Study of monotherapy versus combination therapy for tobacco dependence among heavily addicted smokers.

OBJECTIVES: Combination therapy for tobacco dependence is becoming a standard of care. We sought to compare benefits and adverse events for combination therapy versus monotherapy for smokers in The Smokers' Health Project. METHODS: This secondary data analysis was derived from adult smokers (n = 198) who initially smoked 15 or more cigarettes per day and participated in The Smokers' Health Project. Participants were grouped as taking 1 medication or 2 concurrent medications for tobacco dependence for 1 year over the 2-year study period. Adverse events were compared between medication groups using chi-square tests. Crude and adjusted odds ratios were calculated for cessation at 6, 12, 18, and 24 months using logistic regression. RESULTS: No differences were seen in the proportion of incident adverse events between the monotherapy (28.3%) and combination therapy (32.3%) groups (P = 0.54). At 6 months, the odds of quitting were less in the combination therapy group relative to those taking monotherapy (adjusted odds ratio = 0.47 [95% CI 0.24-0.93]). At 12, 18, and 24 months, the odds of quitting did not differ between therapy groups (P = 0.07, 0.33, 0.55, respectively). CONCLUSION: Monotherapy and combination therapy for smoking cessation are similarly effective up to 24 months, and they exhibit similar adverse event attributes.

Labor epidural anesthesia, obstetric factors and breastfeeding cessation.

Breastfeeding benefits both infant and maternal health. Use of epidural anesthesia during labor is increasingly common and may interfere with breastfeeding. Studies analyzing epidural anesthesia's association with breastfeeding outcomes show mixed results; many have methodological flaws. We analyzed potential associations between epidural anesthesia and overall breast-feeding cessation within 30 days postpartum while adjusting for standard and novel covariates and uniquely accounting for labor induction. A pooled analysis using Kaplan-Meier curves and modified Cox Proportional Hazard models included 772 breastfeeding mothers from upstate New York who had vaginal term births of healthy singleton infants. Subjects were drawn from two cohort studies (recruited postpartum between 2005 and 2008) and included maternal self-report and maternal and infant medical record data. Analyses of potential associations between epidural anesthesia and overall breastfeeding cessation within 1 month included additional covariates and uniquely accounted for labor induction. After adjusting for standard demographics and intrapartum factors, epidural anesthesia significantly predicted breastfeeding cessation (hazard ratio 1.26 [95% confidence interval 1.10, 1.44], p < 0.01) as did hospital type, maternal age, income, education, planned breastfeeding goal, and breastfeeding confidence. In post hoc analyses stratified by Baby Friendly Hospital (BFH) status, epidural anesthesia significantly predicted breastfeeding cessation (BFH: 1.19 [1.01, 1.41], p < 0.04; non-BFH: 1.65 [1.31, 2.08], p < 0.01). A relationship between epidural anesthesia and breastfeeding was found but is complex and involves institutional, clinical, maternal and infant factors. These findings have implications for clinical care and hospital policies and point to the need for prospective studies.

The effect of immediate postpartum depot medroxyprogesterone on early breastfeeding cessation.

BACKGROUND: This study evaluated the effect of immediate postpartum depot medroxyprogesterone (DMPA) on breastfeeding cessation within 6 weeks postpartum. STUDY DESIGN: At low-income-serving obstetric and pediatric clinics, eligible mothers within 1 year postpartum were recruited to participate in a retrospective cohort study. The 183 participants completed a self-administered survey. Surveys were merged with birth certificate data and perinatal maternal/infant medical records. Kaplan-Meier distributions assessed the relationship between DMPA use and breastfeeding cessation. A multivariable Cox proportional hazards model estimated hazard ratios (HRs) and included five known risk factors (age, education, race, parity and parental cohabitation) and identified potential confounders. RESULTS: Consistent with the biologic model, the Kaplan-Meier results raised the possibility of a detrimental effect of DMPA on duration of any breastfeeding, but differences in these distributions did not achieve statistical significance (p=.24); after adjustment for potential confounders, this nonstatistically significant association remained (HR: 1.22; confidence interval: 0.75-1.98). CONCLUSION: Given the state of the evidence, it is unclear whether a causal effect does or does not exist. However, if there is a causal effect of DMPA on breastfeeding duration, it is minimal. Additional well-designed research is warranted.

A systematic review of early postpartum medroxyprogesterone receipt and early breastfeeding cessation: evaluating the methodological rigor of the evidence.

BACKGROUND: Breastfeeding has numerous maternal and infant benefits. Progesterone contraception after birth is frequently recommended, but because a decrease in progesterone is required to initiate lactation, early postpartum progesterone contraception use could inhibit lactation. The purpose of this article is to critically evaluate the scientific basis for conflicting clinical recommendations related to postpartum medroxyprogesterone use among breastfeeding women. METHODS: Relevant peer-reviewed literature was identified through a comprehensive search of PubMed through December 2010. The search was restricted to clinical trials, randomized clinical trials, or comparative studies written in English and conducted among humans. The studies included in this review addressed the effect of medroxyprogesterone administration at <6 weeks postpartum on breastfeeding exclusivity and/or duration and measured breastfeeding outcomes at ≥ 6 weeks postpartum. RESULTS: Of the 20 articles identified, only three studies satisfied the inclusion criteria. However, all three studies were of low-quality methodological rigor, and none accounted for potential confounders. CONCLUSION: Current evidence is methodologically weak and provides an inadequate basis for inference about a possible causal relationship between early postpartum medroxyprogesterone use and poor breastfeeding outcomes. However, given the presence of a strong biological model describing the potential deleterious effect of postpartum medroxyprogesterone use on lactation, further research that improves on current literature is warranted. Meanwhile, we recommend that potential breastfeeding risks associated with early (<6 weeks) postpartum medroxyprogesterone use be disclosed to allow for a fully informed consent and decision-making process.