Evaluation of biochemical validation measures in determination of smoking status

The effectiveness of smoking cessation interventions in rural and remote populations: Systematic review and meta-analyses

BACKGROUND

Rural and remote residents are more likely to smoke tobacco than those in major cities. However, they may experience unique systemic, provider, and individual barriers to accessing smoking cessation treatments, including distance and limited resources. Understanding the effectiveness of smoking cessation interventions in this population is important due to higher smoking-related disease burden and death compared to those in major cities.

METHODS

Medline, EMBASE, Scopus, PsychINFO, and Cochrane Library were searched until 19-02/2021. Inclusion criteria were randomised controlled trials (RCTs), cluster RCTs, randomised trials, or cluster randomised trials investigating behavioural interventions and pharmacotherapies for smoking cessation in rural and remote populations compared with a control or another smoking cessation treatment; and published in English. Given there is no internationally-standardised rurality index, definitions of 'rural' and 'remote' used by authors of studies were applied to reflect their country. Exclusion criteria were studies of non-combustible smoking cessation; and studies with urban participants in the sample. Two reviewers independently screened records for eligibility, extracted data from studies utilising a modified Cochrane Effective Practice and Organisation of Care Group form, and rated methodological quality using the Quality Assessment Tool for Quantitative Studies.

RESULTS

Sixteen studies were included. Meta-analysis revealed a statistically significant treatment effect of individual face-to-face counselling on smoking cessation (RR 2.35, 95% CI 1.16-4.76, I²=0%) in rural and remote populations. There was no statistically significant treatment effect for nicotine replacement therapy (RR 2.97, 95% CI 0.84-10.53, I²=47%), telephone-counselling (RR 1.69, 95% CI 0.56-5.06, I²=62%), and community-based multiple-interventions (RR:1.57, 95% CI 0.89-2.78, I²=85%). Certainty of evidence was rated very low for each meta-analysis.

CONCLUSION

Despite limited resources in rural and remote settings, individual face-to-face counselling for smoking cessation appears promising. Given the limited number of studies, further research about the effectiveness of smoking cessation interventions in rural and remote populations is warranted.

Association between age at first reported e-cigarette use and subsequent regular e-cigarette, ever cigarette and regular cigarette use

BACKGROUND AND AIMS

Association of electronic cigarette use and subsequent smoking has received considerable attention, although age of first use has not. This study tested differences in regular (e-cigarettes, cigarettes) and ever (cigarettes) use between e-cigarette user groups: early versus never users, late versus never users, early versus late users and effects of controlling for covariates.

DESIGN

Prospective study with 12- and 24-month follow-up of e-cigarette/cigarette ever/regular use with data from an intervention.

SETTING

Forty-five schools in England (Staffordshire and Yorkshire).

PARTICIPANTS

Never smokers (3289 13-14-year-olds) who were part of a cluster randomized controlled trial.

MEASUREMENTS

The sample was divided into groups of e-cigarette users: early users (at 13-14 years), late users (at 14-15 years) and never users (at 13-14 and 14-15 years). Dependent variables were self-reported regular e-cigarette and cigarette use and ever cigarette use at 15-16 years. Covariates were assessed.

FINDINGS

Early and late users compared with never users were significantly more likely to be regular e-cigarette users [early: odds ratio (OR) = 9.42, 95% confidence interval (CI) = 5.38, 16.49, P < 0.001; late: OR = 6.89, 95% CI = 4.11, 11.54, P < 0.001], ever cigarette users (early: OR = 7.96, 95% CI = 6.02, 10.53, P < 0.001; late: OR = 5.13, 95% CI = 3.85, 6.84, P < 0.001) and regular cigarette users (early: OR = 7.80, 95% CI = 3.99, 15.27, P < 0.001; late: OR = 4.34, 95% CI = 1.93, 9.77, P < 0.001) at age 15-16 years. Late users compared with early users had significantly lower rates of ever use of cigarettes at 15-16 years (OR = 0.48, 95% CI = 0.35, 0.66, P < 0.001), although this difference was non-significant at 12 months after first use of e-cigarettes (OR = 0.89, 95% CI = 0.64, 1.25, P = 0.498). Controlling for covariates did not change the findings.

CONCLUSIONS

Adolescents in England who report using e-cigarettes at age 13-14 years have higher rates of subsequently initiating cigarette use than adolescents who report using e-cigarettes at age 14-15 years, a difference that may be attributable to a longer period of time to initiate cigarette use in former group.

Evidence that an intervention weakens the relationship between adolescent electronic cigarette use and tobacco smoking: a 24-month prospective study

BACKGROUND

The electronic cigarette (e-cigarette) use to subsequent smoking relationship in adolescents has received much attention. Whether an intervention to reduce smoking initiation attenuated this relationship was assessed.

METHOD

Data were from 3994 adolescent never smokers (aged 13-14 years at baseline) as part of a cluster randomised controlled trial. Self-report measures of smoking, e-cigarette use and covariates were assessed and used to predict ever smoked cigarettes, any recent tobacco smoking and regularly smoked cigarettes at 24-month follow-up.

RESULTS

Baseline ever use of e-cigarettes was associated with ever smoked cigarettes (OR=4.03, 95% CI 3.33 to 4.88; controlling for covariates, OR=2.78, 95% CI 2.20 to 3.51), any recent tobacco smoking (OR=3.38, 95% CI 2.72 to 4.21; controlling for covariates, OR=2.17, 95% CI 1.76 to 2.69) and regularly smoked cigarettes (OR=3.60, 95% CI 2.35 to 5.51; controlling for covariates, OR=1.27, 95% CI 1.17 to 1.39) at follow-up. For ever smoked cigarettes only, the impact of e-cigarette use was attenuated in the intervention (OR=1.83) compared with control (OR=4.53) condition. For ever smoked cigarettes and any recent tobacco smoking, the impact of e-cigarette use was attenuated among those with friends who smoked (OR=2.05 (ever smoked); 1·53 (any tobacco use)) compared with those without friends who smoked (OR=3.32 (ever smoked); 2·17 (any tobacco use)).

CONCLUSIONS

This is one of the first studies to show that e-cigarette use was robustly associated with measures of smoking over 24 months and the first to show an intervention to attenuate the relationship. Further research with a broader age range of adolescents is required.

Effectiveness and cost-effectiveness of repeated implementation intention formation on adolescent smoking initiation: A cluster randomized controlled trial

OBJECTIVE

Forming implementation intentions (if-then plans) about how to refuse cigarette offers plus antismoking messages was tested for reducing adolescent smoking.

METHOD

Cluster randomized controlled trial with schools randomized (1:1) to receive implementation intention intervention and messages targeting not smoking (intervention) or completing homework (control). Adolescents (11-12 years at baseline) formed implementation intentions and read messages on 8 occasions over 4 years meaning masking treatment allocation was not possible. Outcomes were: follow-up (48 months) ever smoking, any smoking in last 30 days, regular smoking, and breath carbon monoxide levels. Analyses excluded baseline ever smokers, controlled for clustering by schools and examined effects of controlling for demographic variables. Economic evaluation (incremental cost effectiveness ratio; ICER) was conducted. Trial is registered (ISRCTN27596806).

RESULTS

Schools were randomly allocated (September-October 2012) to intervention (n = 25) or control (n = 23). At follow-up, among 6,155 baseline never smokers from 45 retained schools, ever smoking was significantly lower (RR = 0.83, 95% CI [0.71, 0.97], p = .016) in intervention (29.3%) compared with control (35.8%) and remained so controlling for demographics. Similar patterns observed for any smoking in last 30 days. Less consistent effects were observed for regular smoking and breath carbon monoxide levels. Economic analysis yielded an ICER of $134 per ever smoker avoided at age 15-16 years.

CONCLUSIONS

This pragmatic trial supports the use of repeated implementation intentions about how to refuse the offer of a cigarette plus antismoking messages as an effective and cost-effective intervention to reduce smoking initiation in adolescents. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Effects of salivary thiocyanate levels on oral mucosa in young adult smokers: A biochemical and cytological study

BACKGROUND AND OBJECTIVES

Cigarette smoking is one of the major global health issues. Accurate measurement of smoking is essential for accepting patterns of adolescent smoking behavior and for the evaluation of health education programs aimed at reducing or preventing the habit. The aim of the present study was to estimate and compare the salivary thiocyanate levels in young adult smokers and nonsmokers and also to evaluate and correlate the cellular and nuclear changes in cytological smears with salivary thiocyanate levels.

MATERIALS AND METHODS

The study included a total of 70 individuals in the age range of 18-25 years comprising of 35 smokers and 35 nonsmokers. A volume of 2 ml unstimulated whole saliva samples were collected by spitting method and were carried in a vaccine carrier with ice pack to the laboratory to avoid biochemical changes. Each sample was analyzed on the same day of collection by spectrophotometric method. In addition, cytosmears were prepared using Cytobrush® plus and stained with rapid Papanicolaou stain for cytological evaluation.

RESULTS

Salivary thiocyanate levels were significantly higher in smokers than nonsmokers. When these levels were compared with pack-years, there was a progressive significant increase in salivary thiocyanate levels as the pack-years increased. Duration of habit showed no statistically significant effect on salivary thiocyanate levels. Cytological evaluation revealed increase in nuclear-cytoplasmic area ratio and number of micronuclei in smokers than nonsmokers. The correlation between salivary thiocyanate levels and cytological changes showed insignificant result.

CONCLUSION

Salivary thiocyanate levels were significantly higher in smokers than controls and showed significant correlation with the number of pack years. Although the present study failed to reveal any significant correlation between salivary thiocyanate level and cytological alterations, few early alterations in the oral mucosa even in the absence of clinical manifestations were detected by exfoliative cytology. Salivary thiocyanate determination is a safe, inexpensive, noninvasive method to differentiate early smokers from nonsmokers.

Do electronic cigarettes increase cigarette smoking in UK adolescents? Evidence from a 12-month prospective study

BACKGROUND

In cross-sectional surveys, increasing numbers of adolescents report using both electronic cigarettes (e-cigarettes) and cigarettes. This study assessed whether adolescent e-cigarette use was associated prospectively with initiation or escalation of cigarette use.

METHODS

Data were from 2836 adolescents (aged 13-14 years at baseline) in 20 schools in England. At baseline, breath carbon monoxide levels, self-reported e-cigarette and cigarette use, sex, age, friends and family smoking, beliefs about cigarette use and percentage receiving free school meals (measure of socioeconomic status) were assessed. At 12-month follow-up, self-reported cigarette use was assessed and validated by breath carbon monoxide levels.

RESULTS

At baseline, 34.2% of adolescents reported ever using e-cigarettes (16.0% used only e-cigarettes). Baseline ever use of e-cigarettes was strongly associated with subsequent initiation (n=1726; OR 5.38, 95% CI 4.02 to 7.22; controlling for covariates, OR 4.06, 95% CI 2.94 to 5.60) and escalation (n=318; OR 1.91, 95% CI 1.14 to 3.21; controlling for covariates, this effect became non-significant, OR 1.39, 95% CI 0.97 to 1.82) of cigarette use.

CONCLUSIONS

This is the first study to report prospective relationships between ever use of e-cigarettes and initiation and escalation of cigarette use among UK adolescents. Ever use of e-cigarettes was robustly associated with initiation but more modestly related to escalation of cigarette use. Further research with longer follow-up in a broader age range of adolescents is required.

Overview of Cotinine Cutoff Values for Smoking Status Classification

While cotinine is commonly used as a biomarker to validate self-reported smoking status, the selection of an optimal cotinine cutoff value for distinguishing true smokers from true nonsmokers shows a lack of standardization among studies. This review describes how the cutoff values have been derived, and explains the issues involved in the generalization of a cutoff value. In this study, we conducted an English-language literature search in PubMed using the keywords “cotinine” and “cutoff” or “self-reported” and “smoking status” and “validation” for the years 1985–2014. We obtained 104 articles, 32 of which provided (1) sensitivity and specificity of a cutoff value and (2) determination methods for the given cutoff value. We found that the saliva cotinine cutoff value range of 10–25 ng/mL, serum and urine cotinine cutoff of 10–20 ng/mL and 50–200 ng/mL, respectively, have been commonly used to validate self-reported smoking status using a 2 × 2 table or a receiver operating characteristics (ROC) curve. We also found that recent large population-based studies in the U.S. and UK reported lower cutoff values for cotinine in serum (3 ng/mL) and saliva (12 ng/mL), compared to the traditionally accepted ones (15 and 14 ng/mg, respectively).

Improvement in blood pressure after short-term inorganic nitrate supplementation is attenuated in cigarette smokers compared to non-smoking controls

Dietary supplementation with inorganic nitrate (NO₃^-) has been reported to improve cardiovascular health indices in healthy adults. Cigarette smoking increases circulating thiocyanate (SCN^-), which has been suggested to competitively inhibit salivary nitrate (NO₃^-) uptake, a rate-limiting step in dietary NO₃^- metabolism. Therefore, this study tested the hypothesis that dietary NO₃^- supplementation would be less effective at increasing the circulating plasma nitrite concentration ([NO₂^-]) and lowering blood pressure in smokers (S) compared to non-smokers (NS). Nine healthy smokers and eight healthy non-smoking controls reported to the laboratory at baseline (CON) and following six day supplementation periods with 140 mL day^-1 NO₃^--rich (8.4 mmol NO₃^- day^-1; NIT) and NO₃^--depleted (0.08 mmol NO₃^- day^-1; PLA) beetroot juice in a cross-over experiment. Plasma and salivary [SCN^-] were elevated in smokers compared to non-smokers in all experimental conditions (P < 0.05). Plasma and salivary [NO₃^-] and [NO₂^-] were elevated in the NIT condition compared to CON and PLA conditions in smokers and non-smokers (P < 0.05). However, the change in salivary [NO₃^-] (S: 3.5 ± 2.1 vs. NS: 7.5 ± 4.4 mM), plasma [NO₃^-] (S: 484 ± 198 vs. NS: 802 ± 199 μM) and plasma [NO₂^-] (S: 218 ± 128 vs. NS: 559 ± 419 nM) between the CON and NIT conditions was lower in the smokers compared to the non-smokers (P < 0.05). Salivary [NO₂^-] increased above CON to a similar extent with NIT in smokers and non-smokers (P > 0.05). Systolic blood pressure was lowered compared to PLA with NIT in non-smokers (P < 0.05), but not smokers (P > 0.05). These findings suggest that dietary NO₃^- metabolism is compromised in smokers leading to an attenuated blood pressure reduction compared to non-smokers after NO₃^- supplementation. These observations may provide novel insights into the cardiovascular risks associated with cigarette smoking and suggest that this population may be less likely to benefit from improved cardiovascular health if they increase dietary NO₃^- intake.

Smoking cessation support for pregnant women: role of mobile technology

Background

Smoking during pregnancy has deleterious health effects for the fetus and mother. Given the high risks associated with smoking in pregnancy, smoking cessation programs that are designed specifically for pregnant smokers are needed. This paper summarizes the current landscape of mHealth cessation programs aimed at pregnant smokers and where available reviews evidence to support their use.

Methods

A search strategy was conducted in June–August 2015 to identify mHealth programs with at least one component or activity that was explicitly directed at smoking cessation assistance for pregnant women. The search for text messaging programs and applications included keyword searches within public health and medical databases of peer-reviewed literature, Google Play/iTunes stores, and gray literature via Google.

Results

Five unique short message service programs and two mobile applications were identified and reviewed. Little evidence was identified to support their use. Common tools and features identified included the ability to set your quit date, ability to track smoking status, ability to get help during cravings, referral to quitline, and tailored content for the individual participant. The theoretical approach utilized was varied, and approximately half of the programs included pregnancy-related content, in addition to cessation content. With one exception, the mHealth programs identified were found to have low enrollment.

Conclusion

Globally, there are a handful of applications and text-based mHealth programs available for pregnant smokers. Future studies are needed that examine the efficacy of such programs, as well as strategies to best promote enrollment.

The impact of tetrahydrobiopterin administration on endothelial function before and after smoking cessation in chronic smokers

Cardiovascular disease mortality is reduced following smoking cessation but the reversibility of specific atherogenic risk factors such as endothelial dysfunction is less established. We assessed brachial artery flow-mediated dilation (FMD) in 57 chronic smokers and 15 healthy controls, alone and after oral tetrahydrobiopterin (BH4) administration, to assess the extent to which reduced bioactivity of BH4, a cofactor for the endothelial nitric oxide synthase enzyme (eNOS), contributes to smoking-associated reductions in FMD. Thirty-four smokers then ceased cigarette and nicotine use for 1 week, after which FMD (±BH4 administration) was repeated. Brachial artery FMD was calculated as the peak dilatory response observed relative to baseline (%FMD). Endothelium-independent dilation was assessed by measuring the dilatory response to sublingual nitroglycerin (%NTG). Chronic smokers exhibited reduced %FMD relative to controls: (5.6±3.0% vs. 8.1±3.7%; P<0.01) and %NTG was not different between groups (P=0.22). BH4 administration improved FMD in both groups (P=0.03) independent of smoking status (P=0.78) such that FMD was still lower in smokers relative to controls (6.6±3.3% vs. 9.8±3.2%; P<0.01). With smoking cessation, FMD increased significantly (from 5.0±2.9 to 7.8±3.2%;P<0.01); %NTG was not different (P=0.57) and BH4 administration did not further improve FMD (P=0.33). These findings suggest that the blunted FMD observed in chronic smokers, likely due at least in part to reduced BH4 bioactivity and eNOS uncoupling, can be restored with smoking cessation. Post-cessation BH4 administration does not further improve endothelial function in chronic smokers, unlike the effect observed in nonsmokers, indicating a longer-term impact of chronic smoking on vascular function that is not acutely reversible.

The Collection and Analysis of Carbon Monoxide Levels as an Indirect Measure of Smoke Exposure in Pregnant Adolescents at a Multidisciplinary Teen Obstetrics Clinic

STUDY OBJECTIVE

In this study we aimed to collect and analyze CO levels as an indirect measure of smoke exposure in pregnant adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Participants included pregnant adolescents who received antenatal care over 18 months (2012-2013) at the Multidisciplinary Teen Obstetrics Clinic at a tertiary-care hospital in Southeastern Ontario.

INTERVENTIONS

The CO breath test is a noninvasive method that is used to assess smoke exposure, in which nonsmokers have levels of 0-6 ppm, and levels of 7-10, 11-20 and more than 20 ppm are consistent with light, typical, and heavy smokers, respectively. Expired CO, smoking status, cigarette number, and home secondhand smoke exposure were documented at 3 clinic visits.

MAIN OUTCOME MEASURES

To determine mean CO levels as a measure of smoke exposure and prevalence of secondhand smoke exposure.

RESULTS

The mean age of participants was 17.6 years. CO means (ppm) across 3 visits were 6.0, 5.9, and 4.8. Sixty-two percent of patients were self-reported nonsmokers, 38% were self-reported smokers (n = 93). CO means (standard error of the mean) were consistently different for nonsmokers vs smokers at visits 1 to 3, respectively: 2.9 (0.79) vs 9.7 (1.8); 3.0 (0.71) vs 12.9 (2.2), and 2.4 (0.71) vs 8.8 (1.5; P < .01, t test; n = 91). Of patient's highest CO (COmax), 62%, 9%, 15%, and 12% had levels of 6 or less, 7-10, 11-20, and greater than 20, respectively. Eighty-four percent of pregnant adolescents had home secondhand smoke exposure, which included 40% of nonsmokers and 100% of smokers (n = 57). Although most nonsmokers had a COmax of 6 or fewer ppm, 56% of smokers had COmax greater than 10 ppm (P < .05, χ(2)).

CONCLUSION

Emphasis on smoking cessation is imperative in pregnant adolescents and should particularly target partners and families, because secondhand smoke exposure was very prevalent.

Effects of varenicline, nicotine or placebo on depressive symptoms in postmenopausal smokers

BACKGROUND

Varenicline carries a black box warning for neuropsychiatric adverse events.

OBJECTIVE

We examined varenicline use and past history of major depressive disorder (MDD) on depressive symptoms during smoking cessation.

METHOD

This is a secondary analysis of two smoking cessation studies in 152 postmenopausal women who received placebo or nicotine patch, or 78 women who received varenicline with relaxation. Lifetime history of MDD (LH-MDD) was assessed at baseline and women with current MDD were excluded. Center for Epidemiologic Study Depression scale (CESD) measured depressive symptoms at baseline, 6 and 12 weeks.

RESULTS

Baseline CESD scores were 5.3 + 4.4. Those with a LH-MDD reported higher CESD scores (p > .001). Those taking varenicline reported lower scores over all time periods compared to nicotine or placebo (p < .01). The differences between varenicline and the other treatments remained when controlling for LH-MDD, indicating an independent effect. CESD scores were associated with concurrent smoking status (p < .001), and with withdrawal symptoms (p < .001).

CONCLUSION

CESD score were lower in those receiving varenicline, whether this is due to an anti-depressant effect, subject selection, use of relaxation or another cause is unknown. Varenicline does not increase depressive symptoms during smoking cessation in postmenopausal women without current MDD. Subjects with a LH-MDD are susceptible to developing depressive symptoms during smoking cessation, regardless of pharmacologic aid.

SCIENTIFIC SIGNIFICANCE

Pharmacologic aids did not increase depression symptoms in this select population of postmenopausal women without current depression. Smoking cessation does increase depressive symptoms in those with LH-MDD, though the degree of increase was not clinically meaningful.

Topiramate for smoking cessation: a randomized, placebo-controlled pilot study

INTRODUCTION

Topiramate (TOP) blocks glutamate receptors and facilitates GABA (γ-aminobutyric acid) neurotransmission, effects that may facilitate smoking cessation. We compared the effects of behavioral counseling combined with (a) TOP, (b) TOP/nicotine patch (TOP/NIC), or (c) placebo (PLC) for smoking cessation.

METHODS

We conducted a 10-week randomized trial in which subjects and research personnel were blinded to TOP versus PLC but not to the TOP/NIC patch condition. In groups receiving TOP, the medication dosage was titrated gradually up to 200 mg/day. The smoking quit date (QD) was scheduled after 2 weeks of medication treatment. NIC (21 mg) was started on the QD in subjects randomized to the TOP/NIC condition. The main outcome measure was the end-of-treatment, 4-week continuous abstinence rate (CAR; biochemically confirmed).

RESULTS

Fifty-seven subjects were randomized to treatment. The 4-week CAR was 1 of 19 (5%) in the PLC group, 5 of 19 (26%) in the TOP group, and 7 of 19 (37%) in the TOP/NIC group (p = .056). Pairwise comparisons showed a difference between TOP/NIC and PLC (p = .042) and a nonsignificant difference between TOP and PLC (p = .18). The PLC group gained 0.37 lb/week, the TOP group lost 0.41 lb/week, and the TOP/NIC group lost 0.07 lb/week (p = .004). Pairwise comparisons showed a difference between TOP and PLC (p < .001) and between TOP/NIC and PLC groups (p = .035). Paresthesia was more frequent in subjects on TOP than PLC (p = .011).

CONCLUSIONS

TOP, alone or in combination with the NIC, resulted in a numerically higher quit rate than PLC and decreased weight. A larger, PLC-controlled trial is needed to confirm these findings.

Study protocol: A cluster randomised controlled trial of implementation intentions to reduce smoking initiation in adolescents

Background

The current literature suggests that forming implementation intentions (simple ‘if-then’ plans) about how to refuse the offer of a cigarette may be an effective intervention to reduce smoking initiation in adolescents. This study is a pragmatic trial to test the effectiveness and cost-effectiveness of such an intervention in reducing smoking initiation in a sample of UK adolescents.

Methods/Design

A cluster randomised controlled trial with at least 36 schools randomised to receive an implementation intention intervention targeting reducing smoking initiation (intervention group) or increasing homework (control group). Interventions will be conducted at the classroom level and be repeated every six months for four years (eight interventions). Objectively assessed (carbon monoxide monitor) and self-reported smoking plus smoking related cognitions (e.g., smoking intentions, attitudes, norms and self-efficacy) will be assessed at baseline and 12, 24, 36 and 48 months post baseline. Objectively assessed smoking at 48 months post baseline will be the primary outcome variable. Health economic analyses will assess life years gained.

Discussion

The results of the trial will provide information on the impact of a repeated implementation intention for refusing offers of cigarettes on rates of smoking initiation in adolescents.

Trial registration

ISRCTN27596806

Does the use of ingredients added to tobacco increase cigarette addictiveness?: a detailed analysis

The possibility that ingredients added to tobacco contribute to the addictiveness of cigarette smoking was evaluated by comparing cessation rates of smokers of traditional blended cigarettes to those of smokers of flue-cured cigarettes. Such a comparison is a valid means of assessing cigarette ingredients as traditional blended cigarettes contain ingredients (>20), whereas flue-cured cigarettes contain no or very few ingredients. Separate analysis of 108 treatment groups and 108 control groups from randomized clinical trials of nicotine replacement therapy (NRT) were performed by multiple logistic regressions. The results of these analyses demonstrated slightly higher quit rates for smokers of blended cigarettes (OR = 1.90, 95% CI 1.70-2.13 and OR = 1.32, 95% CI 1.14-1.53 for treatment and control groups, respectively). The control groups were also investigated using classification tree analysis from which no difference in quit rates were observed for smokers of either type of cigarette. Further analyses showed that studies that utilized a high level of psychological support in conjunction with NRT produced at least a two-fold increase in quit rates compared to studies that utilized a low level of psychological support. It was also demonstrated that there is a large difference when results were reported by sustained abstinence compared to point prevalence. Additional meta-analyses found the pooled OR for NRT treatment to be in exact agreement with a recent review that assessed the effectiveness of NRT. Overall these results strongly suggest that ingredients used in the manufacture of traditional blended cigarettes do not increase the inherent addictiveness of cigarettes.

Role of anticipated regret, intentions and intention stability in adolescent smoking initiation

OBJECTIVES

To examine the impact of anticipated regret within the theory of planned behaviour (TPB) on intentions of adolescents to initiate smoking. To examine the moderating role of anticipated regret and intention stability on the relationship between intentions and smoking initiation in adolescents.

METHODS

We conducted two studies measuring anticipated regret within the TPB applied to adolescent smoking initiation. In the first study, 347 non-smoking adolescents (between 11 and 12 years of age) completed the TPB and anticipated regret measures about smoking initiation. In the second study, 675 non-smoking adolescents (between 11 and 12 years of age) completed the TPB, anticipated regret, and intention stability measures in relation to smoking initiation. Smoking was assessed objectively by carbon monoxide breath monitor 9 months later.

RESULTS

In Studies 1 and 2, regret significantly added to predictions of intentions over and above components of the TPB (p < .001). In Study 2, smoking behaviour was predicted by intentions and the relationship of intentions to behaviour was moderated by regret and intention stability.

CONCLUSIONS

Regret and intention stability were shown to be important variables within the TPB in understanding intentions and behaviour of smoking initiation in adolescents.

Effects of smoking cessation on body composition in postmenopausal women

BACKGROUND

Smoking cessation is associated with weight gain, but the effects of smoking cessation on measures of body composition (BC) have not been adequately evaluated. The purpose of this study is to examine the effects of 16 months of cigarette abstinence on areas of BC measured by dual-energy x-ray absorptiometry (DXA).

METHODS

One hundred fifty-two postmenopausal women participated in a smoking cessation study using the nicotine patch. Secondary analyses were conducted on data from 119 subjects (age 56 +/- 7 years, range 41-78 years) who had had DXA scans at baseline and 16 months later. Participants were classified either as quitters (self-reported cigarette abstinence confirmed with exhaled carbon monoxide [co]

RESULTS

Quitters significantly increased body weight (p < 0.001), fat mass (p < 0.001), muscle mass (p = 0.04), and functional muscle mass (p = 0.004) over time, when baseline BC measures and other confounding factors were controlled. Regression analysis indicated change in BC could not be accounted for by calorie intake or physical activity.

CONCLUSIONS

Smoking cessation may be associated with increased fat and muscle mass in postmenopausal women. The novel finding of an increase in functional muscle mass suggests that smoking cessation could increase functional capacity. Further studies need to replicate these findings and examine mechanisms of these effects.

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MESH Headings

• Adipose Tissue
• Body Composition
• Body Mass Index
• Female
• Humans
• Middle Aged
• Multivariate Analysis
• Muscle, Skeletal
• Postmenopause
• Smoking Cessation
• Tobacco Use Cessation Devices
• Weight Gain

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Grants

• R01 DA024872 NIDA NIH HHS
• M01RR6192 NCRR NIH HHS

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Affiliation(s)

Alison Kleppinger Center on Aging, University of Connecticut Health Center, Farmington, Connecticut 6030-6147, USA.
Mark D Litt
Anne M Kenny
Cheryl A Oncken

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Validity of self-reported smoking in schizophrenia patients

AIMS

It is important to evaluate smoking status among schizophrenia patients because such patients are highly inclined to take up smoking, but only a few studies have focused on the validity of self-reported smoking in relation to schizophrenia. The aim of the present study was therefore to determine the validity of self-reported smoking and to investigate whether self-reported smoking is biased in schizophrenia patients.

METHODS

A total of 158 schizophrenia patients answered self-rated questions of smoking status, and the level of carbon monoxide (CO) in expired air was measured. The relationship of the self-reported smoking to the CO levels was determined, and interaction of the disease duration and education level on this relationship was evaluated using correlation and receiver operating characteristic analyses.

RESULTS

The CO levels in the expired air were found to be positively related to the self-reported data (P < 0.01). The stratified data on the duration of schizophrenia indicated that the positive relationship between self-reported smoking and the CO concentration became less obvious with the increase in duration of schizophrenia (P(trend) < 0.01). In contrast, the stratified data on education level did not indicate any such significant modifying effect.

CONCLUSIONS

Although self-reporting is useful for evaluating smoking status, psychiatrists should use objective methods of measurement to assess the smoking status of chronic schizophrenia patients.

Direct, mediated and moderated impacts of personality variables on smoking initiation in adolescents

Role of 'Big Five' personality traits as predictors of smoking and moderators of the intention-smoking relationship was tested. Five hundred and fifty-three adolescents (aged 11-12) completed measures of self-reported past smoking, gender, intentions to smoke, perceived behavioural control, family smoking, friends smoking at times 1 and 2 (6 months apart). At time 3, 2 years later, the same adolescents completed measures of the Big Five and self-reported smoking (a subset of 300 also provided an objective smoking measure). At time 4, two years after time 3, a sub-sample of 122 adolescents provided a self-report measure of recent smoking. Simple correlations indicated significant direct effects of conscientiousness (self-reported smoking, times 3 and 4), extraversion (time 4 smoking) and neuroticism (all smoking measures) on smoking. Logistic regression showed intention, and the interaction between conscientiousness and intention to significantly predict both self-reported and objectively assessed smoking (both at time 3) after controlling for other variables. Multiple regression showed intentions, family smoking and the interaction between conscientiousness and intention to significantly predict self-reported smoking at time 4 after controlling for other variables. The findings indicate that the impact of personality variables on smoking is through mediated (through cognitions) and moderated (conscientiousness by intention interaction) pathways.

Gender differences in smoking: A longitudinal study of beliefs predicting smoking in 11-15 year olds

This longitudinal study investigated differences in beliefs and perceived behavioural control between smokers and non-smokers in a large sample of adolescents. Positive and negative instrumental beliefs, normative beliefs, perceived behavioural control (PBC) and smoking status were assessed in the same participants at 11, 13 and 15 years of age. Prospective analyses among non-smokers revealed that for boys, negative instrumental beliefs in non-smokers at age 11 predicted smoking at age 15 years. For girls, normative beliefs and PBC in non-smokers at age 11 predicted smoking status at age 13; normative beliefs at age 11 predicted smoking at age 15; and positive instrumental beliefs and normative beliefs at age 13 predicted smoking status at age 15. Cross-sectional data revealed that smokers were significantly more likely than non-smokers to endorse positive instrumental beliefs, less likely to agree with negative instrumental belief items, more likely than non-smokers to perceive social pressure to smoke, and less likely to report control over smoking, and that female smokers reported less control over smoking and fewer negative instrumental beliefs than all other groups including male smokers at age 13. The need for belief-based preventative interventions that are age- and gender-relevant is discussed.

The validity and reliability of an interactive computer tobacco and alcohol use survey in general practice

BACKGROUND

Uncertainty regarding the accuracy of the computer as a data collection or patient screening tool persists. Previous research evaluating the validity of computer health surveys have tended to compare those responses to that of paper survey or clinical interview (as the gold standard). This approach is limited as it assumes that the paper version of the self-report survey is valid and an appropriate gold standard.

OBJECTIVES

First, to compare the accuracy of computer and paper methods of assessing self-reported smoking and alcohol use in general practice with biochemical measures as gold standard. Second, to compare the test re-test reliability of computer administration, paper administration and mixed methods of assessing self-reported smoking status and alcohol use in general practice.

METHODS

A randomised cross-over design was used. Consenting patients were randomly assigned to one of four groups; Group 1. C-C : completing a computer survey at the time of that consultation (Time 1) and a computer survey 4-7 days later (Time 2); Group 2. C-P: completing a computer survey at Time 1 and a paper survey at Time 2; Group 3. P-C: completing a paper survey at Time 1 and a computer survey at Time 2; and Group 4. P-P: completing a paper survey at Time 1 and 2. At Time 1 all participants also completed biochemical measures to validate self-reported smoking status (expired air carbon monoxide breath test) and alcohol consumption (ethyl alcohol urine assay).

RESULTS

Of the 618 who were eligible, 575 (93%) consented to completing the Time 1 surveys. Of these, 71% (N=411) completed Time 2 surveys. Compared to CO, the computer smoking self-report survey demonstrated 91% sensitivity, 94% specificity, 75% positive predictive value (PPV) and 98% negative predictive value (NPV). The equivalent paper survey demonstrated 86% sensitivity, 95% specificity, 80% PPV, and 96% NPV. Compared to urine assay, the computer alcohol use self-report survey demonstrated 92% sensitivity, 50% specificity, 10% PPV and 99% NPV. The equivalent paper survey demonstrated 75% sensitivity, 57% specificity, 6% PPV, and 98% NPV. Level of agreement of smoking self-reports at Time 1 and Time 2 revealed kappa coefficients ranging from 0.95 to 0.98 in each group and hazardous alcohol use self-reports at Time 1 and Time 2 revealed kappa coefficients ranging from 0.90 to 0.96 in each group.

CONCLUSION

The collection of self-reported health risk information is equally accurate and reliable using computer interface in the general practice setting as traditional paper survey. Computer survey appears highly reliable and accurate for the measurement of smoking status. Further research is needed to confirm the adequacy of the quantity/frequency measure in detecting those who drink alcohol. Interactive computer administered health surveys offer a number of advantages to researchers and clinicians and further research is warranted.

Prenatal tobacco prevention and cessation interventions for women in low- and middle-income countries

Although the prevalence of tobacco use is decreasing in many high-income countries, it is increasing in many low- and middle-income countries. The health and economic burden of increasing tobacco use and dependence is predictable and will have devastating effects in countries with limited resources, particularly for vulnerable populations such as pregnant women. We sought to review effective tobacco prevention and intervention strategies for decreasing tobacco use and secondhand smoke exposure before and during pregnancy in high-, middle-, and low-income countries. We reviewed several types of interventions, including population-level efforts (increasing tobacco prices, implementing tobacco control policies), community interventions, clinical interventions, and pharmacological treatments. A second purpose of this report is to present findings of an international expert working group that was convened to review the evidence and to establish research priorities in the following areas: (a) preventing the uptake and reducing tobacco use among girls and women of reproductive age; and (b) reducing tobacco use and secondhand smoke exposure among pregnant women. The working group considered the evidence on existing interventions in terms of burden of disease, intervention impact, intervention costs, feasibility of integration into existing services, uniqueness of the contribution, and overall feasibility. Finally, we present the working group's recommendations for intervention research priorities.

The accuracy of self-reported smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking status

INTRODUCTION

Smoking is a leading cause of premature mortality and preventable morbidity. Surveillance is most often based on self-reported data, but studies have shown that self-reports tend to underestimate smoking status.

METHODS

This study systematically reviewed the literature to measure the concordance between self-reported smoking status and smoking status determined through measures of cotinine in biological fluids. Four electronic databases were searched to identify observational and experimental studies on adult populations over the age of 18 years.

RESULTS

Searching identified 67 studies that met the eligibility criteria and examined the relationship between self-reported smoking and smoking confirmed by cotinine measurement. Overall, the data show trends of underestimation when smoking prevalence is based on self-report and varying sensitivity levels for self-reported estimates depending on the population studied and the medium in which the biological sample is measured. Sensitivity values were consistently higher when cotinine was measured in saliva instead of urine or blood. Meta-analysis was not appropriate because of the substantial heterogeneity among the cutpoints used to define smokers and the poor reporting on outcomes of interest.

DISCUSSION

Further research in this field would benefit from the standardization of cutpoints to define current smokers and the implementation of standard reporting guidelines to enhance comparability across studies. Accurate estimation of smoking status is important as data from population studies such as those included in this review are used to generate regional and national estimates of smoking status and in turn are used to allocate resources and set health priorities.

Agreement between self-reported smoking and cotinine concentration in adolescents: a validation study in Brazil

PURPOSE

To validate self-reported data on smoking in adolescents in comparison with cotinine concentration.

METHODS

Two thousand two hundred nine seventh- and eighth-grade students from 32 public schools in Pelotas, Brazil. Adolescents were contacted twice--before and after an educational intervention--and samples of urine for cotinine analyses were taken. In this paper, only data from the baseline phase are presented. High-performance liquid chromatography was used for cotinine analysis. Two cutoff points for cotinine were used: 10 ng/mL and 30 ng/mL. Two self-reported smoking variables were used: at least one cigarette smoked in the previous 30 days; and daily smoking.

RESULTS

The self-reported prevalence of smoking in the previous 30 days was 7.4%, and 0.9% of the adolescents reported to be daily smokers. Those who reported smoking in the previous 30 days presented mean cotinine values 10 times greater than those who reported to be nonsmokers. Using a cutoff of 10 ng/mL for cotinine, sensitivity of self-reported smoking was 16.3% (95% confidence interval [CI] 11.7; 20.9) and specificity was 93.6% (95% CI 92.8; 95.0). Using a cutoff of 30 ng/mL, sensitivity was 22.6% (95% CI 15.6; 29.6) and specificity was 93.7% (95% CI 92.6; 94.8).

CONCLUSIONS

Self-reported smoking presents low agreement with cotinine concentration, suggesting that adolescents underestimate tobacco consumption.

Impact of smoking cessation on bone mineral density in postmenopausal women

BACKGROUND

Although clinical guidelines recommend smoking cessation to improve bone health, the impact of short-term smoking cessation (i.e., 1 year) on bone mineral density (BMD) is not known. We examined the effects of smoking cessation on BMD measurements, markers of bone turnover, and hormone profiles in postmenopausal women.

METHODS

Postmenopausal women (n = 152) who smoked at least 10 cigarettes per day were randomly assigned to behavioral counseling and either nicotine or placebo patch for smoking cessation (3-month treatment with a 1-month taper) and followed for an additional year. The BMD at various sites (hip, spine, wrist, and total body), serum and urine biochemical markers of bone turnover, and sex hormones were measured at baseline and again 1 year after smoking treatment. Women who continuously abstained from smoking between the end of treatment and 1 year later (quitters) (n = 42) were compared with women who completed the study and continued to smoke (n = 77).

RESULTS

Femoral trochanter BMD increased by 2.9% among quitters vs. 0.6% among continued smokers (p = 0.02). Total hip BMD increased by 1.52% among quitters vs. 0.43% among continued smokers (p = 0.03). Changes in BMD at the femoral neck, radius, spine, and total body did not significantly differ between groups. The effects of smoking cessation on bone were mediated in part by weight gain. Smoking cessation was also associated with an increase in bone alkaline phosphatase.

CONCLUSIONS

Smoking cessation, relative to continued smoking, increases BMD at the femoral trochanter and total hip in postmenopausal women.

Transdermal nicotine for smoking cessation in postmenopausal women

This study examined the efficacy of transdermal nicotine in postmenopausal smokers, and whether a history of depression or hormone replacement therapy (HRT) moderated smoking cessation outcomes. Postmenopausal smokers (N=152) received intensive smoking cessation counseling and were randomly assigned to use either a 21-mg nicotine patch for 3 months, with a 1-month taper, or a placebo patch. The primary outcome was biochemically validated 7-day point prevalence smoking abstinence during treatment (i.e., 1, 2, 6, and 12 weeks after the quit date) and 1 year after study medication was discontinued. Subjects who received transdermal nicotine were significantly more likely than placebo-treated subjects to remain abstinent from smoking during treatment, but not at the 1-year follow-up. The majority of subjects (>50%) in both groups accurately identified their treatment assignment. History of depression was associated with a decreased likelihood to abstain from smoking throughout the study. HRT did not moderate smoking outcomes. These data indicate that transdermal nicotine may provide short-term benefits for smoking cessation in postmenopausal women. However, efforts are needed to improve long-term abstinence rates and smoking outcomes among women with a history of depression.

Serum thiocyanate concentration as an indicator of smoking in relation to deaths from cancer

All residents aged 40 years or more in Oyabe City, Toyama Prefecture, Japan were involved in an annual medical check-up between 1987 and 1988. The cohort was followed and death certificates from cancers were confirmed prospectively. During follow-up to December 31 st, 1994, 100 deaths (28 gastric, 17 lung and 55 other cancers) from cancers occurred, and these subjects were included in this study as the case group. Subjects in the control group, matched for gender and age with the cases, were selected randomly from participants whose serum samples had been stocked during annual medical check-up. The concentration of serum thiocyanate in all (79.8 μmol/l), gastric (86.7 μmol/l) and lung (90.0 μmol/l) cancer patients were significantly higher than that of relevant controls (64.3 μmol/l, 59.0 μmol/l and 61.0 μmol/l, respectively; and p<0.001, p<0.001 and p<0.05, respectively). After adjusting for BMI, blood pressure and total serum cholesterol, the results of multiple logistic regression analysis showed that the risk of all cancers (OR=3.40, 95% confidence interval (95% Cl): 1.67-6.96, p<0.01), gastric cancer (OR=7.98, 95% CI: 1.91-33.34, p<0.05) and lung cancer (OR=8.83, 95% CI: 1.19-65.65, p<0.05) were elevated significantly with logarithm transformed values of serum thiocyanate increased. The present findings suggested that in epidemiological studies confirmation of smoking status with biomarkers such as serum thiocyanate may be important, although considering the small sample size, a relatively weaker risk to interested factors rather than the strong relationship between smoking and cancer was noted.

Assessing the impact of a nurse-led health education intervention for people with peripheral vascular disease who smoke: the use of physiological markers, nicotine dependence and withdrawal

This study evaluated the impact of a nurse-led health education programme on the behaviour, nicotine dependence and nicotine withdrawal in patients who smoke and suffer from peripheral vascular disease, based in a large teaching hospital in the north of England. Smoking behaviour was measured by self report, end-expired carbon monoxide and urinary cotinine. Nicotine dependence and withdrawal were measured using a nicotine dependence scale and a nicotine withdrawal scale. The findings demonstrated that the programme did have some impact on behaviour. The study raised issues concerning the measurement of physiological markers for smoking as nursing outcomes. Issues about the measurement of nicotine dependence and withdrawal are highlighted.

Validation of self-reported smoking status by simultaneous measurement of carbon monoxide and salivary thiocyanate

OBJECTIVE

The objective of this study was to determine the validity of tobacco questionnaires when using as gold standard either a single biomarker or a combination of two biomarkers.

METHODS

The methods were self-reported smoking compared with salivary thiocyanate and expired carbon monoxide in a 1996, population-based, Swiss survey of 552 men and 565 women.

RESULTS

Sensitivity of self-reported smoking relative to salivary thiocynate or carbon monoxide alone was low (38.2% for salivary thiocyanate > or = 100 mg/L, 56.4% for salivary thiocyanate > or = 150 mg/L and 62.6% for carbon monoxide > or = 9 ppm). When defining true positive smokers as people with high concentration of both salivary thiocyanate and carbon monoxide, overall, sensitivity was 88.6% and specificity was 87.2%. In women, sensitivity increased from 85 to 89% when removing subjects exposed to passive smoking. When excluding heavy smokers, sensitivity decreased to 63% in men and to 71% in women. Older women had tendency to misreport smoking.

CONCLUSIONS

This comparison of questionnaire data with the simultaneous measurement of salivary thiocyanate and expired carbon monoxide indicates that valid responses can be obtained for self-reported, current smoking in population-based surveys. However, the validity of questionnaires can be underestimated if the gold standard (of exposure to tobacco smoke) is either high levels of carbon monoxide or high levels of salivary thiocyanate.

Effects of smoking on periodontal health: a review

Cigarette smoking is a risk factor for several diseases, and recent evidence strongly suggests an adverse effect on periodontal health. Nevertheless, the nature of the relationship between smoking and periodontal disease is not clear. Smoking causes defects in neutrophil function, impairs inflammatory and immune responses to periodontal pathogens, and exerts both systemic and local effects. Smoking is associated with an increased rate of periodontal disease in terms of alveolar bone loss and attachment loss, as well as pocket formation. Nicotine, the major component of cigarette smoke, may weaken host defenses to the bacterial invasion induced by plaque.

Smoking behavior among casino employees: self-report validation using plasma cotinine

The veracity of behavioral self-reports is often challenged, particularly when the motivation to avoid stigma and win social approval holds potential to introduce bias into the data collected. This study employed plasma cotinine tests to validate the self-reports of tobacco use collected from 3,841 casino employees as part of a comprehensive health survey. Rates of discordance were calculated by comparing employee self-reports with results from plasma colinine tests. This study provides evidence that casino employees can provide valid self-report data. Further, discordance rates of self-reported tobacco use vary according to operational definitions of tobacco use. These findings highlight the methodological importance of recognizing the inherent heterogeneity of smoking behavior.

The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review

OBJECTIVE

To critically review the literature concerning the accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease among the general population.

METHOD

A literature search was conducted on three major health research databases: MEDLINE, HealthPLAN, and PsychLit. The bibliographies of located articles were also checked for additional relevant references. Studies meeting the following five inclusion criteria were included in the review: They were investigating the accuracy of self-report among the general population, as opposed to among clinical populations. They employed an adequate and appropriate gold standard. At least 70% of respondents consented to validation, where validation imposed minimal demands on the respondent; and 60% consent to validation was considered acceptable where validation imposed a greater burden. They had a sample size capable of estimating sensitivity and specificity rates with 95% confidence intervals of width +/-10%. The time lag between collection of the self-report and validation data for physical measures did not exceed one month.

RESULTS

Twenty-four of 66 identified studies met all the inclusion criteria described above. In the vast majority, self-report data consistently underestimated the proportion of individuals considered "at-risk." Similarly, community prevalences of risk factors were considerably higher according to gold standard data sources than they were according to self-report data.

CONCLUSIONS

This review casts serious doubts on the wisdom of relying exclusively on self-reported health information. It suggests that caution should be exercised both when trying to identify at-risk individuals and when estimating the prevalence of risk factors among the general population. The review also suggests a number of ways in which the accuracy of individuals' self-reported health information can be maximized.

Telephone support as an adjunct to transdermal nicotine in smoking cessation

OBJECTIVES

Transdermal nicotine patches have shown considerable promise in improving smoking cessation outcomes. The present study assessed telephone support as an adjunct to a managed care-based, single-session group orientation smoking cessation program with nicotine patch therapy.

METHODS

The unit of randomization was the orientation session (n = 35). Subjects (n = 509) were randomly assigned to a group session without telephone support, the session plus access to a toll-free help line, or the session with telephone help line plus active telephone outreach.

RESULTS

Contrary to hypothesis, there were no differences between treatment conditions. Overall abstinence rates were 22% at 6 months and 21% at 1 year. Fewer than 1% of eligible subjects called the toll-free help line. An average of 3.8 of a possible 4 calls were completed in the telephone outreach condition.

CONCLUSIONS

Abstinence results obtained in this program were comparable to those obtained with more extensive counseling. However, there was no evidence of benefit from telephone support beyond the initial physician-led group orientation session.

Effects of short-term use of nicotine gum in pregnant smokers

OBJECTIVES

To compare blood concentrations of nicotine and cotinine and maternal and fetal hemodynamic effects resulting from use of nicotine gum versus cigarette smoking in pregnant smokers.

METHODS

Pregnant women (24 to 36 weeks' gestation) who smoked chronically were randomly assigned with a 1:2 randomization scheme to either a group that smoked cigarettes (n = 10) or to a group that stopped smoking and chewed at least six pieces of nicotine gum (2 mg nicotine per piece) per day (n = 19). Blood nicotine and cotinine concentrations, maternal heart rate and blood pressure, uterine resistance index, and fetal heart rate and umbilical artery resistance index were obtained before and after one cigarette was smoked at baseline and after 5 continuous days of either chewing gum or smoking.

RESULTS

A significant reduction from baseline in nicotine (p < 0.0001) and cotinine (p < 0.0025) concentrations was observed in those who chewed nicotine gum compared with those who smoked cigarettes. No significant differences in the changes in maternal or fetal hemodynamic parameters from baseline to estimated time of peak nicotine exposure were observed between those who smoked cigarettes and those who chewed nicotine gum.

CONCLUSION

Short-term use of nicotine gum delivers less nicotine than usual cigarette smoking in pregnant women.

Serum cotinine levels, smoking, and periodontal attachment loss

Cigarette smoking and tobacco use have been the subjects of numerous studies for many years. Smoking has also been associated with periodontal disease. However, no relationship between a reliable biochemical marker and increased severity of the periodontal condition has yet been described. It was thus the aim of this study to apply the measurement of cotinine, the major metabolite of nicotine, as a quantitative method to assess levels of smoking, and to correlate serum levels of cotinine with severity of periodontal disease. The degree of association between smoking and periodontal attachment loss was investigated in a study including 79 patients 25 to 64 years old suffering from periodontitis. Patients were examined and the following parameters recorded: Gingival Assessment (GA), Probing Pocket Depth (PPD), Clinical Attachment Level (CAL), and Bone Crest Height (BCH). In addition, self-reported histories of tobacco use as well as blood samples for quantitative analysis of serum levels of cotinine were taken. The serum samples were analyzed for cotinine content by means of a competitive-inhibition ELISA technique. The differences in mean cotinine levels were statistically significant (p = 0.0001) between smokers and non-smokers, showing no overlap between the groups. Severity of periodontal attachment loss was positively correlated with serum levels of cotinine for both measures of periodontal disease (CAL p = 0.005; BCH p = 0.008). Results from the present study indicate that serum cotinine levels used as a biochemical marker of smoking status are correlated with severity of periodontal attachment loss.

Alcohol and tobacco use in the Minnesota Heart Health Program

Correlations between alcohol intake and cigarette smoking have been extensively documented. Prospective data on the relationship between smoking and alcohol remain quite limited. The Minnesota Heart Health Program (MHHP) collected such data as part of a 10-year research and demonstration project intended to reduce the prevalence of heart disease. The study involved six communities, three that received intervention and three, comparison. The current analyses focused upon baseline relationships and longitudinal changes in alcohol and tobacco use. Contrary to prediction, those who quit smoking were no more likely than continuing smokers to reduce alcohol intake. Furthermore, alcohol intake at baseline did not predict smoking status at follow-up. Gender differences were found in a number of comparisons. Further study is needed of changes in smoking and drinking patterns over time in the general population.

The validity of self-reported smoking: a review and meta-analysis

OBJECTIVES

The purpose of this study was to identify circumstances in which biochemical assessments of smoking produce systematically higher or lower estimates of smoking than self-reports. A secondary aim was to evaluate different statistical approaches to analyzing variation in validity estimates.

METHODS

Literature searches and personal inquiries identified 26 published reports containing 51 comparisons between self-reported behavior and biochemical measures. The sensitivity and specificity of self-reports of smoking were calculated for each study as measures of accuracy.

RESULTS

Sensitivity ranged from 6% to 100% (mean = 87.5%), and specificity ranged from 33% to 100% (mean = 89.2%). Interviewer-administered questionnaires, observational studies, reports by adults, and biochemical validation with cotinine plasma were associated with higher estimates of sensitivity and specificity.

CONCLUSIONS

Self-reports of smoking are accurate in most studies. To improve accuracy, biochemical assessment, preferably with cotinine plasma, should be considered in intervention studies and student populations.

The validity of self-reported smoking: a review and meta-analysis

OBJECTIVES

The purpose of this study was to identify circumstances in which biochemical assessments of smoking produce systematically higher or lower estimates of smoking than self-reports. A secondary aim was to evaluate different statistical approaches to analyzing variation in validity estimates.

METHODS

Literature searches and personal inquiries identified 26 published reports containing 51 comparisons between self-reported behavior and biochemical measures. The sensitivity and specificity of self-reports of smoking were calculated for each study as measures of accuracy.

RESULTS

Sensitivity ranged from 6% to 100% (mean = 87.5%), and specificity ranged from 33% to 100% (mean = 89.2%). Interviewer-administered questionnaires, observational studies, reports by adults, and biochemical validation with cotinine plasma were associated with higher estimates of sensitivity and specificity.

CONCLUSIONS

Self-reports of smoking are accurate in most studies. To improve accuracy, biochemical assessment, preferably with cotinine plasma, should be considered in intervention studies and student populations.

Use and effectiveness of buddy support in a self-help smoking cessation program

Purpose. This study assesses buddy support in a community-based, minimal-contact smoking cessation program. Design. Telephone interviews with participants (n=641, response=74%) before and after (end-of-program, n=1,023, response=83%; three months n=757, response=74%; six months, n=859, response=84%; and 12 months, n=713, response=70%) intervention provided the data to be analyzed. Setting. The Chicago metropolitan area was the setting. Subjects. Subjects were a random sample of registrants for the intervention program. Intervention. A self-help smoking cessation program was used, which included a manual and complementary televised segments. Engaging a buddy was optional. Measures. Background and psychosocial characteristics of participants, characteristics of buddies, program compliance, and smoking behavior were the measures used. Results. Almost one third (30.3%) engaged a buddy. Those most likely to engage a buddy were female (33.4%), younger than 30 (37.2%), educated beyond high school (33.4%), highly determined to quit (41.8%), and more likely to need help from others (39.8%). More than half of the buddies were from outside the participant's household (55.1%), and more than half were nonsmokers (60.9%). Having a buddy was associated positively with manual use (gamma=.38), viewing televised segments (gamma=.23), recalling manual segments (gamma=.33), and recalling televised segments (gamma=.26). Among those who read the manual least, having a buddy was associated with viewing televised segments (gamma=.26, p less than .05) and with end-of-program quitting (16.8% vs. 9.8%, p less than .05). Having a buddy also was associated with higher abstinence through 12 months (5.8% vs. 2.7%, p=.013). Among those with lower determination, the end-of-program quit rate was more than three times greater (p=.013) for those with a buddy (16.1%) than without a buddy (5.2%). Participants whose buddy was their spouse or partner were more likely to quit at end-of-program (29.1% vs. 18.4%, p=.031). Conclusions. Buddy support should be promoted as an adjunct to minimal-contact smoking cessation programs. Impact of buddy support might be improved by guiding participants in choosing a buddy.

Simple selected ion monitoring capillary gas chromatographic-mass spectrometric method for the determination of cotinine in serum, urine and oral samples

A capillary gas chromatographic-mass spectrometric method using selected ion monitoring was developed for the analysis of cotinine in urine, serum and oral samples. The procedure requires 500 microliters of an oral sample, 250 microliters of a serum sample and 50 microliters of urine and can detect 5 ng/ml cotinine in oral samples, 10 ng/ml in serum and 50 ng/ml in urine with good precision and accuracy. The method was used to determine the cotinine concentration in samples of all three fluids collected from a group of smokers and non-smokers.

Improvement in pulmonary function following smoking cessation

This study investigated improvement in pulmonary function following smoking cessation. It employed three indices of lung function that are sensitive to improvement following smoking cessation and that can be easily assessed within a clinical setting: maximum mid-expiratory flow (MMF), forced expiratory volume in 1 second (FEV1), and forced vital capacity (FVC). Smoking status was verified by saliva thiocyanate analysis. Significant improvement in MMF was evident after 3 months of cessation and was maintained at the 6-month follow-up. This study demonstrates that significant improvement in at least one parameter of lung function occurs within the time span typically used in smoking cessation programs.

Smokeless tobacco abstinence effects and nicotine gum dose

There were two experiments on abstinence from smokeless tobacco. The purpose of the first experiment was to determine abstinence effects from smokeless tobacco. The purpose of the second experiment was to examine the effects of different doses of nicotine gum on smokeless tobacco abstinence effects. The subjects were male Copenhagen smokeless tobacco users who underwent 3 days of baseline measurement while continuing to use smokeless tobacco ad libitum, and 5 days of the experimental condition. In the first experiment, the subjects were assigned randomly to one of two groups and compared: continuous smokeless tobacco users (n = 10), and deprivation plus no nicotine gum (n = 10). In the second experiment, subjects were assigned randomly and in a double-blind fashion to one of three groups and compared: (1) deprivation plus 0 mg nicotine gum (n = 20); (2) deprivation plus 2 mg nicotine gum (n = 20); and (3) deprivation plus 4 mg nicotine gum (n = 20). The first experiment showed significant increases upon abstinence for the following variables: (1) craving; (2) difficulty concentrating; (3) restlessness; (4) excessive hunger; (5) eating; (6) reaction time; (7) variability of reaction time and (8) total withdrawal scores for both the self-rated and the observer-rated forms. The second experiment showed that nicotine gum failed to significantly reduce smokeless tobacco abstinence effects, although those with high cotinine levels may receive some benefit from nicotine gum.

Processes of change across five stages of smoking cessation

A cross-sectional design with 190 smokers and exsmokers selected by random digit dialing was used to determine differences in processes individuals use to modify behavior across five stages of smoking cessation. Five stages of cessation are: precontemplation, contemplation, recent quitting, long-term quitting, and relapse. Ten processes of change (POC) or ways individuals modify behavior were assessed. Examples of POCs are: consciousness raising, self-liberation, reinforcement management, and stimulus control. Biochemical validation of smoking abstinence was performed on a random subset of exsmoker subjects. Individuals in five stages of smoking cessation used processes of change differently as reflected by a significant MANOVA, F (40,590) = 5.02, p = .0001. It is important to assess an individual's stage of smoking cessation when planning interventions related to POCs.

Misclassification of smoking status in the CARDIA study: a comparison of self-report with serum cotinine levels

BACKGROUND

Although widely used in epidemiological studies, self-report has been shown to underestimate the prevalence of cigarette smoking in some populations.

METHODS

In the CARDIA study, self-report of cigarette smoking was validated against a biochemical marker of nicotine uptake, serum cotinine.

RESULTS

The prevalence of smoking was slightly lower when defined by self-report (30.9%) than when defined by cotinine levels equal to or greater than 14 ng/mL (32.2%, P less than .05). The misclassification rate (proportion of reported nonsmokers with cotinine levels of at least 14 ng/mL) was 4.2% and was significantly higher among subjects who were Black, had a high school education or less, or were reported former smokers. Possible reasons for misclassification include reporting error, environmental tobacco smoke, and an inappropriate cutoff point for delineation of smoking status. Using self-report as the gold standard, the cotinine cutoff points that maximized sensitivity and specificity were 14, 9, and 15 ng/mL for all, White, and Black subjects, respectively. The misclassification rate remained significantly higher in Black than in White subjects using these race-specific criteria.

CONCLUSIONS

Misclassification of cigarette smoking by self-report was low in these young adults; however, within certain race/education groups, self-report may underestimate smoking prevalence by up to 4%.