomly assigned to immediately receiving either an online, individually tailored counseling report or a personalized but untailored generic report. Participants were invited by e-mail to report any smoking in the previous 24 hours, 48 hours after baseline. We used an intention-to-treat analysis, where nonrespondents at follow-up were counted as smokers. There were 2,872 participants at baseline and 2,226 at follow-up (78%). At baseline, there were 76% of current smokers (mean = 18 cigarettes/day) and 24% of recent quitters (median = 7 days of abstinence). The same proportion of smokers in both study groups had made a 24-hour quit attempt at follow-up (12.1%, P = 1.0). In baseline recent quitters, lapse/relapse rates at follow-up were similar in both groups (tailored: 25.1%, untailored: 23.5%, P = 0.64). We conclude that untailored reports were as effective as tailored reports in the short term. Even though these particular computer-tailored reports were not more effective than untailored reports, meta-analyses show that computer-tailored documents are in general more effective than untailored ones.

Smoking cessation in HIV patients: rate of success and associated factors

BACKGROUND

Smoking is the modifiable cardiovascular (CV) risk factor that contributes most to causing premature CV disease. Prevalence of smoking in patients with HIV infection is double that of the general population.

OBJECTIVES

To determine the rate of patients succeeding in quitting smoking after 12 months, factors associated with this success, and the characteristics of tobacco consumption and nicotine dependence.

METHODS

Longitudinal descriptive study. Three hundred and sixty-eight HIV-infected patients were interviewed. Smokers in Prochaska's stage of action began a programme to quit smoking. We registered the variables related to tobacco consumption and the level of success of cessation.

RESULTS

63.9% of the patients were active smokers and 14% of them began the cessation programme. Average motivation for cessation was 7.8 +/- 1.4 (Richmond) and nicotine dependence rate 5.5 +/- 3.0 (Fagerström). After 1 year, 25% had quit smoking. Those patients who stopped smoking presented a higher motivation level (8.8 +/- 1.3 vs. 7.5 +/- 1.5, P=0.048). Cessation significantly reduced their CV risk at 12 months [2.5 [interquartile range (IQR) 2.0-5.2] vs. 1.7 [IQR 1.0-3.5], P=0.026].

CONCLUSIONS

The prevalence of smokers in our population of HIV-infected patients was 63.9%. Only 14% began a smoking cessation programme. Twelve months after a programme to quit smoking, cessation rate was 25%; this was influenced mostly by the level of motivation of the patient.

Assessing motivation to quit smoking in people with mental illness: a review

BACKGROUND

People with mental health (MH) disorders smoke at higher rates, are more nicotine-dependent and suffer greater morbidity and mortality from smoking-related illnesses than the general population. Helping these people to quit smoking is a public health priority; however, many MH professionals assume that those with mental illness are not motivated to quit.

OBJECTIVES

To use predetermined criteria to identify, review critically and evaluate empirically all English language, peer-reviewed data on motivation to quit smoking in MH populations.

METHODS

A systematic search was conducted and key data on subject characteristics, measures of motivation and other variables abstracted. chi(2) analyses were used to compare motivation between MH and general populations, between in-patients and out-patients and between people with depression and people with psychotic disorders.

RESULTS

Evidence suggests that people with MH disorders are as motivated to quit smoking as the general population, although those with psychotic disorders may be less motivated than individuals with depression. Although readiness to cease smoking was assessed in 14 studies, only two evaluated motivation to quit smoking in in-patient populations.

CONCLUSIONS

People with MH disorders are motivated to quit smoking, although more research is needed looking at in-patient populations. The commonly held false belief that people with MH disorders are not motivated to cease smoking means that opportunities to encourage smoking cessation among this disenfranchised group are being missed.

Intention to quit moderates the effect of bupropion on smoking urge

INTRODUCTION

The behavioral mechanisms by which bupropion reduces smoking have been explored in laboratory behavioral studies, with some inconsistent results. Intention to quit smoking has been found to moderate some effects of nicotine replacement, and the degree to which that characteristic may affect responses to other smoking pharmacotherapies is unknown.

METHODS

This laboratory study examined the effects of 300 mg/day bupropion, compared with placebo, on baseline and smoking cue-elicited urge to smoke and other measures in smokers who stated that they did (n = 8) or did not (n = 17) intend to quit smoking within 6 months.

RESULTS

Significant interactions indicated that bupropion reduced the effects of acute abstinence on smoking urges in the presence of neutral cues, only in those who intended to quit. Bupropion and intention to quit did not reduce the effects of acute abstinence on urges in the presence of smoking cues and did not reduce nicotine withdrawal symptoms or smoking behavior between sessions.

DISCUSSION

This study is one of the first placebo-controlled examinations of the effects of bupropion on cue reactivity and provides support for the idea that laboratory smoking studies may be more likely to detect effects of pharmacological treatments for smoking when they enroll smokers who intend to quit.

Intention to change smoking in pregnant and postpartum women according to number of pregnancies

BACKGROUND

The status of a pregnant woman might add to the motivation to stop smoking. However, little is known about whether women who are pregnant for the first time (primigravidae) show a motivation to quit smoking that is different from women who are pregnant at least the second time (multigravidae). The goal of the current study was to compare smoking status, urge to smoke and intention to change smoking behaviour of primigravidae and multigravidae. We hypothesized that amongst primigravidae there are less current smokers, that the smokers consume less cigarettes per day, have less urge to smoke and that more stop smoking after delivery when compared with multigravidae.

METHODS

Among 642 women postpartum who had smoked before pregnancy smoking status, the Fagerström Test for Nicotine Dependence and intention to change smoking behaviour were assessed. The data were analysed with the Chi-square test, Mann-Whitney's U-test and the Sign-test.

RESULTS

Primigravidae smoked less cigarettes (P < 0.01) and showed less urge to smoke (P < 0.05) than multigravidae. They did not differ according to the intention to change smoking behaviour (P > 0.05).

CONCLUSION

Experience of first pregnancy does not seem to automatically induce more smoking cessation compared to multigravidae. Prevention measures are needed for primigravida women and multigravida women to the same extent.

Decision making in the transtheoretical model of behavior change

Decision making is an integral part of the transtheoretical model of behavior change. Stage of change represents a temporal dimension for behavior change and has been the key dimension for integrating principles and processes of change from across leading theories of psychotherapy and behavior change. The decision-making variables representing the pros and cons of changing have been found to have systematic relationships across the stages of change for 50 health-related behaviors. Implications of these patterns of relationships are discussed in the context of helping patients make more effective decisions to decrease health risk behaviors and increase health-enhancing behaviors.

Effectiveness of computer-tailored Smoking Cessation Advice in Primary Care (ESCAPE): a randomised trial

BACKGROUND

Smoking remains a major public health problem; developing effective interventions to encourage more quit attempts, and to improve the success rate of self-quit attempts, is essential to reduce the numbers of people who smoke. Interventions for smoking cessation can be characterised in two extremes: the intensive face-to face therapy of the clinical approach, and large-scale, public health interventions and policy initiatives. Computer-based systems offer a method for generating highly tailored behavioural feedback letters, and can bridge the gap between these two extremes. Proactive mailing and recruitment can also serve as a prompt to motivate smokers to make quit attempts or to seek more intensive help. The aim of this study is to evaluate the effect of personally tailored feedback reports, sent to smokers identified from general practitioners lists on quit rates and quitting activity. The trial uses a modified version of a computer-based system developed by two of the authors to generate individually tailored feedback reports.

METHOD

A random sample of cigarette smokers, aged between 18 and 65, identified from GP records at a representative selection of practices registered with the GPRF are sent a questionnaire. Smokers returning the questionnaire are randomly allocated to a control group to receive usual care and standard information, or to an intervention group to receive usual care and standard information plus tailored feedback reports. Smoking status and cognitive change will be assessed by postal questionnaire at 6-months.

DISCUSSION

Computer tailored personal feedback, adapted to reading levels and motivation to quit, is a simple and inexpensive intervention which could be widely replicated and delivered cost effectively to a large proportion of the smoking population. Given its recruitment potential, a modest success rate could have a large effect on public health. The intervention also fits into the broader scope of tobacco control, by prompting more quit attempts, and increasing referrals to specialised services. The provision of this option to smokers in primary care can complement existing services, and work synergistically with other measures to produce more quitters and reduce the prevalence of smoking in the UK.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN05385712.

The barriers to smoking cessation in Swiss methadone and buprenorphine-maintained patients

Background

Smoking rates in methadone-maintained patients are almost three times higher than in the general population and remain elevated and stable. Due to the various negative health effects of smoking, nicotine dependence contributes to the high mortality in this patient group. The purpose of the current study was to investigate Swiss methadone and buprenorphine-maintained patients' willingness to stop smoking and to clarify further smoking cessation procedures.

Methods

Substance abuse history, nicotine dependence, and readiness to stop smoking were assessed in a sample of 103 opiate-dependent patients in the metropolitan area of Zurich, Switzerland. Patients were asked to document their smoking patterns and readiness to quit.

Results

Only a small number of patients were willing to quit smoking cigarettes (10.7%) and, even though bupropione or nicotine replacement therapy was included in the fixed daily treatment care, only one patient received nicotine replacement therapy for smoking cessation. A diagnosis of depression in patients' clinical records was associated with readiness to stop smoking. No significant associations were found between readiness to quit smoking and age, methadone treatment characteristics, and presence of co-dependencies.

Conclusion

The current prescription level of best medicine for nicotine dependence in Swiss methadone and buprenorphine-maintained patients is far from adequate. Possible explanations and treatment-relevant implications are discussed.

The relationship between smokers' motivation to quit and intensity of tobacco control at the population level: a comparison of five European countries

Background

Smoking prevalence differs significantly across Europe. In addition, there are considerable differences in tobacco control activities across European countries. The relationship between prevalence and policy is under-researched. The present analysis examines the motivation to change smoking behaviour across 5 different European countries that differ considerably in their tobacco control activities.

Methods

A population-based, representative survey of 1750 smokers, aged 16–59, from 5 different European countries (Germany, Greece, Poland, Sweden, UK) was used. Demographic variables, smoking status and the motivation to stop smoking were assessed. Motivation was assessed as, first, intending to quit (using the stages of change plus a modified stage for Precontemplation), and second, the desire to quit.

Results

The majority of smokers want to stop smoking (73.5%), while only 35.0% want to stop definitely. Across countries, 10.2% definitely do not want to stop.

Most of the smokers can be categorised in the Precontemplation stage (between 62.6% and 77.7% depending on the country), one of the stages of change categories. The relationship between the stages of change and the country under examination is statistically significant (chi-square = 43.466, p < 0.001). In countries with a high level of tobacco control, the proportion of people in Precontemplation is lower than in countries with low tobacco control activity.

Conclusion

There are differences in the stages of change between the countries under examination. However, the categorisation of the countries into low, medium and high tobacco control activity used in this analysis does not explain these differences. Most smokers want to stop smoking, but a high proportion cannot indicate a time-frame when this is going to happen. Tobacco control efforts or other kinds of support might encourage these smokers to actually try to stop. Longitudinal studies at the population level are needed to assess, relate or monitor tobacco control activities and the intention to stop.

Developing the science base for reducing tobacco harm

The University of Minnesota Transdisciplinary Tobacco Use Research Center has been examining the multiple dimensions and the scientific evidence required to determine the feasibility of tobacco harm reduction as a means to reduce tobacco-related mortality and morbidity. Because of the complexity associated with exploring this area, an interdisciplinary approach is necessary. The research components that have been of particular focus at our center include (a) developing and validating biomarkers of tobacco-related exposure and toxicity, (b) developing animal models and designing studies with humans to assess a variety of smoking reduction approaches and potential reduced exposure products, and (c) determining individual differences in response to these interventions and products. A description of the ongoing activities and challenges in these areas is provided, along with projected directions for the future.

Postintervention effect of nicotine replacement therapy for smoking reduction: a randomized trial with a 5-year follow-up

We tested whether a reduction of cigarette consumption obtained after 6 months of nicotine replacement therapy was maintained 5 years after the end of this treatment. Heavy smokers (mean = 30 cigarettes per day) who had no intention of quitting smoking were randomly assigned to a 6-month treatment of nicotine (15-mg patch, 4-mg gum, and/or 10-mg inhaler, n = 265), placebo (n = 269), or no intervention (n = 389). Products were sent by mail, and education was limited to a booklet. Of 923 participants, 879 (95%) were followed after 6 months and 671 (73%) after 5 years. After 6 months, smoking reduction was larger for nicotine (-10.9 cigarettes per day) than for placebo (-8.7) and no treatment (-4.9, all P <or= 0.022). After 5 years, cigarette consumption (20 cigarettes per day, all P >or= 0.2) and smoking cessation rates (17% to 21%, all P > 0.2) were similar in all groups. In smokers, 5-year continuous abstinence was higher in those who had reduced their cigarette consumption by at least 50% between baseline and 6 months than in those who did not reduce (11.9% vs 5.6%; P = 0.011; odds ratio, 2.3; 95% confidence interval, 1.2-4.2). Thus, the initial effect of the treatment on smoking reduction was not maintained after 5 years. However, reducing cigarette consumption was associated with a higher chance of subsequently quitting smoking. Nicotine replacement therapy in unmotivated smokers had no deleterious effect on dependence levels and smoking behavior.

What are the differences in decisional balance and self-efficacy between Turkish smokers in different stages of change?

This paper reports the results of an examination of decisional balance (pros and cons of smoking), and self-efficacy constructs, sociodemographic and smoking-related variables among smokers from different stages of change as proposed by the transtheoretical model. A convenience sample of 398 smokers completed the research instrument. Almost 60% of the sample were in the precontemplation stage. The results indicated that pros of smoking dropped significantly from precontemplation to contemplation and preparation but then increased again for the action stage smokers. Cons of smoking increased almost linearly from precontemplation to preparation stages and they were the highest for the action stage. Self-efficacy also increased in a linear fashion and preparation and action stages were significantly higher than the precontemplation and contemplation stages. There were also significant differences among stages of change of groups on age, years of education, and smoking duration and number of quit attempts. Results underlined the importance of finding alternatives that may substitute for the pros of smoking and interventions for changing the cognitive evaluations related to cons of smoking. Additionally, smokers may gain from approaches that focus on encouraging and reinforcing self-efficacy during the action and maintenance stages to ensure a long-term positive outcome.

Lung cancer screening as a teachable moment for smoking cessation

BACKGROUND

Lung cancer screening may serve as a 'teachable moment' for smoking cessation, a brief period in which motivation to stop smoking is enhanced. Within the context of two NCI-funded randomized lung screening trials, we conducted an ancillary study to explore the impact of screening on smoking cessation and readiness to stop smoking.

METHODS

We accrued a sample of current and former smokers participating at the Georgetown University site of the Lung Screening Study (LSS; N=144) and of the National Lung Screening Trial (NLST; N=169). In each sample, we assessed reasons for trial participation, interest in smoking cessation interventions, motivations for stopping smoking, and the impact of undergoing screening on tobacco use and readiness to stop smoking. Telephone interviews were conducted prior to screening, and 1-month following receipt of the screening result. The samples were analyzed separately due to differences in age and level of nicotine dependence.

RESULTS

The majority of the findings were consistent across the two samples. Frequently endorsed reasons for trial participation among both current and former smokers included psychological reasons (e.g., wanting peace of mind about lung cancer) and altruism (e.g., wanting to make a contribution to science). Nicotine replacement therapy and free counseling were the cessation methods that were of most interest, and fear of lung health problems was the most frequently endorsed motivation for quitting smoking. Regarding readiness to stop smoking, approximately 20% were ready to stop in the next 30 days, 45% were ready to stop in the next 6 months, while 35% were not thinking of stopping. At the follow-up, 7% of current smokers at baseline reported abstinence, and 4% of former smokers at baseline reported having relapsed. The findings differed across the two samples when considering the readiness to quit outcome. At the 1-month follow-up of the NLST sample, participants became more ready to stop smoking (p<.05). Screening result did not moderate this finding. In the LSS sample, among younger participants (<or=64), an abnormal screening result was significantly associated with becoming more ready to stop smoking, whereas a normal result was associated with becoming less ready to stop smoking (p=.02).

CONCLUSIONS

The current findings demonstrated the feasibility of enrolling lung screening participants into a smoking-related research study, as well as the high level of interest in stopping smoking and in smoking cessation interventions. These data indicate that lung cancer screening may serve as a teachable moment for smoking cessation, and suggest that a smoking cessation trial within the context of lung cancer screening is feasible.

A randomized controlled trial of smoking cessation for pregnant women to test the effect of a transtheoretical model-based intervention on movement in stage and interaction with baseline stage

OBJECTIVES

To examine whether, as predicted by the transtheoretical model (TTM), stage-matched interventions will be more effective than stage-mismatched interventions.

DESIGN

Randomized controlled trial of smoking cessation advice to pregnant smokers.

METHODS

Pregnant women currently smoking at 12 weeks gestation were enrolled in a pragmatic three-arm trial of TTM-based interventions to help them stop smoking. One arm constituted standard midwifery advice and a self-help leaflet on stopping smoking, which is generally appropriate for women in preparation. Two arms were TTM-based. Differences in positive movement in stage towards quitting from enrolment to 30 weeks gestation and 10 days post-partum were calculated for each arm of the trial. We then examined whether, as predicted from the TTM, the relative benefit of the TTM-based intervention was greater for women in precontemplation and contemplation, for whom the control intervention was stage-mismatched, than for women in preparation, for whom the control intervention was stage-matched.

RESULTS

Women in the TTM-based arms were statistically significantly more likely to move forward in stage than were women in the control arm. Contrary to the TTM-derived hypothesis, the greater relative benefit of the TTM-based intervention was seen for women in preparation stage at baseline, rather than women in precontemplation and contemplation.

CONCLUSIONS

The TTM-based intervention was more effective in stage movement, but this could be due to its greater intensity. The failure to confirm that stage-matching was important casts doubt on the validity of the TTM in explaining smoking cessation behaviour in pregnancy.

[Lung cancer in women: a different entity?]

Lung cancer is becoming a real epidemic in developed countries and one of the main causes of cancer death in women. Although it is controversial to state, it is probable that women are more susceptible to lung cancer than men. Molecular and genetic epidemiology studies are underway to prove this statement. Several biological factors, such as family history, histopathology, response to treatment and the prognosis for lung cancer in women have a bearing on the case. While these are not completely clear or consensual, there is a need for wide-ranging prospective studies which compare the differences between males and females. Until now, there has only been one area in which gender could impact on the therapeutic management of lung cancer: the role of gefitinib and erlotinib in inhibiting the epidermal growth factor receptors, since these products are clearly of more benefit to female non-smokers. Given that women have a better lung cancer prognosis, it is recommended that future research protocols include stratification on gender. Prevention of lung cancer in both women and men is a priority public health concern. A mandatory aim of this is the fight against smoking, the largest aetiological factor of lung cancer.

Tailored communications for smoking cessation: past successes and future directions

Tailored communications are one of the most promising approaches to smoking cessation interventions for entire populations. Assessments based on the Transtheoretical Model are processed by computer-based expert systems that generate feedback reports tailored to each individual to accelerate their progress through the stages of change for smoking cessation. Seven studies are reviewed that range from a more traditional clinical trial to trials on entire populations of smokers to population trials designed to change multiple behaviours, including smoking. A series of three tailored communications was found to produce long-term point prevalence abstinence rates within the narrow range of 22-26% abstinence. This same range of abstinence was found even when two or three other behaviours (e.g. diet and sun protection) were treated in the population. These results point to a future in which health behaviour risk interventions will be assessed not solely by their efficacy but by their population impact.

Attitudes, social influences and self-efficacy expectations across different motivational stages among immigrant smokers: replication of the Ø pattern

BACKGROUND

Information about the factors that determine motivation to quit in immigrant populations is needed to enable the development of tailored smoking cessation programs for them. Dutch studies in the general population suggest that attitudes are important for motivating persons to change and self-efficacy for helping motivated persons to change. We analyzed whether this pattern also exists among Surinamese immigrants.

METHODS

Structured face-to-face interviews were held among 1,100 Surinamese people in Amsterdam (The Netherlands), including measures of attitudes towards smoking (cessation), social influences and self-efficacy expectations (between 2001 and 2003).

RESULTS

The majority of the smokers were not motivated to quit and in the pre-contemplation phase (73%). Pre-contemplators perceived significantly weaker advantages of quitting than contemplators and preparators. Self-efficacy expectations of Surinamese pre-contemplators were lower than those of smokers preparing to quit within a month.

CONCLUSION

Similar attitudinal and self-efficacy patterns as those in the general population were found in an immigrant population. However, the items constituting the factors are culturally sensitive. Furthermore, many Surinamese smokers were unmotivated to quit smoking.

Postpartum return to smoking: identifying different groups to tailor interventions

OBJECTIVE

(a) To describe a population-based sample of women postpartum who smoked before pregnancy on grounds of the perceived advantages and disadvantages of nonsmoking and the self-efficacy not to smoke. (b) To identify grouping characteristics that can differentiate among those women. This could lead to the development of intervention strategies that are of different efficacy depending on the cluster the woman is member of.

SAMPLE

A population-based sample of 317 women who had smoked at the beginning of pregnancy and who were smoke-free at the time of giving birth.

DATA

Data about the acquisition stages of change to restart smoking, the perceived advantages of nonsmoking and the self-efficacy to remain smoke free on grounds of the Transtheoretical Model of Behavior Change was assessed. Smoking status was assessed 12 months later.

STATISTICAL ANALYSIS

A cluster analysis was used to identify different groups; a logistic regression was calculated to assure the external validity of the clusters identified.

RESULTS

The acquisition stages of change do not fit the situation of nonsmoking women postpartum in Germany, but four different clusters of ex-smoking women postpartum were identified on grounds of the other TTM-constructs. These are: the protected, the high risk, the premature and the ambivalent group. The clusters are associated with relapse after 12 months, none of the other variables controlled for was statistically significant.

CONCLUSIONS

The TTM contributes to a better understanding of nonsmoking women postpartum. Further studies have to replicate the clusters found and have to find whether interventions tailored to these clusters are more effective in preventing relapse than other interventions.

Lags in behavioral change: A population based comparison of cardiovascular risk behavior in Poland and Sweden

One thousand and twenty Polish men and women and 1,011 Swedish men and women aged 50 and recruited through primary health care took part in a survey relating to their knowledge of health-related behaviour, attitudes to health-related behaviour and self-reported risk behaviour. The results reveal that Poles know as much about cardiovascular risk factors as Swedes, but that Swedes feel that it is more important to change their dietary habits and to influence factors in the working environment to avoid the risk of developing CVD than did Poles. Swedes also displayed less risk behaviour than Poles and more Swedes than Poles had successfully stopped smoking. These findings suggest that differences in stages of health-related behavior that have previously been observed at an individual level may sometimes also be discerned at a national level.

Modeling predicted that tobacco control policies targeted at lower educated will reduce the differences in life expectancy

BACKGROUND AND OBJECTIVE

To estimate the effects of reducing the prevalence of smoking in lower educated groups on educational differences in life expectancy.

METHODS

A dynamic Markov-type multistate transition model estimated the effects on life expectancy of two scenarios. A "maximum scenario" where educational differences in prevalence of smoking disappear immediately, and a "policy target-scenario" where difference in prevalence of smoking is halved over a 20-year period. The two scenarios were compared to a reference scenario, where smoking prevalences do not change. Five Dutch cohort studies, involving over 67,000 participants aged 20 to 90 years, provided relative mortality risks by educational level, and smoking habits were assessed using national data of more than 120,000 persons.

RESULTS

In the reference scenario, the difference in life expectancy at age 40 between highest and lowest educated groups was 5.1 years for men and 2.7 years for women. In the "maximum scenario" these differences were reduced to 3.6 years for men and 1.7 years for women (reduction approximately 30%), and in the "policy target-scenario" differences were 4.7 years for men and 2.4 years for women (reduction approximately 10%).

CONCLUSION

Theoretically, educational differences in life expectancy would be reduced by 30% at maximum, if variations in smoking prevalence were eliminated completely. In practice, tobacco control policies that are targeted at the lower educated may reduce the differences in life expectancy by approximately 10%.

Prevalence and correlates of tobacco use among Russian cancer patients: Implications for the development of smoking cessation interventions at a cancer center in Russia

This study examined the rate of smoking among 399 cancer patients in Russia and assessed correlates of tobacco use and readiness to quit smoking. The results indicated that (a) 41.6% of patients were smokers; and (b) smokers were likely to be male, have lung or colorectal cancer, exhibit low levels of knowledge concerning the negative effects of smoking, report a low level of advantages to quitting smoking and a high level of disadvantages to quitting smoking, show low perceived risk for the adverse effects of smoking, and exhibit high fatalistic beliefs. Though certain findings converge well with data collected from U.S. samples of cancer patients, these results can guide the development of smoking interventions that address the specific needs of Russian cancer patients. In sum, this study fills a critical gap in knowledge concerning the epidemic of tobacco use in Russia and broadens research regarding tobacco use by cancer patients from the United States to the Russian Federation.

A comparison of the psychometric properties of three cigarette withdrawal scales

AIMS

To compare the psychometric properties of three cigarette withdrawal scales.

DESIGN

An internet cohort study.

PARTICIPANTS

Each of 4,644 current (44%), former (49%) and never smokers (7%) completed the three scales via the internet. A subsample completed the scales again after 14 days (n=1309), and indicated their smoking status after 42 days (n=1431).

MEASUREMENTS

The Cigarette Withdrawal Scale (CWS), the Wisconsin Withdrawal Scale (WWS) and the Minnesota Withdrawal Form (MWF).

FINDINGS

All three scales covered the main elements in the Diagnostic and Statistical Manual version IV (DSM-IV) and the International Classification of Diseases version 10 (ICD-10) definitions of tobacco withdrawal, but WWS did not cover weight gain. Factor analyses indicated that only six factors were present in WWS, instead of the expected seven factors. Cronbach's alpha coefficients (0.76-0.93) were high for all scales. Test-retest coefficients were in the range of 0.66-0.86 for CWS and WWS, but were somewhat lower for some MWF items (range 0.52-0.80). In 324 ex-smokers who had quit smoking 31 days or less before baseline, craving predicted relapse at 14-day follow-up (CWS: odds ratio=1.53 per point, P=0.003; WWS: odds ratio=1.40, P=0.04; MWF: odds ratio=1.49, P=0.002). In 34 baseline smokers who had quit smoking by 14-day retest, an increase in craving (WWS and MWF), depressed mood (MWF) and difficulty concentrating (WWS) between baseline and retest predicted relapse at 42-day follow-up. In terms of construct validity, scales performed similarly, but performance on some key tests (e.g. withdrawal will increase post-cessation) were inadequate, due perhaps to methodological limitations.

CONCLUSIONS

No scale showed a decisive advantage over the others. MWF has the advantage of brevity.

Collecting saliva by mail for genetic and cotinine analyses in participants recruited through the Internet

The authors assessed whether collection by mail of saliva and buccal cells for genetic analysis was feasible in participants recruited through the Internet. In 2003, 14,773 visitors of a smoking cessation website were invited by e-mail to take part in the study. Salivettes (plastic vials containing a cotton roll) were mailed to participants, for collection of saliva and buccal cells. Because of limited resources, the authors stopped recruitment when 392 participants (3% of 14,733) were registered. They received 315 saliva samples back (80% of 392). Salivary cotinine was analyzed in 145 daily smokers. Cotinine concentration could be assessed in 141 samples (97%) (range 0.7-899 ng/ml, median 260 ng/ml). DNA extraction was achieved in all the 285 samples in which it was attempted. Quality of DNA was assessed by optical density measurements and by polymerase chain reaction amplification of a gene coding for the alpha-4 nicotinic receptor, with the detection of a known polymorphism. Successful results were obtained in 235 samples (82% of 285). Thus collecting saliva by mail for cotinine and DNA analysis in participants recruited through the internet produced samples of good quality at a reasonable cost. This approach should be valuable for genetic epidemiology and pharmacogenetic research.

Identifying high- and low-success smoking cessation subgroups using signal detection analysis

Signal detection analysis was used to identify mutually exclusive groups of smokers (n = 602) at high and low likelihood for smoking cessation 6- and 18-months post-entry into a smoking cessation intervention. Overall quit rates were 10% at 6-months and 18% at 18-months. Four subgroups were identified at 6-months and five at 18-months. The highest quit-rate subgroup at both time points (42% and 52% cessation, respectively) had low perceived stress. The lowest quit-rate subgroup (7% and 13% cessation, respectively) had higher perceived stress, lower self-efficacy to not smoke, lower use of behavioral processes at 6-months, and higher use of pros of smoking at 18-months. These smoker profiles may be useful in developing targeted smoking cessation interventions. Addressing perceived stress in smoking cessation interventions may help to improve smoking cessation success rates.

Development and validation of Decisional Balance and Temptations measures for Bulgarian adolescent smokers

The goal of this study was to develop measures for Decisional Balance and Situational Temptations for Bulgarian adolescent smokers and to test predicted theoretical relationships with Stages of Change in the same population. Consistent with previous findings for other populations, a 3-factor model for Decisional Balance (CFI = .95) and a hierarchical 4-factor model for Temptations (CFI = .90) best fit the data. The predicted crossover pattern for Decisional Balance and a decreasing trend for Temptations across the Stages of Change were verified. Both measures demonstrated good levels of factorial invariance across gender and across random split-half cross-validation samples. These results support the cross-cultural validity of the TTM constructs and indicate that they can be used as a basis for development of interventions for the population under study.

Methods to assess potential reduced exposure products

The availability of tobacco products purported to reduce toxin exposure or potentially reduce health risks necessitates the development of methods and identification of biomarkers that can be used to assess these products. These assessments occur on multiple levels and stages, from identifying constituents in the tobacco products and smoke, to human exposure and health effects trials, to postmarketing surveillance. A conference of multidisciplinary experts was convened to present and discuss methods and biomarkers to assess these products and to consider the infrastructure necessary to facilitate the evaluation process. Although no currently available set of measures was thought to be sufficient for determining the relative health risk of potential reduced exposure products, this paper provides a blueprint for future research toward this end.

Epidemiology of lung cancer: looking to the future

In the United States, the 20th century witnessed the emergence of a lung cancer epidemic that peaked and began to decline by the century's end, a decline that continues today. However, lung cancer continues to be an unabating pandemic. In research carried out over the last half of the 20th century, many factors were causally associated with lung cancer and studies were implemented to identify determinants of susceptibility to these factors. Cigarette smoking was identified as the single most predominant cause of the lung cancer epidemic, but other causes were found, including workplace agents (eg, asbestos, arsenic, chromium, nickel, and radon) and other environmental factors (passive smoking, indoor radon, and air pollution). Contemporary epidemiologic research on lung cancer now focuses on a new set of issues, primarily related to susceptibility to the well-identified causal factors, particularly smoking, and on the consequences of changes in tobacco products for risks to smokers. Diet and the possibility of reducing risk through chemoprevention remain a focus of research emphasis through experimental and observational approaches. Questions have also been raised about possible differences in susceptibility to lung cancer by sex and race. Population patterns in smoking prevalence will continue to be the most powerful predictor of the future occurrence of lung cancer. Evaluation of recent US patterns in smoking prevalence indicates that for the next approximately 10 to 15 years, lung cancer rates will decrease, but will then level off starting in approximately 2030. Unless further reductions in the prevalence of cigarette smoking are achieved over the next decade, lung cancer will remain as an all too common, but avoidable, disease.

Validation of English-language versions of three scales measuring attitudes towards smoking, smoking-related self-efficacy and the use of smoking cessation strategies

AIMS

To assess the validity of English translations of three scales initially developed in French, measuring perception of the adverse effects of smoking, self-efficacy and the use of smoking cessation strategies.

METHODS

Between 1999 and 2001, 5667 people from 97 countries (4724 smokers and 943 ex-smokers) answered the scales on the internet, of which 997 (18%) took part in a follow-up 86 days later.

FINDINGS

The factor structures of the scales were generally maintained after translation. Internal consistency coefficients were 0.5-0.9. Test-retest reliability was >0.7 for the "Adverse effects" and self-efficacy scales, but was low (0.2-0.4) for self-change strategies, which probably reflects active use of these strategies in this sample. The translated scales performed adequately in most tests of construct validity. In particular, higher self-efficacy ratings predicted smoking cessation at follow-up, and a lower self-efficacy predicted relapse in baseline ex-smokers.

CONCLUSION

The validity of the scales was maintained after translation in English.

Intentions to quit smoking change over short periods of time

To assess the stability of intention to quit smoking, 115 US and Swedish smokers were randomized to complete Stage of Change (SOC) or ladder scales of intentions to quit at either 0, 7, 14 and 30 days or at 0 and 30 days in the absence of intervention. The four-assessment group had more progression in intention to quit than the two-assessment group. Depending on the measure, 12-17% of smokers changed their intention to quit over 7 days, 15-25% changed over 14 days and 17-34% changed over 30 days. Results were similar in Swedish and US participants and replicate the results of prior studies. We conclude intention to quit often spontaneously changes over short periods of time, especially with repeated testing.

Comparing the efficacy of two Internet-based, computer-tailored smoking cessation programs: a randomized trial

Background

Online computer-tailored smoking cessation programs have not yet been compared directly.

Objective

To compare the efficacy of two Internet-based, computer-tailored smoking cessation programs.

Methods

Randomized controlled trial conducted in 2003-2004. Visitors to a smoking cessation website were randomly assigned to either an original online, interactive smoking cessation program or to a modified program. Both programs consisted of tailored, personalized counseling letters based on participants' characteristics, followed by monthly email reminders. The original program was based on psychological and addiction theory, and on preliminary research conducted in the same population. The modified program was shorter and contained more information on nicotine replacement therapy and nicotine dependence, and less information on health risks and coping strategies. In both programs, 1 month and 2 months after entering the study, participants were invited by email to answer the same tailoring questionnaire again in order to receive a second counseling letter. Participants in both programs obtained, on average, 1.2 feedback counseling letters over 2.5 months, and 84% received only 1 feedback letter. The outcome was self-reported smoking abstinence (no puff of tobacco in the previous 7 days), assessed 2.5 months after entry in the program. We report results from intention-to-treat (ITT) analyses, where all non-respondents at follow-up were counted as smokers.

Results

The baseline questionnaire was answered by a total of 11969 current (74%) and former (26%) smokers, and the follow-up survey by 4237 people (35%). In an ITT analysis, abstinence rates in baseline current smokers were respectively 10.9% and 8.9% (odds ratio [OR]=1.24, 95% confidence interval [CI]1.08-1.43, P=.003) in the original and modified programs, and 25.2% and 15.7% (OR=1.81, CI 1.51-2.16, P<.001) in baseline former smokers. While we found statistically significant differences in quit rates in smokers in the contemplation stage favoring the original program (OR=1.54, CI 1.18-2.02, P=.002), no between-group differences in quit rates were observed in smokers in the precontemplation (OR=1.07, CI 0.36-3.14, P=.91) and preparation (OR=1.15, CI 0.97-1.37, P=.10) stages of change.

Conclusions

In smokers in the contemplation stage of change and in former smokers, the original program produced higher smoking abstinence rates than the modified program.

A comparison of the content-, construct- and predictive validity of the cigarette dependence scale and the Fagerström test for nicotine dependence

BACKGROUND

Research showed that the widely used Fagerstrom test for nicotine dependence (FTND) does not cover important aspects of dependence. A new test, the cigarette dependence scale (CDS-12), covers the main elements in DSM-IV and ICD-10 definitions of dependence. We compared the psychometrics of CDS-12, FTND, and CDS-5 and the heaviness of smoking index (HSI), which are short versions of CDS-12 and FTND, respectively.

METHODS

Internet survey in 2002-2003. Participants were invited one month after answering the first survey to answer a second survey on smoking status and withdrawal symptoms.

RESULTS

Eight hundred two smokers answered both surveys. Cronbach's alpha coefficients were higher for CDS-12 (0.91) and CDS-5 (0.77) than for FTND (0.68) and HSI (0.63). Among 231 smokers who quit smoking at follow-up, higher baseline CDS-12 scores predicted higher withdrawal ratings at follow-up, for all withdrawal symptoms except appetite. FTND and HSI predicted higher craving in quitters, but did not predict the intensity of other withdrawal symptoms. Neither CDS-5, FTND or HSI predicted smoking cessation, but higher CDS-12 scores marginally predicted smoking cessation at follow-up (area under the receiver operating characteristic (ROC) curve = 0.55, 95% confidence interval = 0.51-0.59).

CONCLUSIONS

CDS-12 had better content validity and internal consistency than FTND and was a slightly better predictor of withdrawal symptoms. Unexpectedly, higher (not lower) CDS-12 scores predicted subsequent smoking cessation, perhaps because endorsement of some CDS-12 items implies accepting that one is dependent, which in turn could reflect motivation to quit. CDS-12 may represent an alternative to FTND for measuring cigarette dependence.

A self‐administered questionnaire to measure cigarette withdrawal symptoms: The Cigarette Withdrawal Scale

Because few tobacco withdrawal scales have been submitted to appropriate validity analyses, we sought to develop and assess the validity of a new, self-administered scale measuring cigarette withdrawal symptoms. We generated the instrument content by conducting a qualitative survey of 404 smokers and ex-smokers. Then we tested 61 items on the Internet in 3,050 smokers and ex-smokers. Subsamples provided comprehensive retest data after 17 days (n = 1218) and smoking status after 41 days (n = 673). The study resulted in a 21-item, six-dimension scale labeled the Cigarette Withdrawal Scale (CWS-21). The six subscales cover the main components of nicotine or tobacco withdrawal in the Diagnostic and Statistical Manual of Mental Disorders and International Statistical Classification of Diseases and Related Health Problems and in qualitative data: Depression-anxiety, craving, irritability-impatience, appetite-weight gain, insomnia, and difficulty concentrating. The six scores had a satisfactory test-retest reliability (r = .60-.71) and a high internal consistency (Cronbach's alpha = .83-.96). The factor structure of the scale was robust in a bootstrap resampling procedure. In ex-smokers, all scores except appetite-weight gain and insomnia predicted relapse at 41-day follow-up. In recent ex-smokers who had quit smoking less than 14 days before baseline, all scores except appetite-weight gain decreased between baseline and the 17-day retest. In baseline ex-smokers who relapsed to smoking at the 17-day retest, appetite-weight gain decreased and craving increased between baseline and retest. CWS-21 is a reliable, valid, multidimensional measure of cigarette withdrawal symptoms that is sensitive to change over time and predicts relapse to smoking.

The psychological determinants of low-rate daily smoking

AIMS

To compare low-rate daily smokers (one to five cigarettes/day) with other daily smokers, using the Transtheoretical Model of Change as a framework.

DESIGN

Mail survey with a follow-up after 7 months.

SETTING

A randomly selected population sample in French-speaking Switzerland, in 1998.

PARTICIPANTS

A total of 2338 daily smokers aged 25 + years, including 95 smokers of one to five cigarettes/day, 324 smokers of six to 10 cigarettes/day, 399 smokers of 11-15 cigarettes/day and 1520 smokers of 16 + cigarettes/day, and 1765 people (75% of 2338) at 7-month follow-up.

FINDINGS

Compared with smokers of 16 + cigarettes/day, low-rate smokers of one to five cigarettes/day included more women (67% versus 46%, P < 0.001), were 4 years younger (P < 0.001), were less motivated to quit smoking (62% versus 37% in the 'precontemplation' stage of change, P < 0.001), thought that quitting would be easier (-3.4 points on a 0-10 scale, P < 0.001) and were less bothered by the risk of smoking. Low-rate smokers were taking control more actively over their smoking, e.g. they more often stayed away from places where people smoked, sat in the no-smoking sections in public places and tried to delay as much as they could their first cigarette of the day. Only 45% of low-rate smokers were still in the same category 7 months later.

CONCLUSIONS

For many smokers, low-rate smoking may result from a conscious effort to limit their cigarette consumption. Being a low-rate smoker was a temporary condition for most people. Low-rate smokers should be considered as a specific, although heterogeneous group.

The Transtheoretical Model of Behavior Change and Smokers in Southern Appalachia

BACKGROUND

The southern Appalachian states show a high prevalence of smoking, with associated high rates of both heart disease and cancer, yet cultural differences raise questions concerning the applicability of the most frequently used model for smoking cessation, the transtheoretical model, for smokers from this region of the country.

OBJECTIVE

To identify, by examining the applicability of the transtheoretical model for southern Appalachian smokers, the percentage of individuals in each of the five stages of change, the use of the processes of change from the trans-theoretical model, and the scores on recognized predictors of smoking cessation including the temptation to smoke, the perceived barriers to cessation, the pros and cons of smoking, and nicotine dependence.

METHODS

This population-based, descriptive, cross-sectional study used a random sample of 3,800 telephone numbers, which were called up to eight times. The 659 smokers or former smokers who agreed to participate were mailed a written questionnaire consisting of six well-established scales that measure constructs from the transtheoretical model. The final sample consisted of 357 usable questionnaires.

RESULTS

The distribution of smokers in northeastern Tennessee differed from national samples across the first three stages of change, with 56% in precontemplation, as compared with previous findings of 40% in national samples. The subjects' scores for the pros of smoking were similar across the stages of change in this sample, and although the scores for the cons differed significantly across the stages in the sample, post hoc analysis indicated that the only significant change occurred between precontemplation and contemplation. The scores for temptation to smoke did not differ significantly across the stages of change in this sample.

DISCUSSION

Smokers from Appalachian Tennessee differ from smokers in other parts of the United States, and these findings raise questions about the applicability of the transtheoretical model for this population.

Effects of stage-matched repeated individual counseling on smoking cessation: A randomized controlled trial for the high-risk strategy by lifestyle modification (HISLIM) study

OBJECTIVE

The purpose of this study was to evaluate the effects of stage-matched repeated individual behavioral counseling as an intervention for the cessation of smoking.

METHODS

We conducted a multisite randomized controlled trial that enrolled smokers unselected for their readiness to quit. There were 979 smokers with hypertension or hypercholesterolemia recruited from 72 study sites and randomly allocated to the intervention or control group. Smokers in the intervention group received stage-matched individual counseling consisting of a 40 minute initial session and four 20-30 minute follow-up sessions. Smokers in the control group received individual behavioral counseling for hypertension or hypercholesterolemia.

RESULTS

The point prevalence abstinence rate at 6 months, validated by carbon monoxide testing, in the intervention group (13.6%) was 5.4 times higher (p<0.001) than that in the control group (2.5%). When the data were analyzed based on the baseline stage of change, there were significant differences in the abstinence rates at 6 months in smokers versus controls with each stage of change except in immotives. The odds ratio was 6.4 (p<0.001) in precontemplators, 6.7 (p<0.001) in contemplators, and 6.2 (p<0.01) in preparators. There was a positive, consistent effect of the intervention regardless of study site (worksite or community) or the presence of hypertension or hypercholesterolemia.

CONCLUSIONS

We showed the effects of an intervention with repeated individual behavioral counseling on the cessation of smoking in smokers unselected for their readiness to quit. This result suggests that stage-matched individual counseling, based on the transtheoretical model, is effective in smokers with a lower motivation to quit as well as those ready to quit.

Utilization and impact of cigarette pack covers illustrated with antismoking messages

The authors tested whether smokers would use cigarette pack covers illustrated with antismoking messages. In 2001, visitors to a smoking cessation Web site ordered cigarette pack covers and answered a follow-up questionnaire 52 days later. Participants received by mail cardboard boxes designed to contain cigarette packs and illustrated with antismoking messages. Participants were 393 smokers living in France, Belgium, and Switzerland. Participants used their boxes for 21 days out of a possible 28 days, and 31% were still using them at follow-up. Almost one third (32%) said that the boxes often prompted discussions about smoking. The boxes that were submitted to pretests were preferred to the boxes that were not pretested. The authors concluded that the boxes were welcomed by smokers and enabled the display of antismoking messages for 3 weeks in their immediate environments. The intervention had no impact on smoking cessation, but this was not its primary objective.

Asking about quantity and frequency of alcohol consumption before asking the CAGE questions produces lower ratings on the CAGE test

BACKGROUND

We tested whether asking about alcohol consumption before asking the CAGE questions modified the answers to the CAGE test.

METHODS

Randomized trial on a smoking cessation website, in English, in 2003. Half the participants began by answering questions on quantity and frequency of alcohol consumption and then, on a second web page, answered the CAGE questionnaire (format A). The other half answered first the CAGE and then questions on quantity and frequency (format B).

RESULTS

The survey was answered by 1213 people. Fewer people gave positive answers to three of the four CAGE questions in format A than in format B. Cut-down, 32% versus 38% (P= 0.01); annoyed, 13% versus 18% (P = 0.02); eye-opener, 5% versus 8% (P = 0.02). Fewer people had a CAGE score >/=2, indicating possible alcoholism, in format A than in format B (26% versus 32%, P = 0.04). This effect was stronger in men (CAGE > or = 2, format A, 29%; format B, 39%; P = 0.03), and it was not statistically significant in women (CAGE > or = 2, format A, 25%; format B, 28%; P = 0.4).

CONCLUSION

In an internet survey, asking questions about the quantity and frequency of alcohol consumption before asking the CAGE questionnaire produced fewer positive answers to the CAGE. This effect was observed only in men.

Smoking cessation and weight gain

Cigarette smoking is the single most important preventable cause of death and illness. Smoking cessation is associated with substantial health benefits. Weight gain is cited as a primary reason for not trying to quit smoking. There is a great variability in the amount of weight gain but younger ages, lower socio-economic status and heavier smoking are predictors of higher weight gain. Weight change after smoking cessation appears to be influenced by underlying genetic factors. Besides, weight gain after smoking cessation is largely because of increased body fat and some studies suggest that it mostly occurs in the subcutaneous region of the body. The mechanism of weight gain includes increased energy intake, decreased resting metabolic rate, decreased physical activity and increased lipoprotein lipase activity. Although there is convincing evidence for the association between smoking cessation and weight gain, the molecular mechanisms underlying this relationship are not well understood. This review summarizes current information of the effects of nicotine on peptides involved in feeding behaviour. Smoking was shown to impair glucose tolerance and insulin sensitivity and cross-sectional studies have demonstrated that smokers are insulin-resistant and hyperinsulinaemic, as compared with non-smokers. Smoking cessation seems to improve insulin sensitivity in spite of the weight gain. Nicotine replacement - in particular nicotine gum - appears to be effective in delaying post-cessation weight gain. In a group of women who failed to quit smoking because of weight gain, a dietary intervention (intermittent very-low-calorie diet) plus nicotine gum showed to both increase success rate in terms of smoking cessation and prevent weight gain. On the other hand, body weight gain at the end of treatment was significantly lower in the patients receiving bupropion or bupropion plus nicotine patch, compared with placebo. Studies with new drugs available for the treatment of obesity - sibutramine and orlistat - are warranted.

Postintervention effect of nicotine replacement therapy on smoking reduction in smokers who are unwilling to quit: randomized trial

The objective of this study was to assess the post-intervention effect of nicotine replacement therapy on reduction of cigarette consumption 1.5 years after the end of a 6-month treatment. Heavy smokers who had no intention of quitting smoking were recruited from the general population and were randomly assigned to a treatment of nicotine (choice of a 15-mg nicotine patch, a 4-mg nicotine gum, and/or a 10-mg nicotine inhaler, n = 265), matching placebo products (n = 269), or no intervention (n = 389). Products were sent to participants by mail. Education was limited to a booklet. Of 923 participants, 879 (95%) were followed 6 months after randomization and 846 (92%) were followed after 26 months. Mean baseline consumption was 30 cigarettes/day in all groups. After 6 months, cigarette consumption had decreased by a mean of 10.9 cigarettes/day in the nicotine group, 8.7 in the placebo group, and 4.9 among controls (P < or = 0.02 for all pairwise comparisons). After 26 months, compared with baseline, cigarette consumption had decreased by a mean of 9.8 cigarettes/day in the nicotine group, 7.7 in the placebo group, and 7.7 among controls (nicotine vs. placebo or control: P < or = 0.03). After 2 years, smoking cessation rates did not differ significantly among groups (nicotine 11.7%, placebo 9.3%, control, 10.0%; P = 0.6). Thus, a slight effect of nicotine replacement therapy on reduction of cigarette consumption was maintained 1.5 years after the end of the 6-month treatment, but the initially observed placebo effect was not maintained. Nicotine replacement therapy for smoking reduction had no deleterious impact on smoking cessation.

Associations between smoking prevalence, stages of change, cigarette consumption, and quit attempts across the United States

BACKGROUND

We tested whether across the 50 U.S. States, smoking prevalence was associated with smoking behavior among smokers.

METHODS

We used published data on smoking prevalence, cigarette consumption, and quit attempts by State from the Behavioral Risk Factor Surveillance System (BRFSS) for 1993, 1996, and 1999, and published data on the distribution of smokers by stage of change in each State from the Current Population Survey (CPS). Data were weighted for the population size in each State.

RESULTS

For 1993, we found no statistically significant association between smoking prevalence and stages of change. For 1996 and 1999, across the 50 States, each additional percentage point in smoking prevalence was associated with, respectively, 0.62% and 1.19% more smokers in the "precontemplation" stage, that is, smokers not intending to quit smoking (both P < 0.01), with, respectively, 0.82% and 1.21% more "heavy" smokers who smoked 21-40 cigarettes per day (both P </= 0.001), and with, respectively, 1.12% and 0.81% fewer daily smokers who quit smoking for 1+ days in the previous year (both P </= 0.04).

CONCLUSIONS

Across the 50 States, a higher prevalence of cigarette smoking was associated with a lower motivation to quit smoking, fewer quit attempts, and higher cigarette consumption among smokers.

Effects of sustained-release bupropion among persons interested in reducing but not quitting smoking

PURPOSE

To determine whether sustained-release bupropion promotes smoking reduction leading to smoking cessation among persons who wish to reduce their amount of smoking, but who are unwilling to quit or who perceive themselves as being unable to quit.

METHODS

Current smokers were assigned randomly to receive either sustained-release bupropion (150 mg twice daily) or matching placebo. During an initial 6-month smoking reduction phase, those who were willing to quit entered a 7-week cessation phase, during which study medication was continued.

RESULTS

Four-week continuous abstinence rates were 14% (41/295) in the bupropion group and 8% (25/299) in the placebo group (P = 0.02) during treatment. However, this benefit did not continue after treatment was stopped; subsequent continuous abstinence rates were 7% (20/295) in the bupropion group and 5% (16/299) in the placebo group (P = 0.50). Similar proportions of subjects entered the cessation phase in both treatment groups (38% [n = 113] of those in the bupropion group and 34% [n = 101] of those in the placebo group), although the time until a cessation attempt was shorter for those taking bupropion (median, 64 days vs. 118 days, P = 0.008). The extent of smoking reduction (measured by urinary cotinine concentrations) among the 327 subjects who did not enter the cessation phase was significantly greater (P <0.05) in those treated with bupropion during the reduction treatment phase, but not during the month 12 follow-up visit (P = 0.25).

CONCLUSION

Sustained-release bupropion, when used in smokers initially not willing to make a cessation attempt, can help sustain smoking reduction while subjects are on active medication, reduce the time until the next cessation attempt, and increase short-term abstinence rates. However, these benefits were modest and not sustained after bupropion was discontinued.