Effects of Menthol Flavor Cigarettes or Total Urinary Menthol on Biomarkers of Nicotine and Carcinogenic Exposure and Behavioral Measures.

INTRODUCTION: The effects of either menthol flavor cigarettes or total urinary menthol on nicotine dependence, biomarkers of addictive and carcinogenic exposure, and behavioral measures may inform differences and similarities of these two approaches. METHODS: Stratified recruitment by cigarette (menthol flavor or regular) and race (African American and white) yielded a balanced sample of 136 adult smokers in a 36-hour inpatient protocol. Exposure measures assessed during 24-hour data collection included urinary menthol, total NNAL [4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol], 10 polycyclic aromatic hydrocarbon metabolites, baseline plasma cotinine, plasma nicotine pre- and post-smoking, exhaled carbon monoxide pre- and post-smoking, and cigarette puff volumes. The latter three were measured at four specified timepoints throughout the day. RESULTS: There were no significant differences between menthol flavor and regular cigarette smokers in measures of nicotine dependence, biomarkers of addictive and carcinogenic exposures, or behavioral measures. Significant race × cigarette type interaction effects were found for two biomarkers: plasma nicotine and 3-hydroxyphenanthrene. Total urinary menthol was significantly associated with higher levels of nearly all dependent variables including puff volume, exhaled carbon monoxide, plasma nicotine and cotinine, NNAL, and polycyclic aromatic hydrocarbons. The significant effects of total urinary menthol were sustained after adjusting for menthol flavor and regular cigarette type and other covariates (eg, number of cigarettes per day, baseline cotinine, and baseline nicotine). CONCLUSIONS: Urinary menthol is an independent predictive biomarker for nicotine dependence, addictive and carcinogenic exposure, and behaviors. IMPLICATIONS: Comparison of the effects of menthol flavor and total urinary menthol on nicotine dependence, biomarkers of addictive and carcinogenic exposure, and behavioral measures emphasizes the important significant contribution of total urinary menthol concentrations in contrast to no significant associations by dichotomous cigarette type with these biomarkers.

Relationships of PROP Taste Phenotype, Taste Receptor Genotype, and Oral Nicotine Replacement Use.

INTRODUCTION: Recommended dosage of oral nicotine replacement therapy (NRT) product is often not achieved in smoking cessation attempts. n-6-propylthiouracil (PROP) bitter taste phenotype may be a potential risk factor for non-adherence to oral NRT products due to their bitter taste. There is limited literature on this phenotype in the context of smoking and none in relation to oral NRT pharmacotherapy. METHODS: The association of PROP taste phenotype with NRT usage and sensory response to products was examined. In a cross-over experimental design, 120 participants received a 1 week supply of nicotine inhalers and 1 week of nicotine lozenges with random assignment to order. Mixed effects linear model analyses were conducted. RESULTS: PROP taste phenotype and taste receptor genotype were not associated with NRT usage or sensory response to NRT, after adjusting for other factors. However, PROP non-tasters used a higher number of lozenges per day (continuous exposure) than nicotine cartridges (intermittent exposure). Unexpectedly, half of baseline PROP non-tasters shifted to taster phenotype 2 weeks after smoking cessation or reduction. Menthol cigarette smokers identified higher NRT strength of sensation scores than nonmenthol smokers. Taste receptor genotype was related to PROP taste phenotype (Kendall τ = .591, p = .0001). CONCLUSIONS: A nonsignificant relationship of PROP phenotype and NRT usage may be associated with NRT under-dosing and limited variance in the outcome variable. PROP non-tasters' greater use of lozenges is consistent with nicotine exposure being less aversive to non-tasters. Further research of this and other factors impacting NRT usage are warranted to effectively inform smoking cessation pharmacotherapy.

The impact of educational message framing on adherence to continuous positive airway pressure therapy.

Although of proven health benefit to persons with obstructive sleep apnea (OSA), adherence to continuous positive airway pressure (CPAP) therapy is suboptimal, with patterns of use that are established early and that are not easily altered after the initial experience. In a randomized controlled trial, 70 participants with OSA and cardiovascular disease were assigned to receive either positively or negatively framed education about CPAP. Objective adherence was measured following 30 days of home CPAP therapy. Daytime sleepiness, dispositional optimism, self-efficacy, and depression were also evaluated at baseline and after 30 days. CPAP use was greater in the group receiving negative message framing (p = .015).

The role of menthol in cigarettes as a reinforcer of smoking behavior.

INTRODUCTION: The World Health Organization has identified several additives such as menthol in the manufacturing of cigarettes to specifically reduce smoke harshness. These additives may have important implications for reinforcing smoking behavior and motivation to quit smoking. The purpose of this paper is to synthesize research related to the role of menthol's sensory characteristics in strengthening the reinforcing effects of nicotine in cigarettes and the impact on nicotine addiction and smoking behavior. METHODS: Research reports from 2002 to 2010 on the addictive potential of menthol cigarettes were reviewed that included qualitative focus groups, self-reports and biomarkers of nicotine dependence, human laboratory, and epidemiological studies. RESULTS: Positive sensory effects of menthol cigarette use were identified via reports of early smoking experiences and as a potential starter product for smoking uptake in youth. Menthol cigarettes may serve as a conditioned stimulus that reinforces the rewarding effects of smoking. Nicotine dependence measured by shorter time-to-first cigarette upon waking was increased with menthol cigarette use in most of the studies reviewed. Smoking quit rates provide additional indicators of nicotine dependence, and the majority of the studies reviewed provided evidence of lower quit rates or higher relapse rates among menthol cigarette smokers. CONCLUSIONS: The effects of menthol cigarette use in increasing the reinforcing effects of nicotine on smoking behavior were evidenced in both qualitative and quantitative empirical studies. These findings have implications for enhanced prevention and cessation efforts in menthol smokers.

Biological models for studying and assessing tobacco use.

The purpose of this chapter on biological models for studying and assessing tobacco use is to provide an introduction to some of the common concepts and biomarkers in this arena to ultimately inform intervention research by nurse scientists. An overview of selected biomarkers of tobacco exposure in individuals includes exhaled carbon monoxide, cotinine (the proximate metabolite of nicotine), and measurement of an individual's puffing pattern termed smoking topography. Common tobacco contents discussed include tobacco specific nitrosamines (TSNA) and polycyclic aromatic hydrocarbons (PAH) some of which increase disease risk including cancer. Exemplars of additives to cigarettes by the tobacco industry will be described including menthol, one additive marketed by the industry. Genetics and tobacco addiction has emerged as a rapidly expanding field. Illustrative of this area are twin studies, nicotinic receptors, CYP2A6 polymorphisms, and genes that impact dopamine receptors. The cadre of nurse scientists conducting research in this much needed area is small. The opportunity for nurse scientists educated in biological inquiry in tobacco-related research is great. Nurse scientists actively involved in multidisciplinary translational teams to address nicotine addition are needed.

Omega-3 fatty acids effect on wound healing.

Physiological events in the initial inflammatory stage of cutaneous wound healing influence subsequent stages. Proinflammatory cytokines coordinate molecular and cellular processes during the inflammatory stage. Polyunsaturated fatty acids (PUFA) alter proinflammatory cytokine production, but how this phenomenon specifically influences wound healing is not clearly understood. In the present study, effects of marine-derived omega-3 eicosapentaenoic and docosahexaenoic PUFA on proinflammatory cytokines in wound serum and time to complete healing in healthy, human skin were evaluated. We compared plasma fatty acid levels in two groups (N=30) at baseline and after 4 weeks of eicosapentaenoic/docosahexaenoic PUFA supplements (active) or placebo (control). Eight small blisters on participants' forearms were created. Proinflammatory cytokines interleukin-1beta (IL-1beta), IL-6, and tumor necrosis factor-alpha were quantified in blister fluid at 5 and 24 hours after creation. Wound area was calculated daily. Eicosapentaenoic and docosahexaenoic plasma fatty acid levels were significantly higher in the active group. Additionally, we found significantly higher IL-1beta levels in blister fluid in the active group and time to complete wound closure was somewhat longer. These results suggest that eicosapentaenoic and docosahexaenoic PUFA may increase proinflammatory cytokine production at wound sites and thus, depending on the clinical context, have noninvasive, therapeutic potential to affect cutaneous wound healing.

Factors Influencing the Phenotypic Characterization of the Oral Marker, PROP.

In the last several decades, the genetic ability to taste the bitter compound, 6-n-propyltiouracil (PROP) has attracted considerable attention as a model for understanding individual differences in taste perception, and as an oral marker for food preferences and eating behavior that ultimately impacts nutritional status and health. However, some studies do not support this role. This review describes common factors that can influence the characterization of this phenotype including: (1) changes in taste sensitivity with increasing age; (2) gender differences in taste perception; and (3) effects of smoking and obesity. We suggest that attention to these factors during PROP screening could strengthen the associations between this phenotype and a variety of health outcomes ranging from variation in body composition to oral health and cancer risk.

Levels of cigarette availability and exposure in black and white women and efficient smokers.

Purposes of this investigation were to examine differences in smoke exposure and smoking topography across three smoking conditions: usual number of cigarettes, restricted (50%) and increased (167%) simulating restricted and unrestricted cigarette availability. A repeated-measures counterbalanced design with a sample of 25 women (13 African Americans; 12 Caucasians) was implemented with a 6-day inpatient protocol conducted in the General Clinical Research Center (GCRC). There were significantly larger percentage increases in carbon monoxide (CO) postcigarette in the restricted condition compared to usual and increased condition. Women with baseline cotinine/cigarette ratios >20 ng/ml/cigarette, considered efficient smokers, had significantly higher CO increases postcigarette at baseline than participants with lower cotinine/cigarette ratios, yet increased this exposure further during the restricted condition. Efficient smokers had significantly higher nicotine boost in the restricted condition compared to less efficient smokers. Differences by ethnicity were also noted with significantly higher CO percentage increases pre- to postcigarette in African Americans across all conditions, compared to Caucasians. Levels of smoke exposure postcigarette in persons who reduce cigarettes per day in response to restricted cigarette availability may be substantial.

Risk factors for smoking in rural women.

BACKGROUND: This study examined the association between social, demographic, and psychologic factors and smoking status among Appalachian Ohio women. A secondary aim examined whether specific factors could be identified and segmented for future tailored treatment of tobacco dependence. METHODS: A cross-sectional survey (n=570) obtained information about social, demographic, and psychologic factors and smoking. Logistic regression described associations between these characteristics and smoking status. Chi-square automatic interaction detection (CHAID) analyses identified subgroups at risk for smoking. RESULTS: Fifty-two percent never smoked, with 20.5% and 27.5% categorized as former and current smokers, respectively. Women with low adult socioeconomic position (SEP) were more likely to smoke (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.74-5.34) compared to high SEP women. Other factors associated with current smoking included age 31-50 (OR 2.30, 95% CI 1.22-4.33), age 18-30 (OR 3.29, 95% CI 1.72-5.34), Center for Epidemiologic Studies Depression scale (CES-D) score≥16 (OR 1.99, 95% CI 1.31-3.05), and first pregnancy at age<20 (OR 1.74, 95% CI 1.14-2.66). The prevalence of smoking was 50% among those with four or more risk factors compared to 10% for those reporting no risk factors. CHAID analyses identified low adult SEP and depressive symptoms as the combination of risk factors most strongly associated with smoking; 49.3% of women in this subgroup currently smoked. CONCLUSIONS: Low SEP in adulthood, maternal circumstances, and depressive symptoms are associated with current smoking. Tailored cessation interventions that address these risk factors should be developed and further evaluated in an attempt to reduce disparities in smoking prevalence among this vulnerable group of women.

The cultural context of smoking among immigrants from the former Soviet Union.

The purpose of this descriptive, qualitative study was to gain understanding of the cultural context of smoking among immigrants from former Soviet Union countries now living in the Midwest United States. Semistructured interviews were conducted in focus group or individual settings (N = 14), including smokers and former smokers recruited from community settings. Social factors and stress management strongly motivated smoking behavior. Personal willpower was the most helpful cessation strategy, with firm lack of openness to pharmacologic approaches. Top past stressors included food insecurity and societal unrest, with the top current stressors being acculturative issues. The importance of social connectedness and the relatively low priority of prevention were also themes. Based on these interviews, interventions should include acculturative stress management and maintaining social connectedness, while addressing life experiences in the insecurity of basic needs. Smoking cessation interventions that are tailored beyond just language use and address these specific issues are suggested.

The relationships between menthol cigarette preference and state tobacco control policies on smoking behaviors of young adult smokers in the 2006-07 Tobacco Use Supplements to the Current Population Surveys (TUS CPS).

AIM: To examine relationships between the preference for menthol cigarettes and young adult smoking behaviors, including the extent to which state tobacco control policies moderate these relationships. DESIGN: Cross-sectional design using secondary data from the 2006-07 Tobacco Use Supplements to the Current Population Surveys (TUS CPS) surveys appended with 2006 state-policy data. SETTING: United States nationally representative survey. PARTICIPANTS: A total of 2241 young adult daily smokers and 688 young adult non-daily smokers. MEASUREMENTS: The two dependent variables of smoking behaviors were smoking first cigarette within 30 minutes of waking (TTF) and number of cigarettes smoked per day (cpd). Primary independent variables included menthol brand preference and state tobacco control policies (youth access laws, clean indoor air laws and cigarette excise taxes), adjusting for controls. FINDINGS: Among daily smokers, there were no significant associations between menthol brand preference and TTF or cpd. However, lower educational attainment, not being in the labor force and the lack of home smoking rules were associated positively with shorter TTF, being white and the lack of home smoking rules were associated positively with cpd. Among daily smokers, state excise taxes were associated negatively with higher cpd. Among non-daily smokers, menthol brand preference was associated positively with shorter TTF, but associations did not vary with state tobacco control policies. Menthol brand preference was not associated significantly with cpd, but male gender, unmarried status and the lack of home smoking rules were associated positively with greater cpd among non-daily smokers. CONCLUSIONS: Young adult non-daily smokers who preferred menthol cigarettes were significantly more dependent than those who preferred non-menthol cigarettes, as shown through the shorter TTF. Associations between menthol brand preference and smoking behaviors did not vary with state tobacco control policies.

Effect of n-3 oral supplements on the n-6/n-3 ratio in young adults.

Epidemiological studies show that n-6/n-3 polyunsaturated fatty acid (PUFA) ratios have risen dramatically in Western diets and are associated with numerous chronic inflammation-related diseases. More balanced ratios are linked to less inflammation. This study examines the effects of adding oral supplements containing n-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) to diets of healthy young adults on plasma n-6/n-3 ratios. Thirty volunteers are randomly assigned to one of two groups: experimental group, EPA (1.6 g/day) and DHA (1.2 g/day); and the control group, mineral oil (2.4 ml/day). Plasma fatty acids, nutrients from foods, and anthropometric measures are evaluated at baseline and at the Week 4 endpoint. The mean (+/-SD) n-6/n-3 ratio for the experimental group is significantly lower (6.3 +/- 1.6) than the placebo group (16.8 +/- 3.5) by study completion. The results suggest that more balanced n-6/n-3 ratios may be achieved efficiently in healthy, young adults with supplements containing EPA and DHA.

Poor use of cardiac rehabilitation among older adults: a self-regulatory model for tailored interventions.

BACKGROUND: A greater number of older adults now live with coronary heart disease (CHD). This poses a significant public health problem, because older adults are at high risk for CHD-related mortality and morbidity. Overwhelming data support the benefits of cardiac rehabilitation for secondary prevention, yet only a small portion of eligible older adults receive it. METHODS AND RESULTS: Whereas many studies examined factors that affect the use of cardiac rehabilitation among older adults, few interventions aimed to improve their cardiac rehabilitation participation rates. A substantial body of evidence indicates that an individual's illness perceptions play a pivotal role in health behavior, and may be a promising target for intervention. Drawing from the theoretic and empiric findings of others, a self-regulatory model is proposed that explicates how CHD perceptions of older adults may influence participation in cardiac rehabilitation. CONCLUSION: The model may provide a useful guide for the development of effective interventions tailored to older adults.

"Active labor" duration and dilation rates among low-risk, nulliparous women with spontaneous labor onset: a systematic review.

INTRODUCTION: Laboring women are often admitted to labor units under criteria that are commonly associated with the onset of active-phase labor (i.e., cervical dilatation of 3-5 cm in the presence of regular contractions). Beginning with these criteria through complete dilatation, this systematic review describes labor duration and cervical dilation rates among low-risk, nulliparous women with spontaneous labor onset. METHODS: Studies published in English (between 1990 and 2008) were identified via MEDLINE and CINAHL searches. Data were abstracted and weighted "active labor" durations (i.e., from 3-5 cm through complete dilatation) and linear dilation rates were calculated. RESULTS: Eighteen studies (n = 7009) reported mean "active labor" duration. The weighted mean duration was 6.0 hours, and the calculated dilation rate was 1.2 cm per hour. These findings closely parallel those found at the median. At the statistical limits, the weighted "active labor" duration was 13.4 hours (mean + 2 standard deviations) and the dilation rate was 0.6 cm per hour (mean - 2 standard deviations). DISCUSSION: These findings indicate that nulliparous women with spontaneous labor onset have longer "active" labors and therefore slower dilation rates than are traditionally associated with active labor when commonly used criteria are applied as the starting point. Revision of existing active labor expectations and/or criteria used to prospectively identify active phase onset is warranted.

Staying smoke free: an intervention to prevent postpartum relapse.

This pilot study evaluated the effectiveness of a nurse-delivered home-visiting program during the postpartum period that included a low-intensity smoking relapse-prevention intervention. A prospective two-group design was used. Participants were women who had quit smoking during their pregnancy. They were invited to participate during postpartum hospitalization on a university hospital postpartum ward. A brief intervention during postpartum hospitalization, a home visit, and two follow-up phone calls over a 1- to 2-month period were compared with a routine home visit without any prescribed focus on tobacco use. The main outcome was biochemically verified smoking abstinence at 3 and 6 months postenrollment. Abstinence was defined as a salivary cotinine level of 14 ng/ml or less. At 3 months postenrollment, 26.4% of the intervention group were classified as abstinent, compared with 12.4% of the comparison group (OR = 2.4, 95% CI = 1.16-4.98). At 6 months, the proportion of the intervention group categorized as abstinent was 21.5%, compared with 10.2% of comparison group participants (OR = 2.5, 95% CI = 1.13-5.71). Greater than three times as many in the intervention group remained abstinent at both times (18.2%), compared with the comparison group (5.2%; OR = 2.4, 95% CI = 1.16-4.93). The effectiveness of this brief, low-cost, and potentially replicable intervention in improving the rate of persistent postpartum smoke-free status for women who quit smoking during pregnancy is encouraging. A randomized trial of the approach is warranted.

Process evaluation of a nurse-delivered smoking relapse prevention program for new mothers.

The objective of this study(1) is to evaluate the feasibility, recall, and acceptability of an evidence-based intervention using home-health nurses to provide smoking relapse prevention skills to new mothers. The design of this study is process evaluation. Setting and participants include women who had delivered a normal newborn at a university hospital, who quit smoking during pregnancy, were smoke free for 7 days, and had saliva cotinine of less than or equal to 14 nanogram/ml. The intervention is a multicomponent cognitive-behavioral intervention, including inpatient contact, a home-health visit, and 2 follow-up phone calls. Results are as follows: 121 participants enrolled, and the intervention was implemented in 78 home visits. Nurses discussed tobacco issues for an average of 12.0 min. Almost all participants recalled the home visit; nearly two thirds recalled discussing tobacco use. Only 4% reported negative feelings toward discussing tobacco issues. In 87% of home visits, nurses implemented all 5 intervention components with self-reported nonsmokers. The conclusion is as follows: A nurse-delivered smoking relapse prevention intervention for new mothers was feasible and acceptable.

Nursing students' beliefs about smoking, their own smoking behaviors, and use of professional tobacco treatment intervention.

As the largest group of health care professionals, nurses are in a unique position to influence their patients who smoke. They also have more contact with patients than any other provider. The purpose of this survey study was to describe nursing students' beliefs about cigarette smoking, their smoking behaviors, and use of evidence-based tobacco treatment intervention. Of 200 surveyed, undergraduate nursing students, only 6% were smokers. The most inaccurate perception about tobacco treatment was that counseling of less than 3 minutes did not have an effect on improving smoking quit rate. Eight percent of surveyed smokers reported providing tobacco use treatment to all patients who smoke compared with 26% of non-smokers. Smoking-related morbidity and mortality warrant consistent use of clinical practice guidelines by nursing students and professional nurses.

Menthol pharmacology and its potential impact on cigarette smoking behavior.

Menthol is the only tobacco additive promoted and advertised by the tobacco industry. Although a considerable body of research has examined the effects of menthol when it is administered alone and unburned, the effects of menthol when burned in cigarette smoke are more complex because it is administered in a matrix of more than 4,000 substances. Therefore, it is difficult to isolate potential pharmacological and toxic effects of menthol when it is administered in a smoke mixture. Menthol properties include cooling and local anesthesia, as well as effects on drug absorption and metabolism, bronchodilation and respiration changes, and electrophysiology. Subjective effects of smoothness and less harshness have been identified as reasons for menthol cigarette smoking, but findings have been inconclusive regarding the effect of menthol on carbon monoxide exposure and smoking topography parameters. Gaps in the research literature and future research areas include the following: (a) What is the role of menthol in tobacco reinforcement and addiction? (b) In the absence of nicotine, is menthol reinforcing? (c) Are the pharmacological and physiological effects of menthol mediated by a menthol-specific receptor or some other central nervous system-mediated action? (d) What are the influences of menthol and menthol metabolism on the metabolic activation and detoxification of carcinogens in tobacco smoke? and (e) Do differences exist in cigarette smoking topography in relation to the interaction of ethnicity, gender, and menthol cigarette preference? Answers to these questions will help to elucidate the function of menthol in cigarettes and its impact on smoking behavior.

Passive smoking and vascular disease.

Passive smoking, or environmental tobacco smoke, is a causative factor in cardiovascular disease. A 30-minute passive smoking exposure was found to affect coronary flow velocity reserve in nonsmokers, indicating endothelial dysfunction in coronary circulation. This article summarizes empirical work on passive smoking and heart disease. Clinically relevant findings include a dose-response relationship between passive smoking exposure and heart disease and partial reversibility of physical effects after eliminating passive smoking exposure. Appropriate assessment of passive smoking exposure in a variety of settings is warranted, as well as recommendations to avoid such exposure. Policy-based public health initiatives to eliminate passive smoking in the workplace and other public areas are needed.

Smoke constituent exposure and smoking topography of adolescent daily cigarette smokers.

Adolescent smoking prevalence is a major health concern, with 24.4% reporting smoking in the past 30 days and 15.8% considered daily smokers. The purpose of this study was to characterize biobehavioral nicotine dependence, smoke constituent exposure and smoking topography in adolescent daily smokers. Relationships among biological markers of nicotine dependence (nicotine boost, carbon monoxide [CO] boost and cotinine levels) with existing self-report measures (modified Fagerström Tolerance Questionnaire [mFTQ] and the motivations for smoking scale) were examined. Gender differences were characterized. Fifty adolescents 13-18 years old were recruited for the study, 50% female. CO, plasma nicotine levels pre- and postcigarette, cotinine, and smoking topography were measured during a smoking bout with participant's usual cigarette. Average CO boost, pre- to postcigarette was 7.2 + 3.6 ppm, baseline cotinine level averaged 224.0 +/- 169.6 ng/ml and nicotine boost averaged 23.4 +/- 21.7 ng/ml. Mean puffs per cigarette was 14.2 +/- 6.3. Males had significantly higher total puff volumes, but similar smoke constituent exposure to females, and higher handling of cigarettes as smoking motive. In regression analysis, 35% of variance in tobacco use, as indicated by baseline cotinine concentration, was explained by maximum puff duration, postcigarette CO level, and nicotine dependence, as measured by the mFTQ. Results indicated adolescents had considerable smoke constituent exposure and nicotine dependence suggesting the importance of appropriate smoking cessation treatment.