Opioid Use and Rate of Nicotine Metabolism Among Pregnant Smokers.

INTRODUCTION: Smokers who use opioids smoke more cigarettes per day (CPD) than non-opioid users, which could be due to the effects of opioids on nicotine metabolism. Moreover, nicotine metabolism increases during pregnancy, potentially making quitting more difficult for pregnant smokers. We examined nicotine metabolism and its association with opioid use (OU) and CPD in pregnant smokers. METHODS: We recruited pregnant women who smoked at least 5 CPD for a clinical trial of smoking cessation. Plasma nicotine metabolite ratio (NMR; trans-3'-hydroxycotinine (3HC)/cotinine)-a biomarker of nicotine metabolism-OU (involving methadone, buprenorphine, fentanyl, oxycodone, or tramadol), and CPD were assessed at baseline. We used linear regression to examine the associations between log-transformed NMR, OU, and CPD, adjusting for race/ethnicity and menthol smoking. RESULTS: Among 129 pregnant smokers, 25 (19%) were opioid users; most were maintained on methadone (n = 14). Compared to non-OU smokers, OU smokers had higher median CPD (10.0 vs. 7.0, p = .0007), serum 3HC (81.0 vs. 42.0 ng/mL, p = .0001), and NMR (0.63 vs. 0.43, p < .0001). In addition, methadone-maintained smokers had a higher median NMR than non-OU smokers (0.66 vs. 0.43, p = .0004). Adjusting for covariates, log-transformed NMR was greater in OU smokers (p = .012), specifically methadone-maintained smokers (p = .024), than non-OU smokers. CONCLUSIONS: Our preliminary results show that OU is associated with a higher NMR in pregnant smokers. A larger study sample is needed to replicate this finding, examine potential mechanisms, and determine its clinical significance. IMPLICATIONS: Among pregnant smokers, we observed that nicotine metabolism was significantly faster among opioid users-the majority of whom were on methadone maintenance-compared to nonusers, which could have implications for smoking cessation. Further studies are needed to replicate this finding, evaluate potential mechanisms, and determine its clinical significance.

Influence of Baseline Psychological Health on Muscle Pain During Atorvastatin Treatment.

BACKGROUND: 3-hydroxy-3-methylglutaryl coenzyme A reductase reductase inhibitors (statins) are generally well tolerated, with statin-associated muscle symptoms (SAMS) the most common side effect (~10%) seen in statin users. However, studies and clinical observations indicate that many of the self-reported SAMS appear to be nonspecific (ie, potentially not attributable to statins). OBJECTIVE: Mental health and well-being influence self-perception of pain, so we sought to assess the effect of baseline well-being and depression on the development of muscle pain with 6 months of atorvastatin 80 mg/d (ATORVA) or placebo in healthy, statin-naive adults. METHODS: The Psychological General Well-being Index (n = 83) and Beck Depression Inventory (n = 55) questionnaires were administered at baseline in participants (aged 59.5 ± 1.2 years) from the effect of Statins on Skeletal Muscle Function and Performance (STOMP) trial (NCT00609063). Muscle pain (Short-Form McGill Pain Questionnaire [SF-MPQ]), pain that interferes with daily life (Brief Pain Inventory [BPI]), and pain severity (BPI) were then measured before, throughout, and after treatment. RESULTS: At baseline, there were no differences in well-being (Psychological General Well-being Index), depression (Beck Depression Inventory), or pain measures (SF-MPQ and BPI) (P values ≥ .05) between the placebo and ATORVA groups. Baseline well-being correlated negatively with baseline BPI pain severity (r = -0.290, P = .008). Baseline depression correlated with baseline pain (SF-MPQ; r = 0.314, P = .020). Baseline well-being and depression did not predict the change in pain severity or interference after 6 months among the total sample or between groups (P values ≥ .05). CONCLUSION: Baseline well-being and depression were not significant predictors of pain after 6 months of ATORVA (P values ≥ .05). Thus, they do not appear to increase the risk of SAMS in otherwise healthy adults.

A Descriptive Survey Study of Patient Needs and Preferences for Cancer Pain Self-Management Support.

OBJECTIVES: To characterize the needs and preferences for pain self-management support (SMS) among patients with cancer during the transition of cancer care from the hospital to the home setting. SAMPLE & SETTING: 38 participants with cancer pain at a research-intensive cancer center in New England. METHODS & VARIABLES: A descriptive, cross-sectional survey study was conducted to investigate relationships among preferred and received support, extent and management of transitional change, and pain outcomes. Pain intensity and interference were measured using the Brief Pain Inventory-Short Form, transitional change was measured using the Measurement of Transitions in Cancer Scale, and SMS was measured using dichotomous questions. RESULTS: About half of participants reported concordance between preferred and received cancer pain SMS in the hospital and at home. The extent of transitional change in cancer care was found to be a significant predictor of average pain intensity in the hospital and pain interference at home. Satisfaction with cancer pain SMS was a significant predictor of pain intensity at home. IMPLICATIONS FOR NURSING: The extent of change during care transitions should be considered when fulfilling patient needs and preferences for cancer pain SMS to optimize outcomes.

Perceptions of clinical support for employed breast cancer survivors managing work and health challenges.

PURPOSE: A substantial portion of breast cancer survivors are active in the workforce, yet factors that allow survivors to balance work with cancer management and to return to work are poorly understood. We examined breast cancer survivors' most valued/desired types of support in early survivorship. METHODS: Seventy-six employed breast cancer survivors answered an open-ended survey question assessing the most valued/desired support to receive from healthcare providers during early survivorship to manage work and health. Cutrona's (Journal of Social and Clinical Psychology 9:3-14, 1990) optimal matching theory and House's (1981) conceptualization of social support types informed our analyses. Data were content-analyzed to identify themes related to support, whether needed support was received or not, and the types of healthcare providers who provided support. RESULTS: We identified six themes related to types of support. Informational support was valued and mostly received by survivors, but they expected more guidance related to work. Emotional support was valued but lacking, attributed mainly to providers' lack of personal connection and mental health support. Instrumental (practical) support was valued but received by a small number of participants. Quality of life support to promote well-being and functionality was valued and often received. Other themes included non-specific support and non-support. CONCLUSIONS: This study expands our understanding of how breast cancer survivors perceive work-related support from healthcare professionals. Findings will inform targeted interventions designed to improve the support provided by healthcare professionals. IMPLICATIONS FOR CANCER SURVIVORS: Breast cancer survivors managing work and health challenges may benefit by having their unmet support needs fulfilled.

Randomized Trial of Nicotine Inhaler for Pregnant Smokers.

Background: Smoking during pregnancy is a serious public health problem in need of better treatments. Nicotine replacement treatment (NRT) (patch or gum) has not been shown in randomized placebo-controlled trials to be efficacious for smoking cessation during pregnancy. However, the nicotine inhaler may have advantages over other NRTs as it replicates some of the sensory effects of smoking. Objective: The purpose of the study was examine the efficacy and safety of the nicotine inhaler for smoking cessation during pregnancy. We hypothesized that the nicotine inhaler compared to placebo would increase quit rates and reduce smoking during treatment and at the end of pregnancy, result in a higher birth weight and gestational age in the offspring, and reduce the incidence of preterm birth and low birth weight infants. Study Design: We conducted a randomized, double-blind, placebo-controlled trial of the nicotine inhaler for smoking cessation during pregnancy. Pregnant women who smoked ≥5 cigarettes daily received behavioral counseling and random assignment to a 6-week treatment with nicotine or placebo inhaler, followed by a 6-week taper period. Throughout treatment, we assessed tobacco exposure biomarkers, cessation rates, and adverse events. We also obtained information on birth outcomes. The primary outcome was smoking cessation at 32-34 weeks gestation; secondary outcomes were smoking reduction, birth weight and gestational age, and the incidence of preterm birth or low birth weight infants. We compared treatment groups on these measures using t-tests, Fisher's exact tests, and multivariate linear and logistic regression. Results: Participants in the placebo (n=67) and nicotine (n=70) groups were comparable on baseline characteristics, though women in the placebo group reported a higher motivation to quit (p=0.016). Biochemically-validated smoking cessation rates were similar with nicotine and placebo (after 6 weeks of treatment: 4% (3/70) vs. 3% (2/67), respectively, p< 0.99, and at 32-34 weeks gestation: 10% (7/70) vs. 18% (12/67), respectively, p=0.220). Cigarettes per day (CPD) decreased over time in both groups (p< 0.001), with the nicotine inhaler group having a greater decrease than the placebo group two (p=0.022) and six weeks after the quit date (p=0.042), but not at 32-34 weeks gestation (p=0.108). Serum cotinine levels, birth weight, gestational age and reductions in carbon monoxide did not differ by group. However, the incidence of preterm delivery was higher in the placebo than the nicotine group: 15% (10/67) vs. 4% (3/67), respectively, p=0.030). The incidence of delivering a low birth weight infant was also higher in the placebo than the nicotine group: 15% (10/67) vs. 6% (4/67), respectively, p=0.035, but not after adjusting for preterm delivery p=0.268. Conclusions: Although the nicotine inhaler group did not have a higher quit rate during pregnancy than the placebo group, the outcome of preterm delivery occurred less frequently in the nicotine group.

Living with heart despite recurrent challenges: Psychological care for adults with advanced cardiac disease.

The number of people living with advanced heart disease is increasing rapidly as a result of improvements in cardiac treatments, better long-term survival from primary cardiac events, and the increase in the demographic of Americans over the age of 65. Successful living with advanced heart disease now often means patients must manage recurrent challenges to health and function from hospitalizations, exacerbations of illness, and cardiac procedures. Depression, anxiety and strain on intimate relationships are familiar problems for people with advanced heart disease that often go untreated. Though these problems have been studied in populations with acute coronary syndrome, there has been less attention focused on people in later stages of cardiac disease progression. Innovative psychological approaches are needed to address the emotional and behavioral challenges for patients coping with heart failure, implantable cardioverter defibrillators, ventricular assist devices, and heart transplant. This article describes common psychological difficulties for adults living with advanced heart disease and potential psychological targets for intervention. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Efficacy and cost-effectiveness of a clinic-based counseling intervention tested in an ethnically diverse sample of pregnant smokers.

OBJECTIVE: Rates of cigarette smoking are higher among women who receive obstetric care through publicly funded prenatal clinics. This study compared smoking outcomes for pregnant women (n=105) who were randomized to receive either usual care (standard cessation advice from the health care provider) or an intervention conducted in the prenatal clinic consisting of 1.5 h of counseling plus telephone follow-up delivered by a masters prepared mental health counselor. METHODS: Subjects were 105 low income, predominantly Hispanic, pregnant patients in an urban prenatal clinic. Smoking outcomes were assessed at end of pregnancy and 6 months post-partum. RESULTS: At follow-up, 28.3% and 9.4% of participants in the experimental intervention and 9.6% and 3.8% of patients in usual care were abstinent at end of pregnancy (p=.015) and 6 months post-partum, respectively (p=.251). Cost of the intervention was $56 per patient and cost to produce a non-smoker at end of pregnancy was $299. CONCLUSIONS: This model for intervention was cost-effective and was associated with significantly lower smoking rates at end of pregnancy. PRACTICAL IMPLICATIONS: If these findings are replicated, prenatal clinics could offer the option for intensive smoking cessation treatment by training mental health counselors to deliver one extended smoking cessation counseling session.

Randomized clinical trial of an Internet-based versus brief office intervention for adolescent smoking cessation.

OBJECTIVE: Evaluation of novel treatment delivery methods, such as the Internet are notably absent from the adolescent smoking treatment literature. METHODS: Adolescent smokers ages 11-18 years were randomized to a clinic-based, brief office intervention (BOI; N=69) consisting of four individual counseling sessions; or to Stomp Out Smokes (SOS), an Internet, home-based intervention (N=70). Adolescents in SOS had access to the SOS site for 24 weeks. RESULTS: The 30-day, point-prevalence smoking abstinence rates for BOI and SOS were 12% versus 6% at week 24 and 13% versus 6% at week 36, with no significant treatment differences. Among participants who continued to smoke, SOS was associated with a significantly greater reduction in average number of days smoked than BOI (P=0.006). The BOI was found to be feasible with high session attendance rates. SOS participants accessed the site a mean+/-S.D. of 6.8+/-7.1 days. SOS use dropped to less than one-third of participants by week 3. CONCLUSION: Additional research is needed to tap the potential capabilities of the Internet for adolescent smoking cessation using proactive, personalized, patient-education components. PRACTICE IMPLICATIONS: Augmenting the SOS type of intervention with more structured, personal and proactive patient-education components delivered in-person or by telephone or electronic mail is recommended.

Spontaneous smoking cessation during pregnancy among ethnic minority women: a preliminary investigation.

This study examined the postpartum relapse rates and characteristics of pregnant women who stopped smoking without professional intervention. Baseline characteristics of women who spontaneously quit were compared to women who continued to smoke. Women who spontaneously quit were also randomized to a psychotherapy relapse prevention treatment, or to usual care. The sample was ethnically diverse, containing 141 low-income women who were predominantly Hispanic, 23% (n=33) of whom spontaneously quit smoking. The variables that significantly differentiated between "spontaneous quitters" and ongoing smokers were entered into a regression analysis, which revealed that higher self-confidence, smoking fewer cigarettes per day, and younger age accounted for 25% of the variance in spontaneous cessation. Adding the psychotherapy intervention conferred no additional protection against relapse in this subgroup of spontaneous quitters. The six-month abstinence rate of 36% is similar to that found in Caucasian and higher-income populations. These results extend research with pregnant smokers to a new population and may have implications for healthcare providers and policy makers.

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.

Predictive validity of the attitudes toward medical help-seeking scale.

OBJECTIVE: This study examines the predictive validity of the action/intention subscale of the attitudes toward seeking medical help scale in a college sample. PARTICIPANTS: Participants were 51 female undergraduates recruited from psychology classes. Data were collected at two time points between January and April, 2011. METHODS: Students completed the attitudes subscale and a measure of medical contacts twice, over a two month interval. RESULTS: Internal consistency and test-retest reliability of the measure were supported. Correlations between time one attitudes and medical contacts/intentions at time two provide evidence for predictive validity of the measure. CONCLUSION: This relatively brief, psychometrically sound measure of attitudes toward medical help seeking can be used to identify individuals who may be reluctant to seek health care and to assess the effectiveness of health education programs.

The effects of peer counseling on smoking cessation and reduction.

OBJECTIVE: To evaluate a peer counseling intervention for pregnant smokers. METHODS: One hundred forty-two pregnant, predominantly Hispanic women were assigned to a peer-led smoking cessation program or to usual care. RESULTS: Compared with usual care, peer counseling reduced smoking (-9.1 versus -4.5 cigarettes daily, P =.03), but did not affect absolute quit rates (24% versus 21%) at 36 weeks' gestation. Infant birth weight negatively correlated with cigarettes smoked per day (r = -0.29, P <.01) and expired carbon monoxide (r = -0.39, (P <.001) at delivery. Birth weight for infants born to women who quit smoking averaged 7.2 lb versus 6.8 and 6.3 lb for mothers smoking one to six and more than six cigarettes per day at delivery (P <.01). CONCLUSION: Peer counseling reduced the number of cigarettes smoked daily but did not increase cigarette abstinence rates. Infant birth weight increases with both smoking cessation and smoking reduction, suggesting that peer counseling intervention programs may improve newborn health despite their failure to affect smoking cessation.

Changes in readiness to quit and self-efficacy among adolescents receiving a brief office intervention for smoking cessation.

PURPOSE: To examine changes in readiness to quit and self-efficacy among adolescents who received a clinic-based, brief office intervention (BOI) for smoking cessation. METHODS: This study utilized a prospective, pre-post- treatment design. Participants were adolescent smokers (34 females, 35 males) with a mean +/- SD age of 15.8 +/- 1.4 years; 86% were Caucasian, who were randomly assigned to receive the BOI as part of a larger clinical trial. They were recruited from three cities in the Midwest and Northeastern part of the United States. After the baseline assessment, the BOI was designed for adolescents to receive four weekly individual sessions with a research counselor lasting between 10 and 40 min each. The BOI includes motivational interviewing and cognitive-behavioral techniques. Readiness to quit was assessed at each treatment session using the stages of change algorithm. The validated Adolescent Smoking Self-Efficacy Scale (SES) was used to assess self-efficacy at baseline (week 0) prior to the intervention and at post-treatment (week 4). The SES items comprise three factors or subscales: opportunities to smoke, emotional stress, and friends' influence. RESULTS: The percentage of adolescents who made improvement on readiness to quit from the baseline treatment session was statistically significant (p < .001) for each of the three subsequent treatment sessions. Self-efficacy scores increased significantly (p < .004) from baseline to post-treatment for all three subscales. CONCLUSIONS: Adolescents receiving a BOI progressed in their readiness and self-efficacy to quit. Understanding the change process among adolescent smokers during treatment could influence the design of future stop smoking interventions.

Urban ethnic minority women's attendance at health clinic vs. church based exercise programs.

Older, sedentary, urban-living, ethnic minority women are at high risk for preventable disease, but it is difficult to engage this population in health promotion efforts. This study tested two methods of engaging Hispanic and African American women, who were at high risk for cardiovascular disease, in a 10-week aerobic fitness program. The program was offered to 76 participants, in either a women's health clinic or a church. Attendance was the primary dependent variable and was recorded at each exercise session. Other variables, including the Baecke Questionnaire of Habitual Physical Activity, Fat Frequency Questionnaire, Self-Efficacy for Exercise Behaviors Scale, Social Support and Exercise Survey, and Psychological General Well-Being Schedule, were measured prior to the intervention, at the end of the 10-week program, and at 3-month follow-up. Age predicted attendance, independently of site. Women in the highest age quartile (50 - 70 years) attended more than twice as many exercise sessions compared to women in the lowest age quartile (17 - 27 years). The relationship between older age and attendance was particularly strong for Hispanic women. Church parishioners were primarily women over the age of 40, making it impossible to disentangle the relative effect of locale. These findings are relevant for clinicians who design exercise programs targeting older, ethnic, minority women. Administrators who design exercise programs for urban-living women should consider age of the target population when selecting the most conducive setting.

Frequency and type of use of a home-based, Internet intervention for adolescent smoking cessation.

PURPOSE: The Internet offers a potential medium for delivering smoking cessation treatment to adolescents. However, few Internet-based cessation programs for adolescents have been evaluated. We describe adolescent use of a home-based Internet intervention to stop smoking (Stomp Out Smokes [SOS]) and explore baseline characteristics associated with SOS use. METHODS: Participants were 70 adolescent smokers aged 12-18 years (50% female, 90% Caucasian) randomized to receive the SOS intervention for 24 weeks as part of a larger clinical trial. SOS comprised 40 components, of which eight were primarily interactive (e.g., discussion support group, ask an expert, quit plan) and 32 were primarily informational (e.g., managing withdrawal, medications to stop smoking). SOS use data were captured electronically, including total logins to the site, and type of SOS components used defined by page hits on the interactive and information components. RESULTS: A total of 7,708 SOS website pages (6825 interactive and 883 informational) were accessed over the 24 weeks. The highest proportion of page hits was for the discussion support group (35%) and quit plan (30%). Interactive pages were significantly more likely to be used than informational pages (median 65 vs. 6, p < .001). Males accessed fewer interactive pages compared with females (p = .04). No other baseline characteristics were univariately associated with total logins or use of informational or interactive pages. CONCLUSIONS: Adolescent smokers most often used a discussion support group and other interactive Internet-based cessation components. Future studies designed to increase adolescent use, and efficacy of, Internet-based cessation programs are warranted.

Reported willingness among adolescent nonsmokers to help parents, peers, and others to stop smoking.

BACKGROUND: This study of 1025 adolescent nonsmokers aged 11-19 years examined level of interest and factors associated with reported willingness to help someone stop smoking. METHODS: Data were collected from a survey distributed primarily in the schools at four geographic and ethnically diverse study sites. RESULTS: A total of 692 adolescents identified someone close to them who smokes whom they thought should quit. Of these, 90% reported that they would be willing to help this person stop smoking. Multivariate predictors of willingness to help were female gender, less difficulty reading English, and greater level of comfort with talking to the smoker about their smoking. The smoker that the adolescents were willing to help was most often a parent or same age friend. CONCLUSIONS: If this strong interest among adolescents could be tapped, engaging teens as support persons could be a novel public health approach to reaching parents, adolescents, and other smokers in the population.

Differences in adolescent smoker and nonsmoker perceptions of strategies that would help an adolescent quit smoking.

This study assessed adolescent smoker and nonsmoker perceptions of strategies that would help an adolescent smoker in his or her attempt to stop smoking. Surveys were distributed primarily in the schools at 4 geographic and ethnically diverse study sites. Respondents were 965 adolescents (49% female; 46% minority). Current smokers (n = 232) were asked to rate the extent to which they agreed or disagreed that supportive behaviors of friends and family, quitting strategies, or learning about quitting strategies would be helpful if they decided to quit. Nonsmokers (n = 733) were asked to indicate the degree to which they agreed or disagreed that these behaviors and strategies would be helpful if a friend decided to quit. Responses to each of the 33 attitude items were rated on a 5-point scale ranging from strongly disagree to strongly agree. Marked differences were observed between smokers and nonsmokers in the level of agreement on each item. In general, smokers reported far less enthusiasm for cessation strategies than nonsmokers. After adjusting for gender, age, and other covariates, smoking status was the strongest independent predictor of the number of items endorsed as agree or strongly agree. The results have implications for the design of peer-based and other interventions for adolescent smokers.