Estimating the impact of smoking cessation during pregnancy: the San Bernardino County experience.

We examined the relation between maternal smoking and adverse infant outcomes [low birth weight (LBW), and preterm birth (PTB)] during 2007-2008 in San Bernardino County, California-the largest county in the contiguous United States which has one of the highest rates of infant mortality in California. Using birth certificate data, we identified 1,430 mothers in 2007 and 1,355 in 2008 who smoked during pregnancy. We assessed the effect of never smoking and smoking cessation during pregnancy relative to smoking during pregnancy for the 1,843/1,798 LBW, and 3,480/3,238 PTB's recorded for 2007/2008, respectively. To describe the effect of quitting smoking during pregnancy, we calculated the exposure impact number for smoking during pregnancy. Major findings are: (1) relative to smoking during pregnancy, significantly lower risk of LBW among never smoking mothers [OR, year: 0.56, 2007; 0.54, 2008] and for smoking cessation during pregnancy [0.57, 2007; 0.72, 2008]; (2) relative to smoking during pregnancy, significantly lower risk of PTB was found for never smoking mothers [0.68, 2007; 0.68, 2008] and for smoking cessation during pregnancy [0.69, 2007; 0.69, 2008]; (3) an exposure impact assessment indicating each LBW or PTB outcome in the county could have been prevented either by at least 35 mothers quitting smoking during pregnancy or by 25 mothers being never smokers during pre-pregnancy. Our findings identify an important burden of adverse infant outcomes due to maternal smoking in San Bernardino County that can be effectively decreased by maternal smoking cessation.

Beliefs about tobacco, health, and addiction among adults in Cambodia: findings from a national survey.

There remains a very high rate of smoked and smokeless tobacco use in the Western Pacific Region. The most recent findings from national adult tobacco surveys indicate that very few daily users of tobacco intend to quit tobacco use. In Cambodia, a nation that is predominantly Buddhist, faith-based tobacco control programs have been implemented where, under the fifth precept of Buddhism that proscribes addictive behaviors, monks were encouraged to quit tobacco and temples have been declared smoke-free. In the present study, we included items on a large national tobacco survey to examine the relation between beliefs (faith-based, other) about tobacco, health, and addiction among adults (18 years and older). In a stratified, multistage cluster sample (n=13,988) of all provinces of Cambodia, we found that (1) 88-93% believe that Buddhist monks should not use tobacco, buy tobacco, or be offered tobacco during a religious ceremony; (2) 86-93% believe that the Wat (temple) should be a smoke-free area; (3) 93-95% believe that tobacco is addictive in the same way as habits (opium, gambling, alcohol) listed under the fifth precept of Buddhism; and (4) those who do not use tobacco are significantly more likely to cite a Buddhist principle as part of their anti-tobacco beliefs. These data indicate that anti-tobacco sentiments are highly prevalent in the Buddhist belief system of Cambodian adults and are especially evident among non-users of tobacco. Our findings indicate that faith-based initiatives could be an effective part of anti-tobacco campaigns in Cambodia.

Differences in health and religious beliefs about tobacco use among waterpipe users in the rural male population of Egypt.

Waterpipe use is a highly prevalent form of tobacco use in the Eastern Mediterranean Region that is rooted in long-held cultural traditions that predate the use of cigarettes and present a particular challenge for tobacco control efforts. We did a stratified sampling of 4,994 Egyptian men from rural households of Egypt in order to conduct an interviewer-administered prevalence survey to identify differences in attitudes and beliefs toward smoking and smoking cessation between waterpipe users, cigarette smokers, mixed users (cigarette + waterpipe), and non-smokers. We found that cigarette smokers, mixed users, and/or non-smokers were (1) two- to ninefold more likely to believe that smoking decreased adult life expectancy and harmed a fetus than waterpipe users, (2) significantly more likely to believe that smoking is a sin ("haram") than were waterpipe users. Among tobacco users, we found that cigarette smokers and/or mixed users were significantly more likely to indicate pre-contemplation, contemplation, or intention to quit tobacco than waterpipe users. Our findings from rural Egyptian men indicate that waterpipe users are distinct from cigarette smokers in their perception that their form of tobacco use is less harmful and/or less subject to religious proscription. These beliefs may explain why waterpipe users seem less inclined to quit their tobacco habit and need to be considered in the design of tobacco cessation and prevention methods in Egypt and the region.

Exposure to environmental tobacco smoke in the nonsmoking population of Cambodia.

OBJECTIVE: To estimate the extent of environmental tobacco smoke (ETS) exposure among nonsmokers in the adult population of Cambodia. METHODS: A cross-sectional survey was conducted on a nationally representative sample of 13,988 Cambodian adults in 2005. Information on smoking and exposure to ETS was obtained by trained interviewers using a standard questionnaire. RESULTS: Overall, 37.4% of the 10,263 nonsmoking responders, or an estimated 1,629,700 nonsmoking Cambodians, were exposed to ETS. One third of pregnant women (31.4%) were exposed to ETS at home. In both unadjusted and adjusted models, men were less likely to be exposed to ETS at home (OR=0.34; 95% CI=0.29-0.41) and more likely to be exposed to ETS at work and in public places (OR=3.08; 95% CI=2.14-4.43 and OR=2.17; 95% CI=1.82-2.59, respectively). Education was inversely related to ETS exposure at home (OR=0.51; 95% CI=0.27-0.96 for 10 years of education vs 5 years or less). Legislators, senior officials, and managers were less likely to be exposed to ETS at home than professionals (OR=0.13; 95% CI=0.04-0.46), but more likely to be exposed at work or in public places. Rural residence was associated with higher ETS exposure in the home (OR=2.52; 95% CI=1.71-3.71) and lower ETS exposure at work (OR=0.42; 95% CI=0.24-0.76) compared to urban residence. CONCLUSIONS: The high prevalence of ETS exposure among adult Cambodians indicates an urgent need for specific measures such as public awareness campaigns, policies, and regulations to protect nonsmokers in Cambodia.

The use of planned behavior theory in predicting cigarette smoking among Waterpipe smokers.

BACKGROUND: Waterpipe and cigarette smoking have been found to be associated with each other as cigarette smokers were more likely to be waterpipe users than non-cigarette smokers. Also, waterpipe smokers were likely to be former daily cigarette users. The aim of this study is to examine the likelihood of waterpipe use leading to cigarette use among current waterpipe users using theory of planned behavior. METHODS: Four hundred six current waterpipe smokers who initially had started tobacco use with the waterpipe were recruited from 15 waterpipe lounges in 2015. From a total of 70 waterpipe lounges in Riyadh, the 15 waterpipe lounges were selected randomly and participants were also selected randomly inside each waterpipe lounge based on the table or section number. The survey was developed using the Qualtrics Online Survey Software and participants completed a survey using iPad tablets. RESULTS: Cigarette smoking and intention to smoke cigarettes were predicted by attitude and perceived behavioral control. There was no direct effect of subjective norm on the cigarette use behavior, yet subjective norm had a statistically significant indirect effect on intentions through attitude and perceived behavioral control. CONCLUSIONS: The findings of this study could be useful in prevention/intervention programs aimed at reducing tobacco smoking behaviors among waterpipe users. Intervention programs might be directed at the attitude and perceived behavioral control by targeting underlying behavioral and control beliefs. The theory of planned behavior provided solid explanations of intention to use cigarettes among waterpipe smokers.

Exploring Demographic and Substance Use Correlates of Hookah Use in a Sample of Southern California Community College Students.

BACKGROUND AND PURPOSE: Hookah smoking is a growing young adult phenomenon, particularly among college students. Many users feel that it is safer than other tobacco products, although its health threats are well documented. Little is known about hookah use rates in community colleges that are attended by nearly half of all US college students. This study examined hookah use in a diverse convenience sample of students attending two southern California community colleges. METHODS: In fall 2011, a cross-sectional, in-classroom survey was administered to 1,207 students. A series of fully adjusted multivariate logistic regressions were conducted to explore demographic, other substance use, and attitudinal correlates of lifetime and current hookah use. RESULTS: Lifetime hookah use (56%) was higher than lifetime cigarette use (49%). Gender and personal socioeconomic status were not related to hookah use. Current use (10.8%) was associated with current use of alcohol, cigars, and cigarettes. Compared to African-Americans, Whites were 2.9 times more likely to be current users, and students who perceive hookah to be more socially acceptable were 21 times more likely to currently use. CONCLUSION: Since hookah use rates are high, colleges should offer health education programs to inform incoming students about the health risks of hookah and cessation programs.

Global epidemiology of obesity, vegetarian dietary patterns, and noncommunicable disease in Asian Indians.

An increase in noncommunicable disease (NCD) in India has been attributed to an epidemiologic transition whereby, due to urbanization, there is an increase in traditional cardiovascular disease risk factors such as obesity. Accumulated biomarker data on the "Asian Indian phenotype" identify central obesity, which occurs at a lower body mass index (BMI), as a particularly potent risk factor in Asian Indians. A revised WHO case definition for obesity in India [BMI (in kg/m(2)) >25] has identified an obesity epidemic that exceeds 30% in some cities and rivals that in Western nations. This review summarizes 2 key lines of evidence: 1) the emergence of an obesity epidemic in urban and rural India and its contribution to the NCD burden and 2) the role of a "nutrition transition" in decreasing the whole plant food content of diets in India and increasing risk of obesity and NCDs. We then present new epidemiologic evidence from Asian Indians enrolled in the Adventist Health Study 2 that raises the possibility of how specific whole plant foods (eg, nuts) in a vegetarian dietary pattern could potentially prevent obesity and NCDs in a target population of >1 billion persons.

Adult tobacco cessation in Cambodia: II. Determinants of intent to quit.

Identifying determinants of intent to quit may aid the design of antitobacco programs and promote effective tobacco control policies. In a nationwide survey in Cambodia, two thirds of tobacco smokers and 45% of female smokeless tobacco users planned to stop in the future. Multivariate determinants of intent in 2279 male smokers were age <37 years, age at initiation ≥ 18 years, Cham versus Khmer ethnicity (odds ratio [OR] = 6.93; 95% confidence interval[CI] = 1.38-34.89), longer education, and professional occupation. In 1188 female smokeless tobacco users, age <25 years, age at initiation ≥ 18 years, and tuberculosis (OR = 3.26; 95% CI = 1.61-6.61) were associated with intent. In female smokers (n = 321), age 18 to 25 years at initiation was associated with intent. In male smokers and female smokeless tobacco users, perceived physical advantages of tobacco were inversely associated with intent. These findings underscore the importance of policies and interventions to delay initiation and promote cessation in young people and counteract perceived physical benefits.

Adult tobacco cessation in Cambodia: I. Determinants of quitting tobacco use.

This study determined factors associated with quitting tobacco in Cambodia, a country with a high prevalence of men who smoke and women who use smokeless tobacco. As part of a nationwide survey, face-to-face interviews were conducted with 5145 current and 447 former tobacco users who had quit for ≥ 2 years. Determinants of quitting in multivariate analyses were age >48 years, age at initiation >25 years, ≥ 7 years of education, income ≥ 1 US dollar per day, professional (odds ratio [OR] = 2.52; 95% confidence interval [CI] = 1.27-5.01) or labor (OR = 1.98, 95% CI = 1.10-3.56) occupations, and heart disease (OR = 1.94; 95% CI = 1.10, 3.42). Smokeless tobacco users were 10-fold less likely to quit (OR = 0.10; 95% = CI 0.05-0.20) than smokers. In conclusion, tobacco cessation among Cambodians was lower than in nations with decades of comprehensive tobacco control policies. Tobacco cessation programs and policies should include all forms of tobacco and target young to middle-aged users before onset of disease and premature death.

Patterns of alcohol and tobacco use in Cambodia.

Few studies have considered whether the habitual use of tobacco in Southeast Asia is part of an established pattern of addiction that includes regular alcohol use. As part of a national survey of adult tobacco use in Cambodia (n = 13 988), we found that men who smoked were 2 times more likely to have drank alcohol in the past week (odds ratio = 2.53, 95% confidence interval = 2.10-3.03). By age 18 to 25 years, 47% of male smokers drank alcohol, and this pattern of alcohol and tobacco use increased to >55% through the fifth decade. Women using smokeless tobacco with betel quid were more likely to be alcohol drinkers (odds ratio = 1.49, 95% confidence interval = 1.12-1.98). Past week's drinking declined by late middle age and was associated with lower education and being currently married; the behavior was lower in some ethnic groups (ie, Cham). Our findings indicate an important association between alcohol and tobacco use, and raise the possibility that reducing alcohol consumption can be an important component of tobacco control.

Maternal use of cigarettes, pipes, and smokeless tobacco associated with higher infant mortality rates in Cambodia.

In the Western Pacific Region, rural women use loose tobacco in betel quid chewing and pipe smoking. We examined the relation between maternal use of tobacco and infant mortality (IM) in a national sample of 24 296 birth outcomes in adult women (n = 6013) in Cambodia. We found that (1) age-adjusted odds of IM were higher for maternal use of any tobacco (odds ratio [OR] = 1.69; 95% confidence interval [CI] = 1.27-2.26); (2) age-adjusted odds of IM were higher for cigarette use (OR = 2.54; 95% CI = 1.54- 4.1), use of pipes (OR = 3.09; [95% CI = 1.86-5.11]), and betel quid chewing (OR = 1.55; 95% CI = 1.10-2.17); and (3) these associations remained after multivariable adjustment for environmental tobacco smoke, malnutrition, ethnicity, religion, marital status, education, income, occupation, and urban/rural dwelling. In addition to finding the established association with cigarettes, we also found that maternal use of smokeless tobacco and pipes was associated with higher rates of infant death in Cambodia.

Validity and reliability of survey items and pictograms for use in a national household survey of tobacco use in Cambodia.

The validity of survey measures of smoked and smokeless tobacco use in the Western Pacific Region is often unknown. We conducted a validation study (n = 201) in a random sample of rural adults in Cambodia. A comparison with salivary cotinine indicated (1) that survey items and pictograms of current tobacco use had an 87% (95% confidence interval [CI] = 78%-93%) sensitivity, 94% specificity (95% CI = 87%-98%), and 93% (95% CI = 85%-97%) positive predictive value in detecting cotinine levels >10 ng/mL; (2) a positive correlation with number of cigarettes smoked (R = 0.34; P = .01); and (3) a positive correlation with the amount of tobacco chewed (R = 0.44; P = .02). The validity of the index for the amount of smokeless tobacco used was enhanced by adding to the index the data from pictograms that were utilized to help participants estimate the amount of loose tobacco used per session. These tobacco items and pictograms were found to have excellent reliability (κ = 0.80-1) over 2 to 3 weeks. Interviewer-administered survey items and pictograms can provide an accurate, quantitative measure of smoked and smokeless tobacco use in rural Cambodia.

Patterns of maternal tobacco use among Cambodian women: findings from a nationwide sample.

Although current trends indicate that the rate of cigarette smoking tends to be low among women in the Western Pacific Region (<10%), recent epidemiologic data from South Asia (India, Bangladesh) and Southeast Asia (Cambodia, Vietnam, Indonesia, Malaysia) identify that a large proportion of women of reproductive age and older chew tobacco--often as part of a betel quid mixture that includes other potentially harmful ingredients (eg, areca nut). Our findings from currently pregnant women identified during a nationwide survey of adult tobacco use in Cambodia indicate that 13.0% (95% confidence interval [CI] = 8% to 17%) were current users of smoked or smokeless (in the form of a betel quid) tobacco. Most pregnant women who used tobacco indicated that their habit was either initiated (29.1%; 95% CI = 16.3-46.3) or increased (33.7%; 95% CI = 18.3-53.5) during pregnancy. Pregnancy-related symptoms such as morning sickness were reported as the reason for more than half (54.9%; 95% CI = 34.8-73.4) of the currently pregnant users to have started a tobacco habit during their lifetime. Among those pregnant women who did not use tobacco, we found strong associations (odds ratios from 2 to 14) with beliefs about the harmful effects of tobacco on adult health, faith-based beliefs in addictive substances, and beliefs that influential members of the community, health professionals, and children should not use tobacco. Our findings indicate that tobacco cessation and prevention programs in Cambodia should specifically target pregnant and reproductive-age women.

Poverty does not limit tobacco consumption in Cambodia: quantitative estimate of tobacco use under conditions of no income and adult malnutrition.

Current data indicate that under conditions of poverty, tobacco is consumed at the expense of basic needs. In a large national sample from Cambodia, we sought to determine whether tobacco consumption declines under extreme conditions of no income and malnutrition. Our major findings are as follows: (1) Among men, there was no significant difference in the number of cigarettes smoked for no income (425, 95% confidence interval [CI] = 395-456) versus >US$2 per day (442, 95% CI = 407-477); (2) among women, there was no significant difference in the amount of loose tobacco (ie, betel quid) consumed for no income (539 g, 95% CI = 441-637) versus >US$2 per day (558 g, 95% CI = 143-973); (3) for the contrast of no income + malnutrition versus >US$2 per day + no malnutrition in a linear model, there was no significant difference for men who smoked (462 vs 517 cigarettes/month, P = .82) or women who chewed (316 vs 404 g tobacco/month, P = .34), adjusting for confounders. Among the poorest and malnourished Cambodian adults, lack of resources did not appear to prevent them from obtaining smoked or smokeless tobacco.

Cigarette smoking and tuberculosis in Cambodia: findings from a national sample.

BACKGROUND: Cambodia has very high rates of tuberculosis and smoked tobacco use among adults. Efforts to control both tobacco use and tuberculosis in Cambodia need to be informed by nationally representative data. Our objective is to examine the relation between daily cigarette smoking and lifetime tuberculosis (TB) history in a national sample of adults in Cambodia. METHODS: In 2011, a multi-stage, cluster sample of 15,615 adults (ages 15 years and older) from all regions of Cambodia were administered the Global Adult Tobacco Survey by interviewers from the National Institute of Statistics of Cambodia. RESULTS: Our findings include: 1) among daily smokers, a significant positive relation between TB and number of cigarettes smoked per day (OR = 1.70 [95% CI 1.01, 2.87]) and pack-years of smoking (OR = 1.53 [95% CI 1.05, 2.25]) 2) a non-significant 58% increase in odds of ever having being diagnosed with TB among men who smoked manufactured cigarettes (OR = 1.58 [95% CI 0.97, 2.58]). CONCLUSION: In Cambodia, manufactured cigarette smoking was associated with lifetime TB infection and the association was most evident among the heaviest smokers (> 1 pack per day, > 30 pack years).

Cotinine levels among betel quid users and cigarette smokers in Cambodia.

Smokeless tobacco use in the form of the betel quid is common in the Western Pacific Region, and yet few studies have determined the nicotine delivery of this habit. During a validation substudy, we randomly sampled 201 adults from a rural province of Cambodia and determined nonparametric (bootstrapped) confidence intervals (CIs) for salivary cotinine levels in tobacco users. We found that cotinine levels for daily betel quid use among women (95% CI = 218.6-350.0 ng/mL) were (1) similar to the levels for daily cigarette smoking in men (95% CI = 240.2-317.1 ng/mL) and (2) significantly higher than the levels for daily cigarette smoking in women (95% CI = 71.8-202.7 ng/mL). The 95% confidence range for these habits exceeded the threshold for addiction. Our findings from rural Cambodia indicate that the typical betel quid habit among women supports the same level of nicotine addiction as the typical cigarette habit in men.