Laura Kann, PhD; Tim McManus, MS; William A. Harris, MM; Shari L. Shanklin, MPH; Katherine H. Flint, MA; Joseph Hawkins, MA; Barbara Queen, MS; Richard Lowry, MD; Emily O’Malley Olsen, MSPH; David Chyen, MS; Lisa Whittle, MPH; Jemekia Thornton, MPA; Connie Lim, MPA; Yoshimi Yamakawa, MPH; Nancy Brener, PhD; Stephanie Zaza, MD.
Youth Risk Behavior Surveillance — United States, 2015.
Surveillance Summaries / June 10, 2016 / 65(6);1–174
Priority health-risk behaviors contribute to the leading causes of morbidity and mortality among youth and adults. Population-based data on these behaviors at the national, state, and local levels can help monitor the effectiveness of public health interventions designed to protect and promote the health of youth nationwide. Reporting Period Covered: September 2014–December 2015. The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority health behaviors among youth and young adults: 1) behaviors that contribute to unintentional injuries and violence; 2) tobacco use; 3) alcohol and other drug use; 4) sexual behaviors related to unintended pregnancy and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection; 5) unhealthy dietary behaviors; and 6) physical inactivity. In addition, YRBSS monitors the prevalence of obesity and asthma and other priority health behaviors. YRBSS includes a national school-based Youth Risk Behavior Survey (YRBS) conducted by CDC and state and large urban school district school-based YRBSs conducted by state and local education and health agencies. This report summarizes results for 118 health behaviors plus obesity, overweight, and asthma from the 2015 national survey, 37 state surveys, and 19 large urban school district surveys conducted among students in grades 9–12.
Results from the 2015 national YRBS also indicated many high school students are engaged in behaviors associated with chronic diseases, such as cardiovascular disease, cancer, and diabetes. During the 30 days before the survey, 10.8% of high school students had smoked cigarettes and 7.3% had used smokeless tobacco.
Shelley Karn, Alejandra Fernandez, Lou Ann Grossberg, Trina Robertson, Barry Sharp, Philip Huang, Alexandra Loukas.
Systematically Improving Tobacco Cessation Patient Services Through Electronic Medical
Health Promotion Practice. July 2016 Vol. 17, No. (4) 482–489
The Health Information Act of 2010 has presented an opportunity to discuss, establish, and promote innovative ways to incorporate tobacco cessation assistance to patients in the health care setting. This article provides an overview of the development and implementation of an electronic tobacco cessation protocol (the eTobacco protocol), into an electronic medical record (EMR) system, while evaluating the barriers and benefits encountered. The protocol was developed to facilitate the process of electronically referring patients to a statefunded quitline service by establishing a one-click connect for providers to use within the EMR system. While evaluating the implementation of the protocol, findings indicate that several barriers were encountered including disruption of clinic workflow, EMR limitations, and training complications. In spite of the barriers, the protocol shows promising results by increasing referrals to the quitline from 7 patients the year prior to implementation to 1,254 patients after the implementation of the electronic solution. Health care systems that have the ability to modify their EMR system can help lower tobacco use rates among their patients while meeting Meaningful Use requirements. Future research should examine if referrals through the eTobacco protocol are directly associated with patients’ tobacco cessation rates.
James Lightwood, Stanton A. Glantz
Smoking Behavior and Healthcare Expenditure in the United States, 1992–2009: Panel Data Estimates.
PLoS Med 13(5): e1002020. doi:10.1371/journal.pmed.1002020
Reductions in smoking in Arizona and California have been shown to be associated with reduced per capita healthcare expenditures in these states compared to control populations in the rest of the US. This paper extends that analysis to all states and estimates changes in healthcare expenditure attributable to changes in aggregate measures of smoking behavior in all states. State per capita healthcare expenditure is modeled as a function of current smoking prevalence, mean cigarette consumption per smoker, other demographic and economic factors, and cross-sectional time trends using a fixed effects panel data regression on annual time series data for each the 50 states and the District of Columbia for the years 1992 through 2009. We found that 1% relative reductions in current smoking prevalence and mean packs smoked per current smoker are associated with 0.118% (standard error [SE] 0.0259%, p
< 0.001) and 0.108% (SE 0.0253%, p
< 0.001) reductions in per capita healthcare expenditure (elasticities). The results of this study are subject to the limitations of analysis of aggregate observational data, particularly that a study of this nature that uses aggregate data and a relatively small sample size cannot, by itself, establish a causal connection between smoking behavior and healthcare costs. Historical regional variations in smoking behavior (including those due to the effects of state tobacco control programs, smoking restrictions, and differences in taxation) are associated with substantial differences in per capita healthcare expenditures across the United States. Those regions (and the states in them) that have lower smoking have substantially lower medical costs. Likewise, those that have higher smoking have higher medical costs. Sensitivity analysis confirmed that these results are robust. Changes in healthcare expenditure appear quickly after changes in smoking behavior. A 10% relative drop in smoking in every state is predicted to be followed by an expected $63 billion reduction (in 2012 US dollars) in healthcare expenditure the next year. State and national policies that reduce smoking should be part of short term healthcare cost containment.
Voci SC, Zawertailo LA, Hussain S, Selby PL.
Association Between Adherence to Free Nicotine Replacement Therapy and Successful Quitting.
Addict Behav. 2016 May 13;61:25-31. doi: 10.1016/j.addbeh.2016.05.012. [Epub ahead of print]
Providing free nicotine replacement therapy (NRT) can be a cost-effective strategy for increasing quit attempts and cessation rates at a population level. However, the optimal amount of NRT to provide is unknown. Associations between duration of NRT use and abstinence may be overestimated as a result of reverse causality due to discontinuation following relapse. We examined the association between adherence to 10weeks of cost-free NRT and quit success at 6-month follow-up, after controlling for reverse causation by excluding participants who reported nonadherence due to relapse. Individuals 18years or older who smoked at least 10 cigarettes daily and intended to quit within 30days received 10weeks of NRT at a smoking cessation workshop. There were 3922 participants who attended one of 114 workshops in 70 different localities in Ontario, Canada from 2007 to 2008.
At end of treatment participants were asked whether they had used "all" of the NRT (20%), "most" of it (28%), "some" of it (27%), or whether they "did not use any" of it (5%). After controlling for reverse causation and adjusting for potential confounding variables, poorer quit success was reported by those who used either some (AOR=0.43, 95% CI=0.26-0.69, p=0.001) or none (AOR=0.30, 95% CI=0.09-0.95, p=0.041) of the NRT versus all 10weeks. Post-estimation contrasts revealed using some versus most of the NRT was also associated with poorer quit success (p=0.026). After controlling for reverse causation, adherence to 10weeks of cost-free NRT was associated with successful abstinence at six months post-treatment.
Tulloch HE, Pipe AL, Els C, Clyde MJ, Reid RD.
Flexible, Dual-form Nicotine Replacement Therapy or Varenicline in Comparison with Nicotine Patch for Smoking Cessation: A Randomized Controlled Trial.
BMC Med. 2016 Jun 7;14(1):80. doi: 10.1186/s12916-016-0626-2.
Extended use of combined pharmacotherapies to treat tobacco dependence may increase smoking abstinence; few studies have examined their effectiveness. The objective of this study was to evaluate smoking abstinence with standard nicotine patch (NRT), extended use of combined formulations of nicotine replacement therapy (NRT+), or varenicline (VR). A total of 737 smokers, including those with medical and psychiatric comorbidities, were randomly assigned to one of the above three treatment conditions. The NRT group received 10 weeks of patches (21 mg daily maximum); the NRT+ group received patches (35 mg daily maximum) and gum or inhaler for up to 22 weeks; and the VR group received 1 mg twice daily for up to 24 weeks (22 weeks post target quit date). All participants also received six standardized 15-minute smoking cessation counseling sessions by nurses experienced in tobacco dependence treatment. The primary outcome was carbon monoxide-confirmed continuous abstinence rates (CAR) from weeks 5-52. Secondary outcomes were: CAR from weeks 5-10 and 5-22, and carbon monoxide-confirmed 7-day point prevalence (7PP) at weeks 10, 22, and 52. Adjusted and unadjusted logistic regression analyses were conducted using intention-to-treat procedures.
The CARs for weeks 5-52 were 10.0 %, 12.4 %, and 15.3 % in the NRT, NRT+, and VR groups, respectively; no group differences were observed. Results with 7PP showed that VR was superior to NRT at week 52 (odds ratio (OR), 1.84; 97.5 % Confidence Interval (CI), 1.04-3.26) in the adjusted intention-to-treat analysis. Those in the VR group had higher CAR at weeks 5-22 (OR, 2.01; CI, 1.20-3.36) than those in the NRT group. Results with 7PP revealed that both NRT+ (OR, 1.72; CI, 1.04-2.85) and VR (OR, 1.96; CI, 1.20-3.23) were more effective than NRT at 22 weeks. As compared to NRT monotherapy, NRT+ and VR produced significant increases in CAR for weeks 5-10 (OR, 1.52; CI, 1.00-2.30 and OR, 1.58; CI, 1.04-2.39, respectively); results were similar, but somewhat stronger, when 7PP was used at 10 weeks (OR, 1.57; CI, 1.03-2.41 and OR, 1.79; CI, 1.17-2.73, respectively). All medications were well tolerated, but participants in the VR group experienced more fatigue, digestive symptoms (e.g., nausea, diarrhea), and sleep-related concerns (e.g., abnormal dreams, insomnia), but less dermatologic symptoms than those in the NRT or NRT+ groups. The frequency of serious adverse events did not differ between groups. Flexible and combination NRT and varenicline enhance success in the early phases of quitting. Varenicline improves abstinence in the medium term; however, there is no clear evidence that either varenicline or flexible, dual-form NRT increase quit rates in the long-term when compared to NRT monotherapy.
Garey L, Farris SG, Schmidt NB, Zvolensky MJ.
The Role of Smoking-Specific Experiential Avoidance in the Relation Between Perceived Stress and Tobacco Dependence, Perceived Barriers to Cessation, and Problems during Quit Attempts Among Treatment-Seeking Smokers.
J Contextual Behav Sci. 2016 Jan;5(1):58-63.
Despite the clinically-significant association between perceived stress and smoking, there is little understanding of the mechanisms underlying this relation. The present study examined smoking-specific experiential avoidance as an explanatory mechanism linking perceived stress and smoking, including nicotine dependence, perceived barriers to cessation, and problems reported during past quit attempts among treatment-seeking daily smokers (n
= 365; 48.5% female; Mage
= 38.02; SD
= 13.10). Results indicated that smoking-specific experiential avoidance had a significant, indirect effect on perceived stress and the studied smoking criterion variables. The present findings provide initial empirical support that smoking-specific experiential avoidance may help explain how perceived stress is associated with smoking. These data suggest that there may be merit to targeting smoking-specific experiential avoidance during smoking cessation among smokers with elevated perceived stress.
Forman-Hoffman VL, Hedden SL, Glasheen C, Davies C, Colpe LJ.
The Role of Mental Illness on Cigarette Dependence and Successful Quitting in a Nationally Representative, Household-based Sample of U.S. Adults.
Ann Epidemiol. 2016 May 12. pii: S1047-2797(16)30132-6. doi: 10.1016/j.annepidem.2016.05.004. [Epub ahead of print]
To begin to explore whether the association between mental illness (MI), cigarette dependence, and unsuccessful quit attempts differs across particular demographic subgroups, this study examines data from adults aged 18 years or older participating in the 2008-2012 National Surveys on Drug Use and Health. Analyses explored the moderating effects of age, gender, and race and/or ethnicity on associations between three levels of MI: (serious mental illness [SMI], any mental illness but no SMI, and no MI) and two smoking-related outcomes (cigarette dependence among current smokers and successful quitting among ever daily smokers).
After confirming that adults with MI were more likely to be dependent on cigarettes and less likely to successfully quit smoking, particularly among those with SMI, adjusted analyses indicated that age (but not gender or race/ethnicity) moderated the associations between MI and cigarette dependence and between MI. The magnitude of the association between MI and cigarette dependence and between MI and successful quitting appears to be stronger among older adults than among younger adults. Identifying subgroups at particular high risk of cigarette dependence is paramount to targeting smoking prevention, cessation, and treatment services appropriately.
Farris SG, Zvolensky MJ, Schmidt NB.
Difficulties with Emotion Regulation and Psychopathology Interact to Predict Early Smoking Cessation Lapse.
Cognit Ther Res. 2016 Jun;40(3):357-367. Epub 2015 Jul 19.
There is little knowledge about how emotion regulation difficulties interplay with psychopathology in terms of smoking cessation. Participants (n
= 250; 53.2 % female, Mage
= 39.5, SD
= 13.85) were community-recruited daily smokers (≥8 cigarettes per day) who self-reported motivation to quit smoking; 38.8 % of the sample met criteria for a current (past 12-month) psychological disorder. Emotion regulation deficits were assessed pre-quit using the Difficulties with Emotion Regulation Scale (DERS; Gratz and Roemer in J Psychopathol Behav Assess 26(1):41-54, 2004) and smoking behavior in the 28 days post-quit was assessed using the Timeline Follow-Back (TLFB; Sobell and Sobell in Measuring alcohol consumption: psychosocial and biochemical methods. Humana Press, Totowa, 1992). A Cox proportional-hazard regression analysis was used to model the effects of past-year psychopathology, DERS (total score), and their interaction, in terms of time to lapse post-quit day. After adjusting for the effects of gender, age, pre-quit level of nicotine dependence, and treatment condition, the model revealed a non-significant effect of past-year psychopathology (OR
= 1.14, CI 95 %
= 0.82-1.61) and difficulties with emotion regulation (OR
= 1.01, CI 95 %
= 1.00-1.01) on likelihood of lapse rate. However, the interactive effect of psychopathology status and difficulties with emotion regulation was significant (OR
= 0.98, CI 95 %
= 0.97-0.99). Specifically, there was a significant conditional effect of psychopathology status on lapse rate likelihood at low, but not high, levels of emotion regulation difficulties. Plots of the cumulative survival functions indicated that for smokers without a past-year psychological disorder, those with lower DERS scores relative to elevated DERS scores had significantly lower likelihood of early smoking lapse, whereas for smokers with past-year psychopathology, DERS scores did not differentially impact lapse rate likelihood. Smokers with emotion regulation difficulties may have challenges quitting, and not having such difficulties, especially without psychopathology, decreases the potential likelihood of early lapse.
Katarzyna A Campbell, Sue Cooper, Samantha J Fahy, Katharine Bowker, Jo Leonardi-Bee, Andy McEwen, Rachel Whitemore, Tim Coleman.
‘Opt-out’ Referrals After Identifying Pregnant Smokers Using Exhaled Air Carbon Monoxide: Impact on Engagement with Smoking Cessation Support’.
Tob Control doi:10.1136/tobaccocontrol-2015-052662
In the UK, free smoking cessation support is available to pregnant women; only a minority accesses this. ‘Opt-out’ referrals to stop smoking services (SSS) are recommended by UK guidelines. These involve identifying pregnant smokers using exhaled carbon monoxide (CO) and referring them for support unless they object. To assess the impact of ‘opt-out’ referrals for pregnant smokers on SSS uptake and effectiveness, we conducted a ‘before–after’ service development evaluation. In the 6-month ‘before’ period, there was a routine ‘opt-in’ referral system for self-reported smokers at antenatal ‘booking’ appointments. In the 6-month ‘after’ period, additional ‘opt-out’ referrals were introduced at the 12-week ultrasound appointments; women with CO≥4 ppm were referred to, and outcome data were collected from, local SSS.
Approximately 2300 women attended antenatal care in each period. Before the implementation, 536 (23.4%) women reported smoking at ‘booking’ and 290 (12.7%) were referred to SSS. After the implementation, 524 (22.9%) women reported smoking at ‘booking’, an additional 156 smokers (6.8%) were identified via the ‘opt-out’ referrals and, in total, 421 (18.4%) were referred to SSS. Over twice as many women set a quit date with the SSS after ‘opt-out’ referrals were implemented (121 (5.3%, 95% CI 4.4% to 6.3%) compared to 57 (2.5%, 95% CI 1.9% to 3.2%) before implementation) and reported being abstinent 4 weeks later (93 (4.1%, 95% CI 3.3% to 4.9%) compared to 46 (2.0%, 1.5% to 2.7%) before implementation). In a hospital with an ‘opt-in’ referral system, adding CO screening with ‘opt-out’ referrals as women attended ultrasound examinations doubled the numbers of pregnant smokers setting quit dates and reporting smoking cessation.
Kerri A Mullen, Douglas G Manuel, Steven J Hawken, Andrew L Pipe, Douglas Coyle, Laura A Hobler, Jaime Younger, George A Wells, Robert D Reid
Effectiveness of a Hospital-initiated Smoking Cessation Programme: 2-year Health and Healthcare Outcomes.
Tob Control doi:10.1136/tobaccocontrol-2015-052728
Tobacco-related illnesses are leading causes of death and healthcare use. Our objective was to determine whether implementation of a hospital-initiated smoking cessation intervention would reduce mortality and downstream healthcare usage. A 2-group effectiveness study was completed comparing patients who received the ‘Ottawa Model’ for Smoking Cessation intervention (n=726) to usual care controls (n=641). Participants were current smokers, >17 years old, and recruited during admission to 1 of 14 participating hospitals in Ontario, Canada. Baseline data were linked to healthcare administrative data. Competing-risks regression analysis was used to compare outcomes between groups.
The intervention group experienced significantly lower rates of all-cause readmissions, smoking-related readmissions, and all-cause emergency department (ED) visits at all time points. The largest absolute risk reductions (ARR) were observed for all-cause readmissions at 30 days (13.3% vs 7.1%; ARR, 6.1% (2.9% to 9.3%); p<0.001), 1 year (38.4% vs 26.7%; ARR, 11.7% (6.7% to 16.6%); p<0.001), and 2 years (45.2% vs 33.6%; ARR, 11.6% (6.5% to 16.8%); p<0.001). The greatest reduction in risk of all-cause ED visits was at 30 days (20.9% vs 16.4%; ARR, 4.5% (0.4% to 8.7%); p=0.03). Reduction in mortality was not evident at 30 days, but significant reductions were observed by year 1 (11.4% vs 5.4%; ARR 6.0% (3.1% to 9.0%); p<0.001) and year 2 (15.1% vs 7.9%; ARR, 7.3% (3.9% to 10.7%); p<0.001). Considering the relatively low cost, greater adoption of hospital-initiated tobacco cessation interventions should be considered to improve patient outcomes and decrease subsequent healthcare usage.
Sharon Cummins, Scott Leischow, Linda Bailey, Terry Bush, Ken Wassum, Lesley Copeland, Shu-Hong Zhu
Knowledge and Beliefs About Electronic Cigarettes Among Quitline Cessation Staff.
Addictive Behaviors. Volume 60, September 2016, Pages 78–83
Smokers are asking health practitioners for guidance about using e-cigarettes as an aid to quitting. Several studies have surveyed physicians. However, in North America many smokers seek help from telephone quitlines rather than physicians. The objective of the current study was to assess quitline counselors’ perceptions of e-cigarettes and what they tell callers about these products. An online cross-sectional survey, conducted in 2014 with 418 quitline counselors in the U.S. and Canada, measured perceptions of e-cigarettes: (1) use as a quitting aid; (2) safety; (3) professional guidance given and organizational guidance received; (4) regulation. The response rate was 90.1%. Analyses included calculating standard errors and 95% confidence intervals around summary statistics.
Nearly 70% of counselors believed that e-cigarettes are not effective quitting aids. Most believed e-cigarettes are addictive (87%) and that secondhand exposure to vapor is harmful (71%). Counselors reported that callers ask for advice about e-cigarettes, but few counselors recommended e-cigarettes (4%). Counselors (97%) reported being instructed by quitline employers to explain to clients that e-cigarettes are not FDA-approved; 74% were told to recommend approved quitting aids instead. Most counselors (> 87%) believed e-cigarettes should be regulated like cigarettes in terms of advertising, taxation, access by minors, and use in public places. Quitline counselors view e-cigarettes as ineffective quitting aids, potentially dangerous, and in need of greater regulations. Counselors can influence how treatment seekers view e-cigarettes, therefore it is imperative that quitlines stay abreast of emerging data and communicate about these products in ways that best serve clients.
Lamberto Manzoli, Maria Elena Flacco, Margherita Ferrante, Carlo La Vecchia, Roberta Siliquini, Walter Ricciardi, Carolina Marzuillo, Paolo Villari, Maria Fiore
Cohort Study of Electronic Cigarette Use: Effectiveness and Safety at 24 Months.
To evaluate the safety and effectiveness of e-cigarettes, by comparing users of only e-cigarettes, smokers of only tobacco cigarettes and dual users. Prospective cohort study. We update previous 12-month findings and report the results of the 24-month follow-up. Direct contact and questionnaires by phone or via internet. Adults (30–75 years) were classified as: (1) tobacco smokers, if they smoked ≥1 tobacco cigarette/day, (2) e-cigarette users, if they inhaled ≥50 puffs/week of any type of e-cigarette and (3) dual users, if they smoked tobacco cigarettes and also used e-cigarettes. Carbon monoxide levels were tested in 50% of those declaring tobacco smoking abstinence. Hospital discharge data were used to validate possibly related serious adverse events in 46.0% of the sample.
Sustained abstinence from tobacco cigarettes and/or e-cigarettes after 24 months, the difference in the number of tobacco cigarettes smoked daily between baseline and 24 months, possibly related serious adverse events. Data at 24 months were available for 229 e-cigarette users, 480 tobacco smokers and 223 dual users (overall response rate 68.8%). Of the e-cigarette users, 61.1% remained abstinent from tobacco (while 23.1% and 26.0% of tobacco-only smokers and dual users achieved tobacco abstinence). The rate (18.8%) of stopping use of either product (tobacco and/or e-cigarettes) was not higher for e-cigarette users compared with tobacco smokers or dual users. Self-rated health and adverse events were similar between all groups. Among those continuing to smoke, there were no differences in the proportion of participants reducing tobacco cigarette consumption by 50% or more, the average daily number of cigarettes and the average self-rated health by baseline group. Most dual users at baseline abandoned e-cigarettes and continued to smoke tobacco. Those who continued dual using or converted from tobacco smoking to dual use during follow-up experienced significant improvements in the 3 outcomes compared with those who continued or switched to only smoking tobacco (p<0.001). E-cigarette use alone might support tobacco quitters remaining abstinent from smoking. However, dual use did not improve the likelihood of quitting tobacco or e-cigarette use, but may be helpful to reduce tobacco consumption. Adverse event data were scarce and must be considered preliminary.
Jessica L. Barrington-Trimis, Robert Urman, Kiros Berhane, Jennifer B. Unger, Tess Boley Cruz, Mary Ann Pentz,Jonathan M. Samet, Adam M. Leventhal, Rob McConnell
E-Cigarettes and Future Cigarette Use.
Pediatrics. June 2016
There has been little research examining whether e-cigarette use increases the risk of cigarette initiation among adolescents in the transition to adulthood when the sale of cigarettes becomes legal. The Children’s Health Study is a prospectively followed cohort in Southern California. Data on e-cigarette use were collected in 11th and 12th grade (mean age = 17.4); follow-up data on tobacco product use were collected an average of 16 months later from never-smoking e-cigarette users at initial evaluation (n
= 146) and from a sample of never-smoking, never e-cigarette users (n
= 152) frequency matched to e-cigarette users on gender, ethnicity, and grade.
Cigarette initiation during follow-up was reported by 40.4% of e-cigarette users (n
= 59) and 10.5% of never users (n
= 16). E-cigarette users had 6.17 times (95% confidence interval: 3.30–11.6) the odds of initiating cigarettes as never e-cigarette users. Results were robust to adjustment for potential confounders and in analyses restricted to never users of any combustible tobacco product. Associations were stronger in adolescents with no intention of smoking at initial evaluation. E-cigarette users were also more likely to initiate use of any combustible product (odds ratio = 4.98; 95% confidence interval: 2.37–10.4), including hookah, cigars, or pipes. E-cigarette use in never-smoking youth may increase risk of subsequent initiation of cigarettes and other combustible products during the transition to adulthood when the purchase of tobacco products becomes legal. Stronger associations in participants with no intention of smoking suggests that e-cigarette use was not simply a marker for individuals who would have gone on to smoke regardless of e-cigarette use.
Use of Electronic Cigarettes Among Cancer Survivors in the U.S.
Ramzi G. Salloum, PhD, Kayla R. Getz, MPH, Andy S.L. Tan, PhD, Lisa Carter-Harris, PhD, Kelly C. Young-Wolff, PhD, Thomas J. George Jr., MD, Elizabeth A. Shenkman, PhD
Am J Prev Med. 2016 May 27. pii: S0749-3797(16)30122-2. doi: 10.1016/j.amepre.2016.04.015. [Epub ahead of print]
The population-level patterns of electronic cigarette (e-cigarette) use among cancer survivors in the U.S. are unknown. The objective of this study was to examine the prevalence and correlates of e-cigarette use among cancer survivors in a nationally representative sample. A cross-sectional analysis was conducted of the 2014 National Health Interview Survey of the U.S. non-institutionalized civilian population. The main study outcomes were the prevalence and correlates of ever and current e-cigarette use among adults with self-reported history of cancer, excluding non-melanoma skin cancer (N=2,695). Multivariable logistic regression analyses examined whether e-cigarette use differed by cigarette smoking status and demographic subgroups. The analyses were performed in 2015.
The prevalence of e-cigarette use among adult cancer survivors was lower than the general population: 2.8% of cancer survivors reported currently using e-cigarettes and an additional 6.3% had previously used e-cigarettes but were not currently using them. Use of e-cigarettes was most common among cancer survivors who currently smoked cigarettes: 34.3% of current smokers were ever e-cigarette users and 15.6% were current e-cigarette users, compared with former smokers (2.7% ever and 1.4% current e-cigarette users) and never smokers (small sample/estimates unavailable). E-cigarettes are not part of current evidence-based smoking-cessation strategies. However, the finding that cancer survivors who currently smoke cigarettes are more likely to use e-cigarettes highlights the importance of addressing e-cigarette use in patient-provider communications around tobacco cessation.
Meg Fluharty, Amy E Taylor, Meryem Grabski, Marcus R Munafò.
Smoking, Depression and Anxiety The Association of Cigarette Smoking with Depression and Anxiety: A Systematic Review.
Nicotine Tob Res
(2016)doi: 10.1093/ntr/ntw140First published online: May 19, 2016
Many studies report a positive association between smoking and mental illness. However, the literature remains mixed regarding the direction of this association. We therefore conducted a systematic review evaluating the association of smoking and depression and/or anxiety in longitudinal studies. studies were identified by searching PubMed, Scopus, and Web of Science and were included if they: 1) used human participants, 2) were longitudinal, 3) reported primary data, 4) had smoking as an exposure and depression and/or anxiety as an outcome, or 5) had depression and/or anxiety as the exposure and smoking as an outcome.
Outcomes from 148 studies were categorized into: smoking onset, smoking status, smoking heaviness, tobacco dependence and smoking trajectory. The results for each category varied substantially, with evidence for positive associations in both directions (smoking to later mental health and mental health to later smoking) as well as null findings. Overall, nearly half the studies reported that baseline depression/anxiety was associated with some type of later smoking behavior, while over a third found evidence that a smoking exposure was associated with later depression/anxiety. However, there were few studies directly supporting a bidirectional model of smoking and anxiety, and very few studies reporting null results. The literature on the prospective association between smoking and depression and anxiety is inconsistent in terms of the direction of association most strongly supported. This suggests the need for future studies that employ different methodologies, such as Mendelian randomisation, that will allow us to draw stronger causal inferences.
Alicia M. Allen, PhD, MPH, Taneisha S. Scheuermann, PhD, Nicole Nollen, PhD, Dorothy Hatsukami, PhD, Jasjit S. Ahluwalia, MD, MPH, Gender
Differences in Smoking Behavior and Dependence Motives Among Daily and Nondaily Smokers.
Nicotine Tob Res
(2016) 18 (6):1408-1413.doi: 10.1093/ntr/ntv138First published online: June 30, 2015
While the overall prevalence of smoking has declined, nondaily smoking is on the rise. Among daily smokers (DS) men tend to smoke more cigarettes per day and have higher dependence. Unfortunately little is known about gender differences in nondaily smokers (NDS). This secondary-data analysis utilized data from a cross-sectional online survey. Participants reported on smoking behavior (eg, cigarettes per day, history of quit attempts) and nicotine dependence motives as assessed by the Brief Wisconsin Inventory of Dependence Motives via the primary and secondary subscales (ie, core features of tobacco dependence such as craving and accessory motives such as weight control, respectively).
Participants were 1175 DS (60% women) and 1201 NDS (56% women). Two interactions between group and gender were noted suggesting that the NDS had greater gender differences in past quit attempts (P
< .01) and reported change in smoking behavior over the past year (P
< .01). Further, among the NDS group, men scored significantly higher than women on both the primary and secondary dependence motives subscales (3.6±0.1 vs. 2.9±0.1, P
< .0001; 3.8±0.1 vs. 3.3±0.1,P
< .0001; respectively). There were no significant differences in dependence motives in the DS group (P
> .05). Gender differences in smoking behavior and dependence motives varied between NDS and DS. Specifically, gender differences in smoking behavior and smoking dependence motives may be larger among NDS compared to DS. Additional research is needed to explore how these relationships may relate to smoking cessation in NDS.
Taghrid Asfar, MD, MSPH, Kristopher L. Arheart, EdD, Noella A. Dietz, PhD, Alberto J. Caban-Martinez, DO, PhD, MPH, Lora E. Fleming, MD, PhD, and David J. Lee, PhD.
Changes in Cigarette Smoking Behavior Among US Young Workers From 2005 to 2010: The Role of Occupation.
Nicotine Tob Res
(2016) 18 (6):1414-1423.doi: 10.1093/ntr/ntv240First published online: October 26, 2015
Young adult workers (18–24 years) in the United States have been identified as a high-risk group for smoking. This study compares changes in smoking behavior by occupational class among this group between 2005 and 2010. Data were pooled from the Tobacco Supplement in the 2005 and 2010 National Health Interview Survey. All respondents 18–24 years who reported that they were employed during the two surveys were selected (n
= 1880 in 2005; and n
= 1531 in 2010). Weighted percentages and 95% confidence interval were reported. Logistic regression analyses were performed to compare smoking behavior between occupational groups (white-collar, blue-collar, and service) and between years (2005–2010), and to examine correlates of smoking, successful quit attempt, and heavy smoking. Smoking prevalence and daily smoking declined in 2010 in white-collar. Smoking prevalence and intensity decreased while age of smoking initiation increased in blue-collar workers. Young workers were more likely to smoke in 2005 than 2010. Service and blue-collar workers were more likely to smoke than white-collar workers. Older young adults, whites, individuals with a high school/or less education, those without health insurance were more likely to smoke. White workers and individuals with a high school/or less education were more likely to be heavy smokers.
White-collar workers have benefited the most from tobacco control efforts. Although improvements were seen in smoking behavior among blue-collar workers, smoking prevalence remained the highest in this group. Smoking behavior among service workers did not change. Young service workers and blue-collar are priority populations for workplace tobacco control efforts. The current study examines changes in smoking behavior among young adult workers (18–24 years) by occupational class (white-collar, blue-collar, and service workers) between 2005 and 2010. Data were pooled from the Tobacco Supplement in the 2005 and 2010 National Health Interview Survey. Smoking prevalence and daily smoking declined significantly in white-collar workers. No change in smoking behavior was observed among service workers. Positive changes in smoking behavior were observed among blue-collar workers, but smoking prevalence remained the highest in this group. Blue-collar and service workers are priority groups for future workplace tobacco control efforts.
Mariel S. Bello, BS, Raina D. Pang, PhD, Karen L. Cropsey, PsyD, Michael J. Zvolensky, PhD, Lorraine R. Reitzel, PhD, Jimi Huh, PhD1 and Adam M. Leventhal, PhD.
Tobacco Withdrawal Amongst African American, Hispanic, and White Smokers.
Nicotine Tob Res
(2016) 18 (6):1479-1487.doi: 10.1093/ntr/ntv231First published online: October 18, 2015
Persistent tobacco use among racial and ethnic minority populations in the United States is a critical public health concern. Yet, potential sources of racial/ethnic disparities in tobacco use remain unclear. The present study examined racial/ethnic differences in tobacco withdrawal—a clinically-relevant underpinning of tobacco use that has received sparse attention in the disparities literature—utilizing a controlled laboratory design. Daily smokers (non-Hispanic African American [n
= 178], non-Hispanic white [n
= 118], and Hispanic [n
= 28]) attended two counterbalanced sessions (non-abstinent vs. 16-hour abstinent). At both sessions, self-report measures of urge, nicotine withdrawal, and affect were administered and performance on an objective behavioral task that assessed motivation to reinstate smoking was recorded. Abstinence-induced changes (abstinent scores vs. non-abstinent scores) were analyzed as a function of race/ethnicity.
Non-Hispanic African American smokers reported greater abstinence-induced declines in several positive affect states in comparison to other racial/ethnic groups. Relative to Hispanic smokers, non-Hispanic African American and non-Hispanic white smokers displayed larger abstinence-provoked increases in urges to smoke. No racial/ethnic differences were detected for a composite measure of nicotine withdrawal symptomatology, negative affect states, and motivation to reinstate smoking behavior. These results suggest qualitative differences in the expression of some components of tobacco withdrawal across three racial/ethnic groups. This research helps shed light on bio-behavioral sources of tobacco-related health disparities, informs the application of smoking cessation interventions across racial/ethnic groups, and may ultimately aid the overall effort towards reducing the public health burden of tobacco addiction in minority populations. The current study provides some initial evidence that there may be qualitative differences in the types of tobacco withdrawal symptoms experienced among non-Hispanic African American, Hispanic, and non-Hispanic white smokers. Extending this line of inquiry may elucidate mechanisms involved in tobacco-related health disparities and ultimately aid in reducing the public health burden of smoking in racial/ethnic minority populations.
Won S. Choi, PhD, MPH, Niaman Nazir, MPH, MBBS, Christina M. Pacheco, JD, Melissa K. Filippi, PhD, MPH, Joseph Pacheco, MPH, Julia White Bull, MA, Christi Nance, BA, Babalola Faseru, MD, MPH, K. Allen Greiner, MD, MPH, and Christine Makosky Daley, PhD, MA, SM
Recruitment and Baseline Characteristics of American Indian Tribal College Students Participating in a Tribal College Tobacco and Behavioral Survey.
Nicotine Tob Res
(2016) 18 (6):1488-1493.doi: 10.1093/ntr/ntv226First published online: October 5, 2015
American Indians (AIs) have the highest cigarette smoking rates of any racial/ethnic group in the United States. Although the overall smoking prevalence in the United States for nonminority populations has decreased over the past several decades, the same pattern is not observed among AIs. The purpose of this observational study was to collect cigarette smoking and related information from American Indian tribal college students to inform tailored interventions. We conducted a repeated cross-sectional survey of American Indian tribal college students, Tribal College Tobacco and Behavior Survey (TCTABS), with a focus on recruiting all incoming freshman at three participating tribal colleges in the Midwest and Northern Plains regions. A total of 1256 students participated in the baseline surveys between April 2011 and October 2014.
The overall smoking prevalence of this sample was 34.7%, with differences by region (Northern Plains—44.0% and Midwest—28%). The majority, 87.5% of current smokers reported smoking 10 or less cigarettes per day, 41% reported smoking menthol cigarettes, 52% smoked Marlboro brand, and the mean age of their first cigarette was 14 years. The majority, 62% had made at least one quit attempt in the past year. The overwhelming majority of respondents, regardless of their smoking status, thought that the current smoking prevalence on campus was greater than 41% and approximately one-third believed that it was as high as 61%. Very few studies of smoking have been conducted in this population and results from our study confirm the need for effective interventions. AIs have the highest cigarette smoking rates compared to other racial/ethnic groups in the United States. Furthermore, limited studies have examined the epidemiology of cigarette smoking among tribal college students. This study addresses health disparities related to smoking among college students by examining the demographic, cultural, and environmental characteristics of smoking and quitting. Results from this study could lead to the development of a culturally-tailored smoking cessation and prevention program for American Indian tribal college students.
Kristen Emory, PhD, Yoonsang Kim, PhD, Francisco Buchting, PhD, Lisa Vera, BA, Jidong Huang, PhD, and Sherry L. Emery, PhD
Intragroup Variance in Lesbian, Gay, and Bisexual Tobacco Use Behaviors: Evidence That Subgroups Matter, Notably Bisexual Women. Nicotine Tob Res
(2016) 18 (6):1494-1501.doi: 10.1093/ntr/ntv208First published online: September 16, 2015
Emerging evidence suggests bisexual populations are at increased risk for a variety of negative health outcomes, including tobacco use. Lesbian, gay, and bisexual (LGB) populations are at increased risk for cigarette smoking, but research on LGB subpopulations’ use of tobacco products beyond cigarettes and tobacco use differences across LGB subgroups is in its infancy. This study explores differences in use of tobacco products across LGB subgroups, including gender differences among bisexuals. This study reports results from a 2013 nationally-representative cross-sectional online survey of US adults (N
= 17 087). Weighted tobacco use prevalence and adjusted logistic regression results are reported. LGB populations reported higher current use of any tobacco product (35.7%) and current use of cigarettes (32.0%), e-cigarettes (8.9%), regular (5.5%) and small cigars (11.6%), compared with non-LGB. Bisexual (odds ratio [OR
] = 2.6, 95% confidence interval [CI]: 1.7–3.9) and lesbian (OR
= 1.7, 95% CI: 1.0–2.7) women have higher odds of any tobacco use than heterosexual women; including greater odds of regular (OR
= 2.9, 95% CI: 1.2–7.0 and OR
= 2.2, 95% CI: 1.3–3.9; respectively) and small cigar use (OR
= 2.4, 95% CI: 1.4–4.1 and OR
= 3.2, 95% CI: 2.0–5.1; respectively). Gay men had lower odds of cigar use (OR
= 0.4, 95% CI: 0.2–0.8) than heterosexual men. This is the first US adult population study to assess differences in use of various tobacco products across adult LGB subpopulations and by gender, confirming their increased risk of use and illuminating differences by subgroup and gender. Exploring LGB as a unified population appears inadequate to accurately characterize LGB tobacco use risk. Tobacco-related LGB health inequities, particularly among bisexual and lesbian women, may be greater than previously indicated. This manuscript provides important contributions to the field of tobacco control and prevention, and more specifically to LGB tobacco-related health disparities research. This is among the first population level studies to explore various tobacco use across LGB populations and across genders, comparing results to non-LGB populations in a national study. We provide novel evidence that bisexual women in particular, have a higher risk for use of various tobacco products, compared with other LGB subpopulations. In order to address this disparity, tobacco control professionals need to be made aware of these important differences in tobacco use behavior.
Deirdre A. Shires, MPH, MSW and Kim D. Jaffee, PhD
Structural Discrimination is Associated With Smoking Status Among a National Sample of Transgender Individuals.
Nicotine Tob Res
(2016) 18 (6):1502-1508.doi: 10.1093/ntr/ntv221First published online: October 5, 2015
Limited evidence suggests that transgender individuals smoke at significantly higher rates than the general population. We aimed to determine whether structural or everyday discrimination experiences predict smoking behavior among transgender individuals when sociodemographic, health, and gender-specific factors were controlled. Data from the National Transgender Discrimination Survey (N
= 4781), a cross-sectional online and paper survey distributed to organizations serving the transgender community, were analyzed in order to determine the association between current smoking and discrimination experiences and other potential predictors. Logistic regression models were used to establish factors that predict smoking.
Participants reported experiencing both structural (80.4%) and everyday (65.9%) discrimination. Multivariate analyses showed that participants who reported attending some college, graduating college, or having a graduate degree were less likely to smoke compared to those with a high school degree or less. Uninsured participants were more likely to report smoking compared to those with private insurance. Those who used alcohol or drugs for coping were also more likely to smoke. Participants whose IDs and records listed their preferred gender were less likely to smoke (OR
= 0.84); those who had experienced structural discrimination were more like to report smoking (OR
= 1.65). Further research is needed in order to explore the relationship between smoking and legal transition among transgender individuals. Strategies to prevent smoking and encourage cessation among this vulnerable population are also needed. In addition, comprehensive collection of gender identity data in the context of national surveys, tobacco-related research, and clinical settings is sorely needed. This study establishes a link between experiences of structural discrimination among transgender individuals and smoking status.
Jenssen BP, Bryant-Stephens T, Leone FT, Grundmeier RW, Fiks AG.
Clinical Decision Support Tool for Parental Tobacco Treatment in Primary Care.
Pediatrics. 2016 May;137(5). pii: e20154185. Epub 2016 Apr 14.
We created a clinical decision support (CDS) tool and evaluated its feasibility, acceptability, usability, and clinical impact within the electronic health record to help primary care pediatricians provide smoking cessation treatment to parents/caregivers who smoke. This prospective study of pediatric clinicians and parents was conducted at 1 urban primary care site. Clinicians received training in smoking cessation counseling, nicotine replacement therapy (NRT) prescribing, referral to an adult treatment program, and use of the CDS tool. The tool prompted clinicians to ask about secondhand smoke exposure, provide an electronic NRT prescription, and refer. Feasibility was measured by using electronic health record utilization data, and acceptability and usability were assessed with the use of clinician surveys. Parents reported clinical impact, including NRT accepted and used.
From June to August 2015, clinicians used the tool to screen for secondhand smoke exposure at 2286 (76%) of 3023 visits. Parent smokers were identified at 308 visits, and 165 parents (55% of smokers) were interested in and offered treatment. Twenty-four (80%) of 30 eligible pediatric clinicians used the tool. Ninety-four percent of clinicians surveyed (n = 17) were satisfied with the tool, and the average system usability scale score was 83 of 100 (good to excellent range). We reached 69 of 100 parents sampled who received treatment; 44 (64%) received NRT, and 17 (25%) were currently using NRT. A CDS tool to help urban primary care pediatric clinicians provide smoking cessation treatment was feasible, acceptable, usable, and influenced clinical care. A larger scale investigation in varied practice settings is warranted.
Ayers JW, Westmaas JL, Leas EC, Benton A, Chen Y, Dredze M, Althouse BM
Leveraging Big Data to Improve Health Awareness Campaigns: A Novel Evaluation of the Great American Smokeout.
JMIR Public Health Surveill. 2016 Mar 31;2(1):e16. doi: 10.2196/publichealth.5304.
Awareness campaigns are ubiquitous, but little is known about their potential effectiveness because traditional evaluations are often unfeasible. For 40 years, the "Great American Smokeout" (GASO) has encouraged media coverage and popular engagement with smoking cessation on the third Thursday of November as the nation's longest running awareness campaign. We proposed a novel evaluation framework for assessing awareness campaigns using the GASO as a case study by observing cessation-related news reports and Twitter postings, and cessation-related help seeking via Google, Wikipedia, and government-sponsored quitlines.
Time trends (2009-2014) were analyzed using a quasi-experimental design to isolate spikes during the GASO by comparing observed outcomes on the GASO day with the simulated counterfactual had the GASO not occurred. Cessation-related news typically increased by 61% (95% CI 35-87) and tweets by 13% (95% CI -21 to 48) during the GASO compared with what was expected had the GASO not occurred. Cessation-related Google searches increased by 25% (95% CI 10-40), Wikipedia page visits by 22% (95% CI -26 to 67), and quitline calls by 42% (95% CI 19-64). Cessation-related news media positively coincided with cessation tweets, Internet searches, and Wikipedia visits; for example, a 50% increase in news for any year predicted a 28% (95% CI -2 to 59) increase in tweets for the same year. Increases on the day of the GASO rivaled about two-thirds of a typical New Year's Day-the day that is assumed to see the greatest increases in cessation-related activity. In practical terms, there were about 61,000 more instances of help seeking on Google, Wikipedia, or quitlines on GASO each year than would normally be expected. These findings provide actionable intelligence to improve the GASO and model how to rapidly, cost-effectively, and efficiently evaluate hundreds of awareness campaigns, nearly all for the first time.
Warren GW, Ostroff JS, Goffin JRLung
Cancer Screening, Cancer Treatment, and Addressing the Continuum of Health Risks Caused by Tobacco.
Am Soc Clin Oncol Educ Book. 2016;35:223-9. doi: 10.14694/EDBK_158704.
Tobacco use is the largest preventable risk factor for the development of several cancers, and continued tobacco use by patients with cancer and survivors of cancer causes adverse outcomes. Worldwide tobacco control efforts have reduced tobacco use and improved health outcomes in many countries, but several countries continue to suffer from increased tobacco use and associated adverse health effects. Continued tobacco use by patients undergoing cancer screening or treatment results in continued risk for cancer-related and non-cancer-related health conditions. Although integrating tobacco assessment and cessation support into lung cancer screening and cancer care is well justified and feasible, most patients with cancer unfortunately do not receive evidence-based tobacco cessation support. Combining evidence-based methods of treating tobacco addiction, such as behavioral counseling and pharmacotherapy, with practical clinical considerations in the setting of lung cancer screening and cancer treatment should result in substantial improvements in access to evidence-based care and resultant improvements in health risks and cancer treatment outcomes.