The Development and Testing of a Perinatal Tobacco Attitudes and Behaviors Survey.

Background and Purpose: Accurate assessment of tobacco use in pregnant smokers is key to effective nursing intervention. There is a lack of valid and reliable tools easily integrated into prenatal care. Therefore, the purpose of this study was to develop and test a perinatal survey, guided by the Health Promotion Model (HPM). Methods: The survey was tested with 107 pregnant women via iPad. Urine cotinine assays and a process evaluation were conducted. Results: Reliability yielded a Cronbach's alpha of .873 for the ever-smoker sample and .835 for the total sample. Factors dovetailed with HPM constructs. Conclusions: Perinatal Tobacco Attitudes and Behaviors Survey (PTABS) exhibits high reliability and validity and is easily utilized. Updates need to include questions on all nicotine products and to be streamlined. With accurate identification of nicotine users nurses can provide targeted interventions early in pregnancy.

Vaping behaviour patterns and daily blood pressure and heart rate variation: a brief report.

BACKGROUND: Vaping, the use of an electronic device to deliver a drug-infused aerosol has become an increasingly popular way to consume nicotine since its introduction to the market in the early 2000s. Despite the differences in consumption patterns relative to combustible tobacco, the impact of ad libitum nicotine vaping on cardiovascular response has not been thoroughly studied. SUBJECT AND METHODS: This research was conducted on vapers (n = 17) and smokers (n = 14) who represent a subsample of a larger study that explored the relationship between nicotine use, activities of daily living and 24-hour cardiovascular response using Spacelabs ambulatory blood pressure monitors. These data were analysed via ANOVA models and t-tests using SPSS 25.0 for Macintosh. RESULTS: Vapers consumed nicotine significantly more frequently than did smokers, at 48.2% and 18.1% of every 15-minute waking measurement, respectively (p = 0.000). The act of nicotine consumption, rather than the mode of delivery, was significantly associated with increases in systolic, diastolic, mean arterial pressure, and heart rate readings. There was no difference in the mean amplitude of response to nicotine between vapers and smokers. CONCLUSIONS: This study's strong statistical findings, visually evident on ambulatory blood pressure monitor reports, demonstrated that ad libitum nicotine consumption has an acute, dose-dependent effect on cardiovascular response regardless of whether it is smoked or vaped. However, since vapers consumed nicotine more frequently, future studies should be conducted with larger sample sizes, and controlled for age and comorbidities to improve statistical strength. IMPLICATIONS: This pilot study reveals that, when ad lib consumption is documented and measured, vaping has unique and potentially harmful effects on blood pressure, pulse, and mean arterial pressure. Because nicotine is consumed for much longer stretches, vapers have fewer rest periods between nicotine doses.

CE: Original Research: The Experiences of Pregnant Smokers and Their Providers.

: Background: The U.S. Department of Health and Human Services' initiative Healthy People 2020 targets tobacco use, including smoking during pregnancy, as a continuing major health concern in this country. Yet bringing the U.S. Public Health Service's 2008 clinical practice guideline, Treating Tobacco Use and Dependence, into routine prenatal care remains challenging. Our previous nurse-managed intervention study of rural pregnant women found no significant cessation effect and significant discordance between self-reported smoker status and urinary cotinine levels. PURPOSE: The overall purpose of this follow-up study was to increase our understanding of the experiences of pregnant smokers and their providers. No qualitative studies could be found that simultaneously explored the experiences of both groups. DESIGN AND METHODS: This qualitative descriptive study used focus group methodology. Nine focus groups were held in two counties in upper New York State; six groups consisted of providers and three consisted of pregnant women. Four semistructured questions guided the group discussions, which were audiotaped and transcribed verbatim. Transcripts were read and coded independently by six investigators. Themes were identified using constant comparative analysis and were validated using the consensus process. RESULTS: The total sample consisted of 66 participants: 45 providers and 21 pregnant women. Most of the providers were white (93%) and female (93%). A majority worked as RNs (71%); the sample included perinatal and neonatal nursery nurses, midwives, and physicians. The pregnant women were exclusively white (reflecting the rural demographic); the average age was 24 years. All the pregnant women had smoked at the beginning of their pregnancies. Four common themes emerged in both the provider and the pregnant women groups: barriers to quitting, mixed messages, approaches and attitudes, and program modalities. These themes corroborate previous findings that cigarette smoking is used for stress relief, especially when pregnancy itself is a stressor, and that pregnant women may feel guilty but don't want to be nagged or preached to. CONCLUSIONS: These results have implications for how smoking cessation programs for pregnant women should be designed. Health care providers need to be cognizant of their approaches and attitudes when addressing the subject of smoking cessation. Specific educational suggestions include "putting a face" to the issue of tobacco use during pregnancy. More research is needed on how best to implement the 2008 clinical practice guideline in specific populations.

Promoting heart health in rural women.

PURPOSE: To compare 2 strategies, stage-matched nursing and community intervention (SMN+CI) and community intervention (CI) alone in changing cardiovascular risk factors in up to 3 behavioral areas: diet, physical activity, and/or smoking among rural women. METHODS: A 14-month, multisite randomized controlled trial of 117 rural women was conducted. Transtheoretical model was used in identification of stage of change and development of the SMN+CI nursing interventions. A social-ecological model was used to address issues of rurality in the development of interventions. FINDINGS: The SMN + CI group was superior on 4 outcomes. There were significant increases in 2 measures of dietary intake; improvement in dietary stage of change for fruits and vegetables; and reduced diastolic blood pressure (DBP) in the SMN + CI group. After log transformation DBP significance was lost. The CI group had a significant reduction in change in total cholesterol; however, significance was lost after control for the initiation of lipid lowering medications. There was a significant reduction in Framingham risk scores pre- to postintervention, regardless of group. CONCLUSIONS: There continues to be a need to improve cardiovascular risk factors in rural women. There should be an exploration of whether intensified dose and fidelity of the intervention strategies of diet and physical activity are effective in improving anthropometric and laboratory values. Further investigation is warranted into factors influencing the pre- to postreduction in Framingham risk scores.

The effects of smoking cessation and a programme intervention on birth and other perinatal outcomes among rural pregnant smokers.

OBJECTIVE: The purpose of this study was to evaluate the perinatal outcomes of rural pregnant smokers enrolled in the Smoke Free Baby & Me trial. METHODS: Data on smoking status and other pre-natal variables were collected during pregnancy. Outcomes were retrieved from a review of hospital records of 161 singleton births (79 from the control group, 82 from the intervention group). RESULTS: The results show that, after adjusting for gender and gestational age, the more self-reported cigarettes at the first pre-natal visit, the less the infant birth weight (p = 0.033), the less maternal weight gain (p = 0.042) and the shorter the labour length (p = 0.041). Infants of women with positive urinary cotinine at the first pre-natal visit in the intervention group had higher 1 minute Apgar scores than those with negative cotinine (p = 0.022). Smokers also had a preponderance of male infants (64% vs 36%), while non-smokers had more females (59% vs 41%) (p = 0.006). CONCLUSIONS: Smoking during pregnancy affects perinatal outcomes. Assuming a foetal origin of chronic disease morbidity, implementing smoking cessation during pregnancy would not only improve maternal and foetal health, but also might contribute to an improvement in the incidence of adult chronic disease morbidity.

A pilot randomized, placebo-controlled, double-blind trial of a multistep herbal program for assisting smokers to quit.

This pilot randomized-controlled trial was designed to evaluate the effectiveness of an over-the-counter multistep herbal smoking cessation regimen, SmokeRx, that employs four different herbal formulations taken at different times during the program. Twenty-two subjects were randomized to a placebo group and 20 to the SmokeRx program. The results show that the odds of reduced or validated cessation of smoking were not significantly different between the groups at any juncture over the 6 months of the trial but that there was a trend for higher odds in the SmokeRx group. Subjects were also more likely to drop out of the placebo group (p = .06), suggesting a possible positive effect of the SmokeRx regimen. Overall, early dropouts (at 2 week follow-up) appeared less motivated to quit smoking, as they were more likely to be younger, had smoked more than 5 years, had greater difficulty refraining from smoking in places where it is forbidden, had fewer previous quit attempts, did not intend to quit smoking in the next month, and exercised fewer hours per week. These results suggest that a larger trial of SmokeRx may be warranted and that more studies that assess the efficacy of herbal formulas are needed to provide valid data for non-nicotine smoking cessation options.

The rate of urinary cortisol excretion at work is persistently elevated in women at familial risk for breast cancer.

We recently reported that healthy women at familial risk for breast cancer (FH+) have higher urinary cortisol levels at work than women without familial risk (FH-). The purpose of this study was to evaluate whether this group difference persisted over a 1-month period. Subjects were healthy women (FH+, N = 42, age = 37.6 +/- 9.3, FH-, N = 93, age 38.4 +/- 9.0) employed primarily in clerical or technical positions at three medical centers in New York City who collected timed urine samples in three contrasting daily environments, at work ( approximately 11AM-3PM), home (approximately 6PM-10PM) and during sleep (approximately 10PM-6AM) on 2 mid-week workdays approximately 1 month apart. Two-way repeated measures ANOVA revealed that cortisol excretion differed across the environments (P < 0.001), and that there was also a significant interaction between daily environment and family history group (P < 0.049), such that FH+ women maintained higher cortisol excretion at work over the 2 days than FH- women. A Bland-Altman plot showed that both overall and by family history group, the rate of cortisol excretion at work was generally reproducible, although there was a heteroscadasticity in the relationship that likely reflected excessive stressfulness on one of the study days in a small minority of subjects. These results suggest that the presence of a potent background stressor (familial breast cancer risk) can influence more acute cortisol responses in daily life over time.

Higher levels of central adiposity in healthy premenopausal women with family histories of premenopausal breast cancer.

Research strongly suggests that lower overall adiposity and higher central adiposity are independent risk factors for premenopausal breast cancer in the general population. We aimed to test the possibility that these factors may contribute to familial risk of premenopausal breast cancer. A convenience sample of healthy women, ages 25-49, was recruited to yield three study groups: (1) Women with first-degree family histories of premenopausal breast cancer, operationally defined as being diagnosed prior to age 50 (Group FH < 50, n = 39); (2) Women with first-degree family histories of postmenopausal breast cancer, operationally defined as being diagnosed at age 50 or after (Group FH > or = 50, n = 33); and (3) Women without a history of breast cancer in first-degree relatives (Group FH-, n = 132). Multinomial logistic regression analyses, including possible confounders, waist circumference, and BMI, revealed a lower BMI among FH < 50 compared to either FH- (OR = 0.72; 95% CI = 0.59-0.87), or FH > or = 50 women (OR = 0.75; 95% CI = 0.60-0.95), and higher waist circumferences in FH < 50 compared to either FH- (OR = 1.15; 95% CI = 1.06-1.25), or FH > or = 50 women (OR = 1.16; 95% CI = 1.05-1.28). No group differences were seen for waist skinfold measures. These results support the possibility that differences in patterns of adiposity may contribute to familial risk of premenopausal breast cancer, and suggest the importance of conducting large scale, population-based studies of the link between body size characteristics and familial breast cancer risk.

Breast cancer-specific intrusions are associated with increased cortisol responses to daily life stressors in healthy women without personal or family histories of breast cancer.

Studies indicate that women fear breast cancer more than any other disease and that women's levels of breast cancer-specific intrusions are related to their perceived risk of breast cancer. Here, we explore possible biological consequences of higher breast cancer risk perceptions and intrusions in healthy women without personal or family histories of the disease. We hypothesized that women with higher perceived risk would have more intrusions about breast cancer, which would constitute a background stressor sufficient to increase hypothalamus-pituitary-adrenal axis (HPA) responsivity to daily stress. HPA responses to an ordinary life stressor (work) were assessed in 141 employed women (age = 37.2+/-9.2) without personal or family histories of breast cancer. Urinary cortisol excretion rates were assessed with timed sample collections at work, home, and during sleep. Repeated measures ANOVA revealed a significant Group by Time interaction with higher work cortisol levels in women with breast cancer-specific intrusions compared to women without intrusions (p < 0.02). Regression analyses revealed a significant association between risk perceptions and intrusions (p < 0.001). Regression analysis with intrusions and risk perceptions predicting work cortisol indicated a significant contribution of intrusions (p < 0.04), but not risk perceptions (p = 0.53). Overestimation of breast cancer risk is associated with higher levels of breast cancer-specific intrusions that can result in increased cortisol responsivity to daily stressors. This heightened responsivity could have long-term negative health implications.

Occupational differences in job strain and physiological stress: female nurses and school teachers in Hawaii.

OBJECTIVES: The two objectives are to test the hypothesis that women in a profession with low decision latitude will have greater catecholamine excretion and higher blood pressure than women in a profession with greater decision latitude, and to assess the influence of ethnicity on the occupational comparison. METHODS: Premenopausal women who were either full-time teachers in public schools (teachers; N = 92) or nurses or nurse's aides (nurses; N = 55) in East Hawaii who were not currently taking antihypertensive medication had ambulatory blood pressure (BP) and urinary catecholamine excretion measured over an approximate 4-hour period at work and home and over an approximate 8-hour period overnight. The women also filled out the Job Content Questionnaire (JCQ). RESULTS: The nurses had significantly lower scores on the "decision latitude" subscale of the JCQ. After controlling for the effects of ethnicity, age, body mass index, JCQ subscale scores, smoking habits, and menopausal status in regression analyses, the nurses also had significantly higher mean systolic and diastolic BP both in work and home settings and higher mean rates of both norepinephrine and epinephrine excretion in all daily settings (p < .05). There were no significant ethnic differences in scores on the JCQ subscales, but Asian-Americans had significantly higher systolic BP in all daily settings and higher diastolic BP overnight (p < .05) than Euro-Americans. CONCLUSIONS: These results suggest that among professional women, physiological stress responses are significantly greater when occupation-related decision latitude is low (nurses) than when it is high (teachers). The physiological response to stress is carried over into the home and overnight settings when occupation-related decision latitude is low (nurses). Individual scores on the JCQ were not significantly related to physiological measures in this study, however. Inclusion of contrasting occupations may be necessary to properly evaluate the relationships between individually reported job strain and heightened physiological stress responses in studies of working women.

The effectiveness of a nurse-managed perinatal smoking cessation program implemented in a rural county.

The present study (a) examined the effectiveness of a nurse-managed smoking cessation program, that was totally integrated into routine perinatal care, on the cessation rates of pregnant smokers in a rural community, and (b) assessed the subject characteristics associated with smoking cessation success. Data were collected from a convenience sample of 194 pregnant women who stated that they were smokers at the onset of their pregnancies. The study compared the effects of usual care (n = 93) versus the Smoke Free Baby & Me program (n = 101), which included the American Cancer Society's Make Yours a Fresh Start Family program. Smoking status was measured by self-report and urinary cotinine at four points during pregnancy and postpartum. At the postpartum visit, more women in the experimental group reported that they were not smoking compared with those in the control group (37.3% vs. 16.7%), Pearson's chi2 (n = 87) = 4.37, p = .037, and they had higher validated (urinary cotinine <200 ng/ml) smoking cessation rates (n = 80, t = 2.449, p = .017) if they had quit smoking by the first prenatal visit. Smoking cessation was positively associated with level of education and negatively associated with gravidity, parity, the number of smokers in the household, and the number of cigarettes smoked per day at the first prenatal visit. Significant discordance was found between self-report and urinary cotinine assays at all prevalence points, regardless of group. In conclusion, this nurse-delivered program integrated into perinatal care influenced the smoking behaviors of "recent quitters" but had no effect on those who reported smoking at the first prenatal visit. Implications for clinical practice are discussed.

Heightened cortisol responses to daily stress in working women at familial risk for breast cancer.

Consistent with animal models and experimental studies with humans facing other 'background' stressors, women at familial risk for breast cancer have been reported to have stronger cortisol responses to laboratory stressors. To explore the relevance of these findings to daily life, we compared work-stress cortisol responses in women with >or=1 first-degree relative with breast cancer (FH+, n = 74) to women without this risk factor (FH-, n = 141). Repeated-measures ANOVA revealed a group by time interaction (p

Comparison of self-reported smoking and urinary cotinine levels in a rural pregnant population.

OBJECTIVES: (a) to assess the accuracy of self-reported smoking status in pregnant women from rural and small metropolitan statistical areas who stated they were smokers at the onset of pregnancy, (b) to compare the characteristics of these women who self-reported a nonsmoker status at the first prenatal visit with those who reported a smoker status, and (c) to determine the characteristics that predict self-reported smoking status and positive/negative urinary cotinine assays. SETTING: Seven private obstetric offices serving rural and small metropolitan statistical areas in upstate New York. PARTICIPANTS: A convenience sample of 94 pregnant women who stated they were smokers at the onset of their pregnancies. Their mean age was 23 years and mean level of education was 11.9 years; 95% were White, 65% were single, and 65% were Medicaid-funded. DESIGN: Descriptive correlational design. At the first prenatal visit, the sensitivity and specificity of smoking and nonsmoking status were determined by comparing self-reports of smoking status with urinary cotinine assays. Data were also analyzed for relationships among demographic variables and for predictors of smoking status and urinary cotinine. RESULTS: The discordance rate between self-reports of smoking status and urinary cotinine assays at the first prenatal visit for the total sample was 16.6%, significant at p < .001, chi-square = 27.80, df = 1. Based on biochemical assays of >200 ng/ml of cotinine indicating active smoking, 34.7% of women who denied smoking (specificity of 65.3%) and 10.4% of women who stated that they smoked (sensitivity of 89.5%) inaccurately reported their status (significant at p < .001). The number of cigarettes smoked per day was positively correlated with age, gravidity, parity, and number of smokers in the household. Gravidity and the number of smokers in the household were significant predictors of positive self-report of smoking status and of positive urinary cotinine assay. CONCLUSION: These results substantiate the unreliability of self-report on smoking status in the pregnant population and in women who are recent quitters. Such findings have implications for clinical practice, such as (a) changes are necessary in how the prenatal interview assesses past and present tobacco use, (b) pregnant smokers who are multigravidae and who live with other smokers need more tailored interventions, and (c) more research is needed on how self-report can be ethically and efficiently validated.

Urinary catecholamine levels in daily life are elevated in women at familial risk of breast cancer.

Recent experimental research has shown that women facing the chronic stress of being at familial risk of breast cancer have greater neuroendocrine reactivity responses to stressful laboratory tasks. Whether this enhanced stress response also occurs outside the laboratory under daily life conditions is unknown. In the present study, urinary epinephrine and norepinephrine excretion rates at work (e.g. 11:00 AM-3:00 PM), home (e.g. 6:00 PM-10:00 PM) and during sleep (e.g. 10:00 PM-6:00 AM) were compared between 73 employed women with family histories of breast cancer in first degree relatives (FH+; age=36.8+/-8.7) and 81 without such family histories (FH-; age=38.1+/-9.4). Differences in sympathetic adrenal medullary responses to an ordinary life stressor (work) were assessed in naturalistic settings. Repeated measures MANCOVA with family history group as a fixed factor, body mass index as a covariate and daily microenvironment (work, home and sleep) as a repeating factor were conducted to evaluate whether catecholamine excretion rates differed between FH+ and FH- groups. The results revealed that women with family histories of breast cancer had a higher rate of epinephrine excretion while at work (p<0.005). In addition, women in the FH+ group were also more reactive to the stress of work, showing a greater percentage of increase in both epinephrine and norepinephrine from sleep to work (p<0.05). The results also indicated that the chronic stress effects associated with a family history of breast cancer were moderated by BMI, such that their impact was more pronounced and apparent when women were not obese. These findings support the idea that the heightened neuroendocrine reactivity to experimental stressors in women at familial risk of breast cancer also occurs when women encounter stressors in ordinary life (work stress). Additional research to explore the health consequences of increased reactivity in women at familial risk of breast cancer, and perhaps in individuals at familial risk of other life-threatening disease, would appear warranted.