"Prequit attrition" among weight-concerned women smokers

Predictors of attrition in a randomized controlled trial of an electronic nicotine delivery system among people interested in cigarette smoking reduction

BACKGROUND

Mitigating attrition is a key component to reduce selection bias in longitudinal randomized controlled trials (RCTs). Few studies of electronic nicotine delivery systems (ENDS) allow for the examination of long-term retention. This analysis explores the relationship between attrition, baseline measures, and condition assigned for a RCT involving ENDS differing in nicotine delivery over a 24-week intervention period.

METHODS

Participants (N = 520) who smoked ≥10 cigarettes per day [CPD] for ≥1 year and reported interest in reducing but not quitting were randomized to 1 of 4 conditions: an ENDS containing 0, 8, or 36 mg/ml liquid nicotine (administered double-blind) or a cigarette-shaped plastic tube. Cox proportional hazards regression models were fit to examine attrition over time and predictors of attrition including baseline characteristics and condition. A stepwise approach was used to determine the final model; alpha was set at 0.05.

RESULTS

Attrition did not differ significantly by condition (223/520), and most (69%) were lost-to-follow-up. Only age, education level, and household income were significantly predictive of attrition. For every additional year of age, attrition risk fell by 3%. Holding a bachelor's degree or higher was associated with reduced attrition risk. Those with the lowest income (<$10 K) were more likely to be withdrawn compared to those earning $10 K-39 K, and those with the highest income ($100 K+) were more likely to be withdrawn compared with the latter bracket and those earning $70-99 K.

CONCLUSION

ENDS nicotine content did not drive differential attrition in this trial, and targeted retention efforts are needed for specific subgroups. Trial Registration #: NCT02342795.

Impact of Weight Concern on Post-Cessation Weight Management, Smoking Cessation, and Program Engagement

PURPOSE

Weight concern is a barrier to smoking cessation. We examined the impact of weight concern on post-cessation weight gain, abstinence and program engagement.

DESIGN

Randomized-controlled trial.

SETTING

Telephone-based and group-based intervention sessions.

SUBJECTS

305 participants were randomized and analyzed.

INTERVENTION

Participants were randomized to receive a self-guided intervention, a weight loss intervention, or a weight stability intervention prior to all receiving the same smoking cessation intervention.

MEASURES

Level of weight concern on three measures, point-prevalence abstinence, weight change, and session attendance at 12 months.

ANALYSIS

Continuous and discrete outcomes were compared between weight-concerned and non-weight-concerned participants using two-sample t-tests and chi-square tests respectively.

RESULTS

There were no significant differences in weight change (range: +1.77, -1.91 kg) when comparing weight-concerned and non-weight-concerned participants. Point-prevalence abstinence ranged from 36% to 64%, with no differences by condition based on level of weight concern. There were no significant differences in session attendance by weight concern (Weight sessions: 50-70%, Smoking cessation sessions: 41-56%, Booster sessions: 28-45%). Weight concern, on all measures, significantly decreased between screening and 2 months (after the weight management intervention), for most of the comparisons made overall and by condition.

CONCLUSION

It may not be necessary to screen for weight concerns in smoking cessation and/or post-cessation weight management programs, as the trial interventions were beneficial regardless of weight concern.

Pilot feasibility trial of dual contingency management for cigarette smoking cessation and weight maintenance among weight-concerned female smokers

Many women who smoke cigarettes report that concern about weight gain is a barrier to quitting. Indeed, most quitters gain weight and some attribute relapses to weight gain concern. Contingency management (CM), which refers to reinforcing a target behavior with financial incentives, has been demonstrated effective for promoting smoking abstinence and weight management independently. We conducted a pilot trial to establish the feasibility of dual CM, in which both smoking cessation and weight maintenance were incentivized, as a smoking cessation intervention for female weight-concerned smokers. Participants (N = 10) received a 12-week intervention during which they earned financial incentives for smoking abstinence, verified by breath carbon monoxide (CO) testing, and for maintaining their weight (larger incentives for gaining less than five pounds, smaller incentives for 5-10 pound gain) while abstaining from smoking. They attended an end of intervention visit at week 13 and a follow-up visit at week 26. Total compensation was up to $550 ($255 for participation independent of smoking and weight, $145 for smoking abstinence incentives, and $150 for weight maintenance incentives). Results indicated that five of the 10 participants (50%) were continuously abstinent for at least 4 weeks and received at least 2 weight maintenance incentives. Three participants (33%) were abstinent at every visit they attended from quit date through week 26; 2 of these 3 had gained more than 10 pounds by week 26. Additional formative research to test alternative incentive schedules and modalities should be conducted before CM-W is evaluated in a larger trial. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A Pilot Randomized Controlled Trial of Distress Tolerance Treatment for Weight Concern in Smoking Cessation Among Women

INTRODUCTION

The majority of women who smoke cigarettes report that concern about weight gain is a barrier to quitting. We developed an intervention incorporating distress tolerance, appetite awareness, and mindful eating skills to target concerns about post-cessation weight gain and emotional eating (DT-W). In the current study, we conducted a pilot randomized controlled trial of DT-W versus a smoking health education (HE) intervention.

METHODS

Participants (N = 69 adult female, weight-concerned smokers) were recruited in cohorts of 4-11. Cohorts were randomized to DT-W or HE. DT-W and HE were matched on format (single individual session followed by eight group sessions), inclusion of cognitive behavioral therapy for smoking cessation (CBT) content, and pharmacotherapy (nicotine patches). Follow-up assessments occurred at 1-, 3-, and 6-months post-treatment.

RESULTS

The recruitment goal was met; 61 of the 69 participants attended at least one group session. There were no significant differences between DT-W and HE in the number of group sessions attended (DT-W adjusted M = 5.09, HE adjusted M = 5.03, p = .92), ratings of treatment effectiveness or usefulness of skills, or retention at 6-month follow-up (79% in DT-W vs. 78% in HE) (ps > .05), but comprehension ratings were lower in DT-W than in HE (p = .02).

CONCLUSIONS

Overall, these results suggest that the study procedures and interventions were feasible and acceptable, but changes to the DT-W intervention content to improve comprehension should be considered prior to conducting a fully powered trial.

IMPLICATIONS

A distress tolerance-based treatment targeting fear of weight gain after smoking cessation and post-cessation emotional eating was feasible and acceptable relative to a smoking HE comparison condition, but changes should be considered before conducting a larger trial. Continued innovation in treatment development for weight-concerned smokers is needed.

Referral to Slimming World in UK Stop Smoking Services (SWISSS) versus stop smoking support alone on body weight in quitters: results of a randomised controlled trial

INTRODUCTION

Most people who stop smoking gain weight. Dietary modification may seem an obvious solution, but food restriction may increase cigarette craving and smoking relapse.

TRIAL DESIGN

An unblinded parallel randomised controlled trial.

METHODS

Participants were adult smokers with a body mass index greater or equal to 23 kg/m². Setting was National Health Service commissioned Stop Smoking Services, interventions were referral to a commercial weight management programme, plus stop smoking support (treatment group), compared with stop smoking support alone (control group). Objective was to compare weight change between interventions in smoking abstainers and not abstinent rates in all. Primary outcome was change in weight (kg) at 12 weeks. Randomisation sequence was computer generated and concealed until allocation.

RESULTS

Seventy-six participants were recruited, 37 were randomised to the treatment group and 39 to the control group. Change in weight was analysed in long-term abstainers (13 treatment, 14 control) only because the aim was to prevent weight gain associated with smoking cessation. Abstinence was analysed on an intention-to-treat basis (37 treatment, 39 control). At 12 weeks weight gain was less in the treatment than the control group with an adjusted mean difference of -2.3 kg 95% CI (-4.4 to -0.1). Craving scores were lower (Mood and Physical Symptoms Scale craving domain -1.6 (-2.7 to -0.5)) and quit rates were higher in the treatment than the control group (32% vs 21%), although the trial was not powered to superiority in cravings and quit rates. No adverse events or side effects were reported.

CONCLUSION

In people who are obese and want to quit smoking, these data provide modest encouragement that providing weight management at the time of quitting may be helpful. Those who are not obese, but who are informed about potential weight gain during their quit attempt, were uninterested in a weight management programme.

TRIAL REGISTRATION NUMBER

ISRCTN65705512.

A Confirmatory Factor Analysis of the Smoking and Weight Eating Episodes Test (SWEET)

INTRODUCTION

The Smoking and Weight Eating Episodes Test (SWEET; Adams et al. 2011) is a self-report measure designed to assess multiple reasons why and when smokers use cigarettes for appetite, weight, and shape management, that was initially developed and validated in young female smokers.

PURPOSE

The aim of the current study was to evaluate the factor structure and psychometric properties of the SWEET measure among both male and female daily cigarette smokers.

METHOD

Participants (n = 577; M_age = 44.42; SD = 13.80; 52.7% female) were daily smokers recruited through Qualtrics Online Sample for an anonymous study on smoking and health. On average, participants reported smoking for 25.7 years (SD = 14.35), smoked 17.0 cigarettes per day (SD = 8.38), and had moderate levels of tobacco dependence.

RESULTS

Confirmatory factor analyses supported the initial factor structure found in the original SWEET measure suggesting a four-factor structure fit the data well, but not a one-factor structure. Factors included using cigarettes for appetite suppression, using cigarettes to prevent overeating, smoking to cope with body dissatisfaction, and using cigarettes to cope with appetite-related withdrawal symptoms. Tests of measurement invariance revealed no significant differences when evaluating SWEET scores by participant sex. The SWEET factor scores evidenced internal consistency, known groups validity, convergent validity with related constructs (compensatory eating behaviors, tobacco dependence) and cessation-relevant variables (smoking abstinence expectancies, prior withdrawal symptoms), and discriminant validity with physical activity and sedentary behavior.

CONCLUSIONS

The present study provides evidence in support of the validity and reliability of scores on the SWEET as a multidimensional measure of smoking for appetite, weight, and body-related concerns in male and female daily cigarette smokers.

Lack of Substantial Post-Cessation Weight Increase in Electronic Cigarettes Users

Minimization of post-cessation weight gain in quitters is important, but existing approaches (e.g., antismoking medications) shows only limited success. We investigated changes in body weight in smokers who quit or reduced substantially their cigarette consumption by switching to electronic cigarettes (ECs) use. Body weight and smoking/vaping history were extracted from medical records of smokers and ex-smokers to match three study groups: (1) regular EC users on at least two consecutive follow-up visits; (2) regular smokers (and not using ECs); (3) subjects who reported sustained smoking abstinence after completing a cessation program. Review of their medical records was conducted at two follow-up visits at 6- (F/U 6m) and 12-months (F/U 12m). A total of 86 EC users, 93 regular smokers, and 44 quitters were studied. In the EC users study group, cigarettes/day use decreased from 21.1 at baseline to 1.8 at F/U 12m (p < 0.0001). Dual usage was reported by approximately 50% of EC users. Both within factor (time, p < 0.0001) and between factor (study groups, p < 0.0001) produced significant effect on weight (% change from baseline), with a significant 4.8% weight gain from baseline in the quitters study group at F/U 12m. For the EC users, weight gain at F/U 12m was only 1.5% of baseline. There was no evidence of post-cessation weight increase in those who reduced substantially cigarette consumption by switching to ECs (i.e., dual users) and only modest post-cessation weight increase was reported in exclusive EC users at F/U 12m. By reducing weight gain and tobacco consumption, EC-based interventions may promote an overall improvement in quality of life.

Initial engagement and attrition in a national weight management program: demographic and health predictors

Inconsistent attendance and participant withdrawal limit the effectiveness of weight control programs, but little is known about predictors of initial and ongoing engagement. The purpose of this study was to identify these predictors with respect to the Veterans Affairs MOVE!® program, using medical record data. Logistic regression models were used to predict initial and ongoing engagement (n = 39,862 and 1985, respectively). Those who initially engaged in MOVE!® (vs. did not) were more likely to have high BMIs, to be female, live closer to the medical center, and receive health benefits from the VA; they also were less likely to use tobacco (ps < 0.02). Older veterans were more likely to continue to engage (p < 0.001), with trends toward continued engagement for those with (vs. without) benefits and higher BMIs (ps < 0.10). Findings highlight characteristics that may inform program improvements that promote ongoing engagement and prevent dropouts in a weight management programs.

Distress Tolerance Treatment for Weight Concern in Smoking Cessation Among Women: The WE QUIT Pilot Study

Fear of gaining weight after quitting cigarette smoking is a major barrier to smoking cessation among women. Distress tolerance, which refers to one's ability and willingness to tolerate physical and emotional discomfort, predicts successful behavior change. Novel interventions rooted in Acceptance and Commitment Therapy (ACT) have emerged that aim to increase distress tolerance and engagement in values-oriented behavior. In this study, we developed a 9-week, group-based distress tolerance intervention for weight concern in smoking cessation among women (DT-W). Using an iterative process, we piloted DT-W with two small groups ( n = 4 and n = 7) of female weight-concerned smokers. Results indicated that we successfully established the feasibility and acceptability of DT-W, which was well-attended and well-received. Biochemically verified 7-day point-prevalence abstinence rates at post-intervention, 1, 3, and 6 months were 64%, 36%, 27%, and 27%, respectively. We are now evaluating DT-W in a randomized controlled trial.

Predictors of retention in a randomised trial of smoking cessation in low-socioeconomic status Australian smokers

BACKGROUND AND AIMS

Little is known about the factors associated with retention in smoking cessation trials, especially for low-socioeconomic status (low-SES) smokers. This study examined the factors associated with retention of low-SES smokers in the Australian Financial Interventions for Smoking Cessation Among Low-Income Smokers (FISCALS) trial.

DESIGN

A two-group parallel block randomised open-label trial with allocation concealment.

SETTING

Australia. The study was conducted primarily by telephone-based interviews with nicotine replacement therapy delivered via mail.

PARTICIPANTS

1047 low-SES smokers interested in quitting smoking were randomised.

MEASUREMENTS

Participants completed computer assisted telephone interviews (CATIs) at baseline, 2-month and 8-month follow-up. Smoking-related, substance use, mental or physical health, general psychological constructs, sociodemographic and recruitment sources association with retention at 8-month follow-up were examined using binary logistic regression.

FINDINGS

946 participants (90%) completed the 2-month follow-up interview and 880 participants (84%) completed the 8-month follow-up interview. Retention at 8-months was associated with higher motivation to quit (OR: 1.15; 95% CI: 1.04, 1.27 p<0.01), more recent quit attempts (OR: 1.20; 95% CI: 1.04, 1.40 p<0.05), increasing age (OR: 1.05; 95% CI: 1.03, 1.07 p<0.01), and higher level of education (OR: 2.24; 95% CI: 1.45, 3.46 p<0.01). Lower retention at 8-months occurred for those participants recruited from posters placed in Department of Human Service Centrelink Offices (OR: 0.56; 95% CI: 0.35, 0.89, p<0.05) compared to participants recruited from Quitline services. No significant differences in retention were found for participants recruited via newspaper advertisements or word of mouth compared to Quitline services. No significant associations were found between health-related or behavioural factors and retention.

CONCLUSIONS

In the context of high overall retention rates from disadvantaged smokers in a randomised trial, retention was greater in those smokers with higher motivation to quit, more recent quit attempts, increased age, higher level of education and for those recruited through Quitline or newspaper advertisements.

Anxiety sensitivity in relation to quit day dropout among adult daily smokers recruited to participate in a self-guided cessation attempt

Anxiety sensitivity (AS; fear of anxiety and internal sensations) has been implicated in a variety of aspects of smoking, including difficulties achieving and maintaining abstinence during tobacco cessation. However, research has yet to evaluate whether AS impacts premature termination of initiating a quit attempt. Therefore, the aim of the present investigation was to explore the extent to which AS was associated with tobacco cessation dropout, as indexed by attendance on the scheduled quit day visit. Participants included 84 adult daily cigarette smokers (61.7% male; Mage=34.6years, SD=13.9), who were recruited to participate in a self-guided quit attempt (an attempt to quit smoking without professional or pharmacological aid). Results indicated that after controlling for the effects of participant sex, race, current (past month) psychological disorder, cigarettes smoked per day, number of years as a regular smoker, and pre-quit levels of motivation to quit, AS significantly predicted increased odds of study dropout prior to attending the scheduled quit day. These findings suggest that AS may be a mechanism involved with challenges in the initiation of quitting.

Smoking relapse and weight gain prevention program for postmenopausal weight-concerned women: A pilot study

OBJECTIVE

Postmenopausal women have substantial concerns about weight gain when quitting smoking, which may contribute smoking relapse. There is a need for smoking cessation and weight gain prevention programs effective in this population.

METHODS

Two formats of a smoking cessation/weight gain prevention follow-up intervention in postmenopausal weight concerned women were compared: a minimally-tailored group format and a highly tailored, multidisciplinary individual format. Effects on sustained abstinence and postcessation weight gain were assessed. Postmenopausal smokers received 6 sessions of behavioral counseling over a 2-week period, 8weeks of the nicotine transdermal patch, and subsequent random assignment to receive follow-up relapse prevention sessions at 1, 3, 8, and 16weeks postcessation in either group or individual format.

RESULTS

The sample (N=98) was 67% Caucasian and 33% African-American. Age: m=52.3 (7.8) years, follicle stimulating hormone: m=42.6 (25.7), body mass index (BMI): m=27.4 (6.2), daily smoking rate: m=20.3 (11.5), for m=29.4 (10.7) years, Fagerström Test for Nicotine Dependence (FTND): m=6.4 (2.1), and carbon monoxide: m=23.8 (13.0) ppm. Abstinence rates in the group condition were significantly higher at 8weeks posttreatment. Group format significantly predicted abstinence rates at 8 and 16weeks posttreatment, even while controlling for age, race, BMI, CPD, years smoking, FTND, and weight concern. Weight concern predicted postcessation weight gain at 8 and 16weeks posttreatment.

CONCLUSIONS

Results indicate that smoking cessation programs for postmenopausal women may best be delivered in a group format and that postcessation weight concerns be dealt with prior to a quit date.

Once bitten, twice shy: concern about gaining weight after smoking cessation and its association with seeking treatment

BACKGROUND

Concern about weight gain after quitting smoking is often cited as a barrier to smokers making a quit attempt or seeking treatment.

AIM

To identify whether smokers who are non-treatment seekers (NTS) are more concerned about weight gain and have lower confidence to maintain weight after quitting smoking as compared with treatment-seeking smokers (TS).

METHODS

Participants were smokers recruited from Penn State Hershey Medical Center and family practice outpatient clinics. A total of 102 NTS and 186 TS, who participated in a smoking cessation trial, completed a survey regarding tobacco use, weight concern and diet. Stepwise logistic regression was used to identify variables associated with treatment seeking, overall and stratified by those who gained and did not gain weight on a previous quit attempt.

RESULTS

Fifty three per cent of the overall sample (47.1% NTS vs. 56.5% TS, p = 0.127) had gained weight on a prior quit attempt. Among smokers who had gained weight, higher weight gain concern (WGC) and lower confidence in ability to maintain weight were significantly associated with being a NTS after adjusting for other factors.

CONCLUSION

Among smokers who gained weight on a previous quit attempt, NTS had greater concern about gaining weight and less confidence in their ability to maintain their weight after quitting than treatment seekers. Clinicians can identify smokers for whom WGC may be a barrier to seeking treatment by asking if they gained weight on a previous quit attempt. These smokers should be assured that this issue will be addressed in treatment.

Slimming World in Stop Smoking Services (SWISSS): study protocol for a randomized controlled trial

Background

Quitting smokers gain weight. This deters some from trying to stop smoking and may explain the increased incidence of type 2 diabetes after cessation. Dieting when stopping smoking may be counterproductive. Hunger increases cravings for smoking and tackling two behaviours together may undermine quitting success. A meta-analysis of randomized controlled trials (RCTs) showed individualized dietary support may prevent weight gain, although there is insufficient evidence whether it undermines smoking cessation. Commercial weight management providers (CWMPs), such as Slimming World, provide individualized dietary support for National Health Service (NHS) patients; however, there is no evidence that they can prevent cessation-related weight gain.

Our objective is to determine whether attending Slimming World from quit date, through referral from NHS Stop Smoking Services, is more effective than usual care at preventing cessation-related weight gain.

Methods

This RCT will examine the effectiveness of usual cessation support plus referral to Slimming World compared to usual cessation support alone. Healthy weight, overweight and obese adult smokers attending Stop Smoking Services will be included. The primary outcome is weight change in quitters 12 weeks post-randomization. Multivariable linear regression analysis will compare weight change between trial arms and adjust for known predictors of cessation-related weight gain.

We will recruit 320 participants, with 160 participants in each arm. An alpha error rate of 5% and 90% power will detect a 2 kg (SD = 2.5) difference in weight gain at 12 weeks, assuming 20% remain abstinent by then.

Discussion

This trial will establish whether referral to the 12-week Slimming World programme plus usual care is an effective intervention to prevent cessation-related weight gain. If so, we will seek to establish whether weight control comes at the expense of a successful quit attempt in a further non-inferiority trial.

Positive results from both these trials would provide a potential solution to cessation-related weight gain, which could be rolled out across England within Stop Smoking Services to better meet the needs of 0.75 million smokers stopping with NHS support every year.

Trial registration

Current Controlled Trials ISRCTN65705512

A Qualitative Perspective on Multiple Health Behaviour Change: Views of Smoking Cessation Advisors Who Promote Physical Activity

There are mixed views on whether smoking cessation advisors should focus only on quitting smoking or also promote simultaneous health behaviour changes (e.g., diet, physical activity), but no studies have qualitatively examined the views and vicarious experiences of such health professionals. Semi-structured interviews were conducted with 11 trained smoking cessation advisors who promote physical activity to their clients. The data were categorised into themes using thematic analysis supported by qualitative data analysis software. We report themes that were related to why advisors promote multiple health behaviour change and issues in timing. Physical activity could be promoted as a cessation aid and also as part of a holistic lifestyle change consistent with a nonsmoker identity, thereby increasing feelings of control and addressing fear of weight gain. Multiple changes were promoted pre-quit, simultaneously and post-quit, and advisors asserted that it is important to focus on the needs and capabilities of individual clients when deciding how to time multiple changes. Also, suggesting that PA was a useful and easily performed cessation aid rather than a new behaviour (i.e., structured exercise that may seem irrelevant) may help some clients to avoid a sense of overload.

Associations between weight change over 8 years and baseline body mass index in a cohort of continuing and quitting smokers

AIM

To examine the association between weight change and baseline body mass index (BMI) over 8 years in a cohort of continuing and quitting smokers.

DESIGN

Prospective cohort.

SETTING

Oxfordshire general practices nicotine patch/placebo trial with 8-year follow-up.

PARTICIPANTS

Eighty-five participants were biochemically proven abstinent at 3, 6, 12 months and 8 years (abstainers). A total of 613 smoked throughout the 8 years (smokers), 26 quit for a whole year but were smoking again by 8 years (relapsed); 116 smoked for the first year but were abstinent at 8 years (late abstainers).

MEASUREMENTS

Weight and BMI was measured at baseline and at 8 years. Regression models were used to examine weight gain by smoking status and the association of BMI at the time of quitting.

FINDINGS

Abstainers gained 8.79kg [standard deviation (SD) 6.36; 95% confidence interval (CI) 7.42, 10.17]. Smokers gained 2.24 kg (SD 6.65; 95% CI 1.7, 2.77). Relapsed smokers gained 3.28 kg (SD 7.16; 95% CI 0.328, 6.24). Late abstainers gained 8.33 kg (SD 8.04; 95% CI 6.85, 9.81). The association between baseline BMI and weight change was modified by smoking status. In smokers there was a negative linear association of BMI, while in abstainers a J-shaped curve fitted best. These models estimated weight change over 8 years in abstainers of +9.8 kg, +7.8kg, +10.2kg, +19.4kg and in smokers of +3.9kg, +2.6kg, 1.0kg and -0.8kg, where BMI was 18, 23, 29 and 36, respectively.

CONCLUSION

Obese smokers gain most weight on quitting smoking, while obese continuing smokers are likely to remain stable or lose weight. Obese quitters have the greatest need for interventions to ameliorate weight gain.

The co-occurrence of cigarette smoking and bipolar disorder: phenomenology and treatment considerations

OBJECTIVES

  Despite recent advances in understanding the causes and treatment of nicotine dependence among individuals with psychiatric disorders, smoking among individuals with bipolar disorder (BD) has received little attention. The goal of this review is to synthesize the literature on the epidemiology, consequences, and treatment of smoking and nicotine dependence among individuals with BD and to delineate a future research agenda.

METHODS

  We conducted a PubMed search of English-language articles using the search terms bipolar disorder, mania, tobacco, nicotine, and smoking, followed by a manual search of the literature cited in the identified articles. Articles were chosen by the authors on the basis of their relevance to the topic areas covered in this selective review.

RESULTS

  Adults with BD are two to three times more likely to have started smoking and, on the basis of epidemiological data, may be less likely to initiate and/or maintain smoking abstinence than individuals without psychiatric disorders. Smoking cessation is achievable for individuals with BD, but challenges such as chronic mood dysregulation, high prevalence of alcohol and drug use, more severe nicotine dependence, and limited social support can make quitting more difficult. Effective treatments for tobacco cessation are available, but no controlled trials in smokers with BD have been conducted.

CONCLUSIONS

  Cigarette smoking is a prevalent and devastating addiction among individuals with BD and should be addressed by mental health providers. Additional research on the mechanisms of, and optimal treatment for, smoking and nicotine dependence in this population is desperately needed.

Trial Protocol: randomised controlled trial of the effects of very low calorie diet, modest dietary restriction, and sequential behavioural programme on hunger, urges to smoke, abstinence and weight gain in overweight smokers stopping smoking

BACKGROUND

Weight gain accompanies smoking cessation, but dieting during quitting is controversial as hunger may increase urges to smoke. This is a feasibility trial for the investigation of a very low calorie diet (VLCD), individual modest energy restriction, and usual advice on hunger, ketosis, urges to smoke, abstinence and weight gain in overweight smokers trying to quit.

METHODS

This is a 3 armed, unblinded, randomized controlled trial in overweight (BMI > 25 kg/m2), daily smokers (CO > 10 ppm); with at least 30 participants in each group. Each group receives identical behavioural support and NRT patches (25 mg(8 weeks),15 mg(2 weeks),10 mg(2 weeks)). The VLCD group receive a 429-559 kcal/day liquid formula beginning 1 week before quitting and continuing for 4 weeks afterwards. The modest energy restricted group (termed individual dietary and activity planning(IDAP)) engage in goal-setting and receive an energy prescription based on individual basal metabolic rate(BMR) aiming for daily reduction of 600 kcal. The control group receive usual dietary advice that accompanies smoking cessation i.e. avoiding feeling hungry but eating healthy snacks. After this, the VLCD participants receive IDAP to provide support for changing eating habits in the longer term; the IDAP group continues receiving this support. The control group receive IDAP 8 weeks after quitting. This allows us to compare IDAP following a successful quit attempt with dieting concurrently during quitting. It also aims to prevent attrition in the unblinded, control group by meeting their need for weight management. Follow-up occurs at 6 and 12 months.Outcome measures include participant acceptability, measured qualitatively by semi-structured interviewing and quantitatively by recruitment and attrition rates. Feasibility of running the trial within primary care is measured by interview and questionnaire of the treatment providers. Adherence to the VLCD is verified by the presence of urinary ketones measured weekly. Daily urges to smoke, hunger and withdrawal are measured using the Mood and Physical Symptoms Scale-Combined (MPSS-C) and a Hunger Craving Score (HCS). 24 hour, 7 day point prevalence and 4-week prolonged abstinence (Russell Standard) is confirmed by CO < 10 ppm. Weight, waist and hip circumference and percentage body fat are measured at each visit.

TRIAL REGISTRATION

Current controlled trials ISRCTN83865809.

Distress tolerance and pre-smoking treatment attrition: examination of moderating relationships

This study focused on the understudied group of smokers who commit to a smoking research study and then subsequently drop out before completing even one session of treatment (pre-inclusion attrition). This is an important group typically not examined in their own right, leaving little knowledge about the characteristics that differentiate them from those who complete treatment. As an initial investigation, the current study examined affective risk factors for attrition in a sample of 53 adults (79% African-American; median income=$30,000-$39,999) enrolled in a smoking cessation study. Twenty-one (40%) participants never attended a session of treatment. Results indicated that lower psychological distress tolerance was related to pre-inclusion attrition, but only among women. Additionally, lower physical distress tolerance corresponded to pre-inclusion attrition, but only among men. These effects remained after including other important affective factors such as anxiety sensitivity and current depressive symptoms. No other predictors examined corresponded with pre-inclusion attrition in the present sample. Results indicate the need for more research attention to this at-risk group of smokers who do not continue on to cessation intervention.

Validity and reliability of the Weight Control Smoking Scale

The Weight Control Smoking Scale (WCSS), originally developed as part of a Reasons for Smoking Scale, includes 3 items (smoke to avoid weight gain; smoke to control appetite; less hungry when smoking). Although widely used, it has not previously been subjected to psychometric analysis. To fill this gap, we analyzed data from 1512 smokers. WCSS score correlated significantly and positively with the Dieting and Bingeing Severity Scale, self-efficacy about relapse if postcessation weight gain occurred, increased appetite/weight gain as a withdrawal symptom, and the Three Factor Eating Questionnaire subscales, and negatively with Body Satisfaction. Cronbach's alpha was .834. Female participants scored significantly higher than males. When only Black and White smokers were included, a significant interaction emerged such that White women scored higher than any other category. In a subsample of 50 smokers who completed the questionnaire twice, test-retest correlations were significant for all items and for the scale as a whole. Overall, our results suggest that the WCSS is a reliable and valid instrument that lends itself to use as a screening tool.

Predictors of pretreatment attrition from smoking cessation among pre- and postmenopausal, weight-concerned women

The present study sought to determine whether postcessation weight gain concerns influenced pretreatment attrition differently for pre- versus postmenopausal women smokers. Participants were pre- and postmenopausal women smokers drawn from two clinical trials for smoking cessation and weight gain prevention [the Smoking Treatment/Obesity Prevention (STOP) studies]. Predictors of attrition from baseline assessment visits prior to entering smoking cessation treatment were identified among these women. Pretreatment attrition was significantly higher among the premenopausal women. The premenopausal women had significantly higher weight concern but lower restraint and disinhibition than the postmenopausal women. Weight concern explained variance in treatment attrition from the programs, while controlling for variables such as Body Mass Index (BMI), smoking rate, number of years smoking, nicotine dependence level, dietary restraint, disinhibition, and hunger, such that the higher the weight concern, the more likely women were to drop out of treatment programs prior to a quitting attempt.

Weight and smoking cessation among low-income African Americans

BACKGROUND

Concerns about weight gain have been a commonly cited barrier to cessation among white, affluent, female populations, but less is known about this relationship among minority smokers and those with low incomes. Although smoking cessation is strongly encouraged for this population, it often leads to weight gain. Cultural differences in weight standards and the high prevalence of weight-related health conditions (e.g., hypertension and diabetes) may influence concerns about smoking cessation-related weight gain.

METHODS

A secondary analysis of low-income African-American smokers (n=367) from a randomized intervention trial was conducted to explore the association of weight concerns with comorbidities and smoking cessation.

RESULTS

Less than one quarter of participants were considered concerned about weight, defined as having high general concern about weight and high expectation of post-cessation weight gain. Those for whom weight gain could be riskiest--obese participants--were least concerned about gaining weight. Further, weight concerns were not associated with successful smoking cessation, quit attempts, confidence in quitting, or desire or readiness to quit.

CONCLUSIONS

Because post-cessation weight gain may be a serious health threat for this population, but weight gain was not a concern for these smokers, smoking-cessation interventions for low-income African-American smokers may need to incorporate weight-gain education and prevention.