Lifetime characteristics of participants and non-participants in a smoking cessation trial: implications for external validity and public health impact.

BACKGROUND: Detailed information about the characteristics of smokers who do and do not participate in smoking cessation treatment is needed to improve efforts to reach, motivate, and treat smokers. PURPOSE: The aim of this study is to explore a broad range of characteristics related to participation in a smoking cessation trial. METHODS: Eligible smokers were recruited from a longitudinal birth cohort. Participants and non-participants were compared on a broad range of sociodemographics, smoking, psychiatric and substance abuse disorders, personality, and prospective measures from early childhood. Eligible smokers were compared to a matched regional subsample of the Behavioral Risk Factor Surveillance System (BRFSS). RESULTS: Few differences were observed, most of which were statistically significant but not clinically meaningful. Compared to non-participants, participants were more likely to be single, have lower income, be more nicotine-dependent, be more motivated to quit, and have higher levels of depressed mood and stress even after covariance of gender, income, and marital status. Sociodemographic differences between participants and the BRFSS sample reflect the skew toward lower socioeconomic status in the original birth cohort. CONCLUSIONS: The encouraging conclusion is that smokers who enroll in cessation trials may not differ much from non-participants. Information about treatment participants can inform the development of recruitment strategies, improve the tailoring of treatment to individual smoker profiles, help to estimate potential selection bias, and improve estimates of population impact.

Field Test of a Hybrid Finite-Difference and Analytic Element Regional Model.

Regional finite-difference models often have cell sizes that are too large to sufficiently model well-stream interactions. Here, a steady-state hybrid model is applied whereby the upper layer or layers of a coarse MODFLOW model are replaced by the analytic element model GFLOW, which represents surface waters and wells as line and point sinks. The two models are coupled by transferring cell-by-cell leakage obtained from the original MODFLOW model to the bottom of the GFLOW model. A real-world test of the hybrid model approach is applied on a subdomain of an existing model of the Lake Michigan Basin. The original (coarse) MODFLOW model consists of six layers, the top four of which are aggregated into GFLOW as a single layer, while the bottom two layers remain part of MODFLOW in the hybrid model. The hybrid model and a refined "benchmark" MODFLOW model simulate similar baseflows. The hybrid and benchmark models also simulate similar baseflow reductions due to nearby pumping when the well is located within the layers represented by GFLOW. However, the benchmark model requires refinement of the model grid in the local area of interest, while the hybrid approach uses a gridless top layer and is thus unaffected by grid discretization errors. The hybrid approach is well suited to facilitate cost-effective retrofitting of existing coarse grid MODFLOW models commonly used for regional studies because it leverages the strengths of both finite-difference and analytic element methods for predictions in mildly heterogeneous systems that can be simulated with steady-state conditions.

Effects of tolerance on the anxiety-reducing function of alcohol.

Thirty-two male social drinkers were arranged into two tolerance groups, based on changes in standing stability after ingestion of alcohol. Subjects consumed either a large (1.0 g/kg) or small (0.5 g/kg) dose of alcohol. On finishing their drinks, subjects were requested to interact with a female confederate whose continued silence induced anxiety. Heart rate, skin conductance, overt behavior, and self-report measures were taken. Heart rate increased more at the small than the large dose, consistent with the tension-reduction hypothesis. Further, heart rate of high-tolerance subjects increased significantly more than that of low-tolerance subjects, which suggests that alcohol was less effective at tension reduction for the high-tolerance group. Finally, measures of both skin conductance and heart rate showed significant dose-by-tolerance interactions. High-tolerance subjects were more aroused than were low-tolerance subjects at the small but not at the large dose, suggesting that high-tolerance subjects must consume more alcohol to achieve the same autonomic effect experienced by the low-tolerance subjects.

Contrasting short- and long-term effects of weight loss on lipoprotein levels.

The short- and long-term effects of weight loss on high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol levels were examined in 42 women who completed a 14-session behavioral weight-loss program. Lipid values were determined from samples taken before treatment, after treatment, and at six-month follow-up. There were significant changes in plasma lipid levels, but the short- and long-term effects differed. Both total and LDL cholesterol levels decreased during treatment and remained lower at follow-up. However, HDL cholesterol level and the HDL/LDL ratio did not change during treatment but increased significantly above pretreatment levels at follow-up. Furthermore, long-term changes in lipoprotein levels were significantly correlated with changes in the body-mass index even after correction for initial values. These results show that weight loss can, in the long term, have a potentially beneficial impact on lipoprotein levels in women.

The efficacy of exercise as an aid for smoking cessation in women: a randomized controlled trial.

BACKGROUND: Smoking prevalence rates among women are declining at a slower rate than among men. OBJECTIVE: To determine if exercise, a healthful alternative to smoking, enhances the achievement and maintenance of smoking cessation. METHODS: Two hundred eighty-one healthy, sedentary female smokers were randomly assigned to either a cognitive-behavioral smoking cessation program with vigorous exercise (exercise) or to the same program with equal staff contact time (control). Subjects participated in a 12-session, group-based smoking cessation program. Additionally, exercise subjects were required to attend 3 supervised exercise sessions per week and control subjects were required to participate in 3 supervised health education lectures per week. Abstinence from smoking was based on self-report, was verified by saliva cotinine level, and was measured at 1 week after quit day (week 5), end of treatment (week 12), and 3 and 12 months later (20 and 60 weeks after quit day, respectively). RESULTS: Compared with control subjects (n = 147), exercise subjects (n = 134) achieved significantly higher levels of continuous abstinence at the end of treatment (19.4% vs 10.2%, P = .03) and 3 months (16.4% vs 8.2%, P=.03) and 12 months (11.9% vs 5.4%, P=.05) following treatment. Exercise subjects had significantly increased functional capacity (estimated VO2 peak, 25+/-6 to 28+/-6, P<.01) and had gained less weight by the end of treatment (3.05 vs 5.40 kg, P = .03). CONCLUSIONS: Vigorous exercise facilitates short- and longer-term smoking cessation in women when combined with a cognitive-behavioral smoking cessation program. Vigorous exercise improves exercise capacity and delays weight gain following smoking cessation.

Effects of behavioral skills training and schedule of nicotine gum administration on smoking cessation.

Eighty-nine smokers were randomly assigned to four nicotine gum treatments for smoking cessation: behavioral treatment plus a fixed schedule of nicotine gum, behavioral treatment plus an ad lib schedule, education plus a fixed schedule, and education plus an ad lib schedule. The four treatment conditions produced similar rates of abstinence (40.9% to 58.3%) at the end of 11 weeks of treatment. However, at 6-month follow-up, the subjects who had received behavioral treatment had a significantly better abstinence rate (36.7%) than those receiving education (17.5%). Nicotine gum schedule had no effect on treatment outcome.

Development of major depressive disorder during smoking-cessation treatment.

BACKGROUND: Several studies have shown an association between smoking and major depressive disorder (MDD), but few have prospectively examined subjects who develop MDD after quitting smoking. This descriptive study evaluated the development of MDD after smoking cessation, as assessed by a structured clinical interview at both baseline and the end of treatment. METHOD: Nondepressed participants (N = 114) in a trial investigating the effect of fluoxetine on smoking cessation were administered the Structured Clinical Interview for DSM-III-R at baseline and posttreatment to evaluate the impact of quitting smoking on the development of MDD. Depressive symptoms were additionally assessed with the Beck Depression Inventory and the Hamilton Rating Scale for Depression. RESULTS: At baseline, 32% of the subjects reported a history of MDD. Sixty-nine subjects completed the SCID at baseline and posttreatment. At posttreatment, 5 subjects (7%) met threshold criteria for MDD; none were taking the highest dose of fluoxetine (60 mg), 4 were taking 30 mg, and 1 was taking placebo. All 5 had a history of MDD; 3 were women. Four had a history of substance abuse and attained at least 3 consecutive biochemically verified weeks of smoking abstinence. Those who developed MDD after treatment scored significantly higher on measures of depressed mood at baseline than those who did not develop MDD after smoking-cessation treatment. CONCLUSION: The results from this descriptive study suggest that a subset of smokers may be at risk for developing MDD after smoking cessation.

Smoking-cessation counseling in the home. Attitudes, beliefs, and behaviors of home healthcare nurses.

BACKGROUND: Despite advances in smoking treatment, cessation rates remain stagnant, possibly a function of the lack of new channels to reach heavily addicted smokers. This cross-sectional study examined home care nurses' attitudes, beliefs, and counseling behaviors regarding counseling their home care patients who smoke. METHODS: Home healthcare nurses (N=98) from the Visiting Nurse Association of Rhode Island were randomly selected to participate in a study helping home-bound medically ill smokers to quit. At baseline, nurses completed a questionnaire that assessed a constellation of cognitive factors (self-efficacy, outcome expectations, perceived effectiveness, risk perception, motivation, and perceived patient adherence) as correlates of self-reported nurse counseling behaviors. RESULTS: Nurses with higher outcome expectations spent more time counseling their patients about quitting (p<0.04). Nurses' self-efficacy was the only variable associated with consistent counseling (p<0.05). While the majority of nurses "asked and advised" their patients, a minority of nurses "assisted or arranged" follow-up. Perceived importance of counseling was associated with a greater likelihood of asking, advising and assisting (p<0.05). None of the nurses who currently smoked (n=13) provided follow-up to their patients. Nurses who reported higher levels of both risk perception (regarding the harmful effects of smoking) and perceived effectiveness were more likely to recommend the nicotine patch. CONCLUSIONS: Attitudes and beliefs about smoking are significantly associated with nurse counseling behaviors. Helping nurses to overcome their barriers to smoking counseling may open up new channels for smoking intervention.

The Contemplation Ladder: validation of a measure of readiness to consider smoking cessation.

Presents evidence for the validity of the Contemplation Ladder, a measure of readiness to consider smoking cessation. Analyses of data collected from more than 400 smokers at two worksites before and during a 10-month intervention indicate that Ladder scores were significantly associated with reported intention to quit, number of previous quit attempts, perceived co-worker encouragement to quit, and socioeconomic status. Ladder scores predicted subsequent participation in programs designed to educate workers about their smoking habit and its contingent risks. The Ladder did not predict biochemically validated abstinence of 24 hr or more. To assess its ability to distinguish between groups known a priori to differ in readiness, we administered the Ladder to 36 participants in a clinic-based smoking cessation program. As predicted, clinic patients scored significantly higher than the workers on the Ladder. The importance of distinguishing between smokers at the lowest stages of readiness to quit is discussed.

Smoking at home: the impact of smoking cessation on nonsmokers' exposure to environmental tobacco smoke.

Nonsmokers who live with smokers are at increased risk for chronic disease. This study evaluated the impact of eliminating smoking in the home on nonsmokers' environmental tobacco smoke (ETS) exposure. Nonsmokers participated in measurements of their ETS exposure before and after the smoker in their home quit smoking. A matched comparison group of nonsmokers from nonsmoking homes was also included. ETS exposure was assessed using passive nicotine monitors, an exposure diary, and a questionnaire. Nonsmokers from smoking homes had significantly higher exposure to ETS than those from nonsmoking homes. There was a 60% reduction in nicotine levels following smoking cessation by the household smoker. However, there were still detectable levels of nicotine measured at posttest. These results have important implications for individual risk reduction and public health policy.

The stages and processes of exercise adoption and maintenance in a worksite sample.

We applied the model of the stages and processes of change to exercise adoption and maintenance. This model has shown promise in advancing theory and treatment of the addictions and other negative health behaviors, but there have been few systematic attempts to apply the model to positive health behaviors, such as exercise adoption. Questionnaires dealing with the stages and processes of exercise change were developed and administered to a sample of 1,172 participants in a worksite health promotion project. The sample was split randomly into halves for (a) initial model development and testing and (b) confirmatory measurement model testing. Additional model confirmation was obtained by examining the hierarchical structure of the processes of change and by conducting Stage x Process analyses. Results suggest that the underlying constructs derived from smoking cessation and other addictive behaviors can be generalized to exercise behavior. Understanding the stages and processes of exercise behavior change may yield important information for enhancing exercise adoption, adherence, and relapse prevention at both individual and public health levels.

Do processes of change predict smoking stage movements? A prospective analysis of the transtheoretical model.

The transtheoretical model (TTM) posits that processes of change and the pros and cons of smoking predict progressive movement through the stages of change. This study provides both a cross-sectional replication and a prospective test of this hypothesis. As part of a larger study of worksite cancer prevention (the Working Well Trial), employees of 26 manufacturing worksites completed a baseline and 2 annual follow-up surveys. Of the 63% of employees completing baseline surveys, 27.7% were smokers (N = 1,535), and a cohort of these smokers completed the 2-year follow-up. Cross-sectional results replicated previous studies with virtually all the processes of change and the cons of smoking increasing in linear fashion from precontemplation to preparation (all ps < .00001), and the pros of smoking decreasing (p < .01). However, contrary to the hypothesis, the baseline processes of change and the pros and cons of smoking failed to predict progressive stage movements at either the 1- or the 2-year follow-ups. Possible explanations for these findings and concerns about the conceptual internal consistency of the TTM are discussed.

Assessing elements of women's decisions about mammography.

We investigated motivational and cognitive processes of behavior change with respect to mammography screening. One hundred forty-two women (ages 40 and older) recruited from three worksites answered a 41-item questionnaire consisting of statements based on constructs from the transtheoretical model of behavior change. Principal-components analysis identified two factors: a six-item component representing positive perceptions of mammography (Pros) and a six-item component representing avoidance of mammography (Cons). Analysis of variance showed that Pros, Cons, and a derived Decisional Balance measure (Pros minus Cons) were associated with stage of mammography adoption. Results are consistent with applications of the model to smoking cessation. The model is also discussed as it relates to other theories of behavior change and as a general strategy for analyzing perceptual data pertinent to health-related actions and intentions for behavioral change.

Psychosocial stress and coping in smokers who relapse or quit.

Relapse remains a major problem in successful smoking cessation. This study evaluated selected responses and coping skills in male and female quitters and relapsers in four situational contexts: general social competence, smoking-specific "high-risk-for-relapse" situations, social anxiety, and relaxation. Results showed that quitters coped better than relapsers with intrapersonal (e.g., negative mood) smoking-specific situations. Quitters had lower heart rates than relapsers during relaxation and intrapersonal situations and had lower anxiety scores at the end of the procedures. Women showed more stress and less confidence in their ability to cope than did men. Groups did not differ in responses to the general social competence and social anxiety procedures. Results are discussed in the context of the importance of considering individual differences in responses and in coping skills for treatment and relapse prevention for smokers.

Transdisciplinary concepts and measures of craving: commentary and future directions.

A new theoretical model of craving is needed that uses a common language and standardized measures. The new conceptual model must fully integrate discoveries from cellular biology, neuroscience, animal and human laboratory, cognitive-behavioral social learning and socio-cultural disciplines. A transdisciplinary synthesis can then guide methods and measurement development. Mapping the structural pathways and interactions among mediators and moderators of craving will improve the diagnostic and prognostic tools in order to inform new treatments and prevention strategies.

Brief coping skills treatment for cocaine abuse: substance use outcomes at three months.

AIMS: Coping skills training, a promising treatment approach for alcoholics, was adapted for use with cocaine abusers and effects on outcome were investigated. DESIGN: A cocaine-specific coping skills training (CST) package was compared to an attention placebo control when both were added to a comprehensive treatment program. SETTING: The sites were two private substance abuse treatment facilities, one residential and rural, and one an urban partial hospital. PARTICIPANTS: Substance abusers in treatment with cocaine abuse or dependence were selected. INTERVENTION: The CST intervention was conducted in individual sessions. It involved functional analysis of high risk situations and coping skills training based on the functional analysis. FINDINGS: Clients who received CST had significantly fewer cocaine use days and the length of their longest binge was significantly shorter during the 3-month follow-up period compared to clients in the control condition. CST did not affect relapse rates or use of other substances. CONCLUSIONS: Results support the notion that cocaine-specific CST is a promising adjunct to treatment for cocaine abusers.

Cue exposure with coping skills training and communication skills training for alcohol dependence: 6- and 12-month outcomes.

AIMS: Cue exposure treatment (CET) has shown promise in preliminary studies with alcoholics, and Communication Skills Training (CST) has been found beneficial, especially in intensive treatment programs. The aim of the present study was to investigate the effects of CET and CST in a larger controlled study when both were added to intensive treatment programs. DESIGN AND INTERVENTIONS: A 2 x 2 design investigated the effects of CET with urge coping skills training compared to a meditation-relaxation control, and CST compared to an education control when all were added to intensive treatment programs for alcoholics. SETTING: The sites were the inpatient or partial hospital substance abuse treatment programs at a private psychiatric hospital, a state-funded residential facility and a VA medical center. PARTICIPANTS: Patients diagnosed with alcohol dependence without active psychosis were eligible. MEASUREMENTS: Participants were assessed for quantity and frequency of drinking, alcohol cue-reactivity, responses to high risk simulations and urge specific coping skills. FINDINGS: Of 100 treated patients, 86% provided 6-month and 84% provided 12-month follow-up data. Patients who received either CET or CST had fewer heavy drinking days in the first 6 months than control patients. In the second 6 months, CET continued to result in fewer heavy drinking days among lapsers and interacted with CST to decrease quantity of alcohol consumed. CST resulted in fewer alcohol-related problems reported at 12 months. CET resulted in greater reductions in urge to drink in a measure of simulated high-risk situations. CET also resulted in greater reports of use of coping strategies during the follow-up, and many of the urge-specific strategies taught in CET were associated with reduced drinking. CONCLUSIONS: Both CET and CST continue to show promise as elements of comprehensive alcohol treatment programs. Limitations and directions for future research are discussed.

Cue exposure treatment for smoking relapse prevention: a controlled clinical trial.

AIMS: In an additive design, test the efficacy of cue exposure treatment for smoking relapse prevention as an adjunct to current standard cognitive behavioral and pharmacological treatments. DESIGN: Randomized, controlled clinical trial. SETTING: Outpatient behavioral medicine clinic. PARTICIPANTS: One hundred and twenty-nine cigarette smokers recruited through newspaper advertisements. INTERVENTION: After receiving an initial counseling session for cessation and setting a quit day, 129 smokers were randomly assigned to one of four relapse prevention treatment conditions: (1) brief cognitive behavioral; (2) cognitive behavioral and nicorette gum; (3) cognitive behavioral and cue exposure; and (4) cognitive behavioral and cue exposure with nicorette gum. All smokers met individually with their counselor for six RP sessions. MEASURES: Seven-day, point-prevalence abstinence rates (CO verified) taken at 1, 3, 6 and 12-months post-treatment and time to first slip. FINDINGS: All manipulation checks and process measures suggested that the treatments were delivered as intended. There were no significant differences between conditions in point-prevalence abstinence rates or in time to first slip. CONCLUSIONS: These results call into question the utility of cue exposure treatment for smoking relapse prevention.

Socioeconomic status over the life course and stages of cigarette use: initiation, regular use, and cessation.

STUDY OBJECTIVE: To investigate the association between multiple indicators of socioeconomic status (SES) over the life course and three stages of cigarette use: initiation, regular use, and cessation. DESIGN: Prospective birth cohort study. SETTING: Providence, Rhode Island. PARTICIPANTS: Subjects (n=657) aged 30 to 39 were offspring of participants in the Brown University cohort of the United States National Collaborative Perinatal Project started in 1959. MAIN RESULTS: A significantly increased risk of smoking initiation was observed among people from lower socioeconomic backgrounds. Low SES in childhood also increased the risk for progression to regular smoking, and was associated with a reduced likelihood of smoking cessation. Progression to regular smoking and smoking persistence were also associated with lower adult SES. CONCLUSIONS: Socioeconomic conditions over the life course accumulate to produce increased rates of smoking uptake and reduced rates of cessation among lower SES people. Addressing SES gradients in smoking will require persistent and extended intervention over multiple life stages.

Increased saliva cotinine concentrations in smokers during rapid weight loss.

Although the effect of smoking cessation on weight gain is well-documented, little is known about the effect of weight loss on smoking. We examined the association between saliva cotinine levels and weight loss in a group of 9 obese female smokers during participation in a protein-sparing modified fast (Optifast). For the first 3 months of treatment, subjects consumed only the protein-sparing supplement; for the next 3 months, food was gradually reintroduced. Body mass index and saliva cotinine concentration were assessed at study entry and at 3 and 6 months. A significant weight loss was noted at 3 and 6 months, yet the cotinine level increased significantly over this time. It is unclear whether the cotinine increase is due to metabolic changes or an actual increase in nicotine intake. The results suggest that smoking-related health risks may increase during periods of significant weight loss.