COVID Protection Behaviors, Mental Health, Risk Perceptions, and Control Beliefs: A Dynamic Temporal Network Analysis of Daily Diary Data.

BACKGROUND: To control infections, behavioral non-pharmaceutical interventions (NPIs) such as social distancing and hygiene measures (masking, hand hygiene) were implemented widely during the COVID-19 pandemic. At the same time, adherence to NPIs has also been implied in an increase in mental health problems. However, the designs of many existing studies are often poorly suited to disentangle complex relationships between NPI adherence, mental health symptoms, and health-related cognitions (risk perceptions, control beliefs). PURPOSE: To separate between- and temporal within-person associations between mental health, health-related cognitions, and NPI adherence. METHODS: Six-month ecological momentary assessment (EMA) study with six 4-day assessment bouts in 397 German adults. Daily measurement of adherence, mental health symptoms, and cognitions during bouts. We used dynamic temporal network analysis to estimate between-person, as well as contemporaneous and lagged within-person effects for distancing and hygiene NPIs. RESULTS: Distinct network clusters of mental health, health cognitions, and adherence emerged. Participants with higher control beliefs and higher susceptibility were also more adherent (between-person perspective). Within-person, similar findings emerged, additionally, distancing and loneliness were associated. Lagged findings suggest that better adherence to NPIs was associated with better mental health on subsequent days, whereas higher loneliness was associated with better subsequent hygiene adherence. CONCLUSIONS: Findings suggest no negative impact of NPI adherence on mental health or vice versa, but instead suggest that adherence might improve mental health symptoms. Control beliefs and risk perceptions are important covariates of adherence-both on between-person and within-person level.

Adhering to COVID protective behaviors might be less detrimental for mental health than some previous claims: Over 6 months in 2021­2022, adults from Germany who adhered to COVID protection recommendations (mask-wearing, hand hygiene, social distancing) on any one day reported better mental health the following days.

Combining Inserts With Warning Labels on Cigarette Packs to Promote Smoking Cessation: A 2-Week Randomized Trial.

BACKGROUND: Cigarette pack inserts with messages on cessation benefits and advice are a promising labeling policy that may help promote smoking cessation. PURPOSE: To assess insert effects, with and without accompanying pictorial health warning labels(HWLs), on hypothesized psychosocial and behavioral outcomes. METHODS: We conducted a 2 × 2 between-subject randomized trial (inserts with efficacy messages vs. no inserts; large pictorial HWLs vs. small text HWLs), with 367 adults who smoked at least 10 cigarettes a day. Participants received a 14-day supply of their preferred cigarettes with packs modified to reflect their experimental condition. Over 2 weeks, we surveyed participants approximately 4-5 times a day during their smoking sessions, querying feelings about smoking, level of worry about harms from smoking, self-efficacy to cut down on cigarettes, self-efficacy to quit, hopefulness about quitting, and motivation to quit. Each evening, participants reported their perceived susceptibility to smoking harms and, for the last 24 hr, their frequency of thinking about smoking harms and cessation benefits, conversations about smoking cessation or harms, and foregoing or stubbing out cigarettes before they finished smoking. Mixed-effects ordinal and logistic models were estimated to evaluate differences between groups. RESULTS: Participants whose packs included inserts were more likely than those whose packs did not include inserts to report foregoing or stubbing out of cigarettes (OR = 2.39, 95% CI = 1.36, 4.20). Otherwise, no statistically significant associations were found between labeling conditions and outcomes. CONCLUSIONS: This study provides some evidence, albeit limited, that pack inserts with efficacy messages can promote behaviors that predict smoking cessation attempts.

Cigarette pack inserts (small leaflets inside packs) with messages about quitting benefits and tips to quit may promote smoking cessation. We randomly assigned 367 adult smokers to one of four groups: control group with small health warning labels (HWLs) on the side of packs; inserts with cessation messages and small HWLs; large picture HWLs showing health effects from smoking; inserts and large picture HWLs. Participants received a 14-day supply of their preferred cigarettes in packs that reflected their assigned group. Over 2 weeks, we surveyed participants 4­5 times a day during times when they smoked, asking their feelings about smoking and smoking-related harms, confidence to reduce cigarettes and quit, hopefulness about quitting, and motivation to quit. Each evening, participants reported on the prior 24 hr: how often they thought about smoking harms and cessation benefits; conversations about smoking cessation or harms; and foregoing or stubbing out cigarettes before they finished smoking. People whose packs had inserts (with or without picture HWLs) were more likely than those whose packs did not include inserts (control group or picture HWLs only) to report foregoing or stubbing out of cigarettes. This study provides some evidence that inserts with cessation messages may promote smoking cessation.

Differential responses to cigarette package labeling alternatives among adults who smoke: Results from a randomized trial.

INTRODUCTION: Little experimental research has evaluated whether the effects of cigarette package inserts with efficacy messages and/or pictorial health warning labels (PHWLs) differ across key subgroups of adults who smoke. METHODS: Adults who reported currently smoking (n=367) were randomly assigned to one of four groups: small text-only health warning labels (HWLs) on pack sides (control); inserts with efficacy messages and small HWLs (inserts-only); PHWLs showing harms of smoking (PHWLs-only); both (inserts+PHWLs). Participants received a 14-day supply of cigarettes labeled to reflect their group. Every evening over two weeks, participants reported forgoing and stubbing out cigarettes before they finished smoking over the prior 24 hours, combined into a binary indicator of either behavior (e.g., forgoing/stubbing). Separate mixed-effects logistic models were estimated to evaluate moderation of labeling group contrasts (i.e., PHWLs vs not; inserts vs. not; inserts-only vs. inserts+PHWLs; PHWLs-only vs. inserts+PHWLs) by baseline covariates (self-efficacy to quit, intention to quit, education, health literacy, time discounting), predicting day-level forgoing/stubbing. RESULTS: Education moderated PHWL effects, with PHWLs predicting more forgoing/stubbing only among those with low education (OR=4.68, p<0.001). Time discounting moderated insert effects, with inserts promoting fogoing/stubbing only among those with low time discounting (i.e., lower impulsivity; OR=4.35, p<0.001). CONCLUSIONS: Inserts with efficacy messages appear effective mostly among people with low time discounting, whereas PHWLs appear most effective amongst those with low education, suggesting their potential to address education-related disparities. Labeling strategies appeared equally effective across subgroups defined by self-efficacy to quit, quit intention, and health literacy. Combining inserts with PHWLs did not appear to mitigate moderation effects. IMPLICATIONS: This randomized trial with adults who smoke suggests that cigarette packs with inserts describing cessation benefits and tips can promote cessation-related behaviors (i.e., forgoing or stubbing out cigarettes) among those with low time discounting (i.e., low impulsivity). Alternative interventions may be needed for people with high time discounting, as found in cessation trials. Pictorial health warning labels (PHWLs) appear most effective among those with low education, potentially addressing education-related disparities. No differential effects were found for those with different levels of self-efficacy to quit, quit intentions, or health literacy. Combining inserts and PHWLs may not be more effective than either alone.

Barriers to smoking interventions in community healthcare settings: a scoping review.

Smoking is one of the major causes of preventable death and is considered the greatest threat to global public health. While the prevalence of smoking has decreased, population growth has led to an increase in the absolute number of smokers. There are many proven smoking cessation interventions available to support smokers in their quit attempts. Most people who smoke, however, underutilize the treatments available to them. This scoping review aimed to identify the current barriers experienced by all stakeholders (smokers, service providers and policymakers) to existing evidence-based smoking cessation interventions in community healthcare settings. Five electronic databases (CINAHL, Ovid MEDLINE, PsycINFO, Scopus and Web of Science) were searched for relevant literature. A total of 40 eligible articles from different countries published between 2015 and 2022 were included in the review and content analysis carried out to identify the key barriers to smoking cessation interventions. Seven key themes were found to be common to all stakeholders: (i) literacy, (ii) competing demands and priorities, (iii) time, (iv) access to product, (v) access to service, (vi) workforce and (vii) motivation/readiness. These themes were mapped to the Capability, Opportunity, Motivation-Behaviour (COM-B) model. This study presents the effect the barriers within these themes have on current smoking cessation services and highlights priorities for future interventions.

A Pilot Randomised Trial Investigating the Effects of Including Efficacy Messaging on Tobacco Warning Labels.

INTRODUCTION: Smokers can respond defensively to health risk communication such as on-pack warning labels, potentially reducing their effectiveness. Theory suggests that risk perception together with self-efficacy reduces defensive responses and predicts target behaviors. Currently, tobacco warning labels globally predominantly target risk and do not explicitly consider efficacy. AIMS: This study explores the effectiveness of combining Australian tobacco warning labels with efficacy content to increase quitting intentions. METHODS: RCT in 83 smokers over 3 weeks. After a seven-day baseline phase (smoking from usual tobacco packaging), participants were randomized to one of two adhesive labels groups for the remaining 14 days: Standard health warning labels (HWLs) featuring enhanced efficacy messages (experimental group) or unmodified standard HWLs (control group). Participants attached these labels to their tobacco packaging and recorded their cognitions and smoking behavior once daily using Smartphones. Multilevel structural equation modeling was used to test theorized effects of the labels on self-efficacy, risk perception, and intentions to quit. RESULTS: There was no effect of exposure to efficacy messages on either self-efficacy, risk perceptions, or intentions to quit. However, self-efficacy and risk perceptions were positively associated with quitting intentions at the within-person level. CONCLUSIONS: The predictive relationships between self-efficacy, risk perception, and intention to quit were supported, however, supplementing standard warning labels with efficacy messages had no effect on these cognitions. Whether this is due to conditioned avoidance of HWLS, characteristics of the messages, or limitations imposed by format are unclear. IMPLICATIONS: Self-efficacy and risk perception predict intentions to quit smoking. Adding efficacy content to tobacco health warnings may have the potential to bolster these cognitions but more research is required to determine the contexts in which this would be effective and who would be likely to benefit. The time course by which exposure to efficacy content might influence cessation self-efficacy and downstream quitting intentions also needs to be investigated.

A mixed-method study of perceptions of cigarette pack inserts among adult smokers from New York and South Carolina exposed as part of a randomized controlled trial.

While many countries require prominent pictorial health warning labels (PHWLs) on the outside of cigarette packs to communicate the harms of smoking, there is evidence that cigarette pack inserts that contain efficacy messages may enhance the effectiveness of PHWLs. The US Food and Drug Administration (FDA) has regulatory authority to communicate with smokers through inserts. While current labeling regulations do not require inclusion of inserts, the FDA could implement them in the future. This study assesses US smokers' perceptions of cigarette package inserts at the conclusion of a two-week randomized trial on cigarette labeling where half of participants were exposed to insert messages (two response-efficacy messages and two self-efficacy messages) in their packs. Participants (n = 359) completed a 30- to 60-min interview with both quantitative and qualitative assessments, including measures of recall and perceived message effectiveness (PME) for specific inserts. Correlates of recall and PME were estimated using mixed-effects regression models. Qualitative responses to PME items were analyzed using thematic analysis. Response-efficacy messages had higher PME and recall than self-efficacy messages. People had diverse responses to the inserts, including that they were positive, thought-provoking, and helpful. Reactions to and perceptions of the inserts indicate potential benefits of integrating efficacy messages into labeling policies.

Relationship between attentional bias and stimulus control: An observational study of real-world eating patterns.

BACKGROUND: Attentional bias towards food related stimuli has been proposed as a potential target for dieting intervention, however the evidence supporting a relationship between attentional bias and food intake is mixed. Theory holds that food related attentional bias should be positively associated with measures of stimulus-controlled eating, and that implicit processes such as impulsivity moderate this association. The aim of the present study was to examine whether the proposed relationship between food-related attentional bias and stimulus control exists, and whether it is moderated by impulsivity. METHOD: A community sample of 68 participants completed a food-related attentional bias task and impulsiveness scale during a laboratory visit, after which they recorded their real-world eating in real-time over 14 days using Ecological Momentary Assessment (EMA). During this time, participants also responded to 4-5 randomly timed assessments per day. Food outlet presence (e.g., fast food restaurants, cafes, corner stores etc.) was assessed during both eating and non-eating assessments. EMA data was then used to determine levels of stimulus controlled eating for each participant. FINDINGS: Substantial variation was seen in both our measure of both food-related attentional bias (Range: 33.9 to 80.0) and in the degree to which the participant's eating could be categorised as being under stimulus control (Range: 0.50 to 0.93). However, food-related attentional bias scores were not a significant independent predictor of stimulus control and nor was this relationship moderated by impulsivity. CONCLUSION: Contrary to theoretical predictions, we found no evidence that of an association between attentional bias, impulsivity, and stimulus control. More work is needed to better understand the implicit processes underlying eating behaviour in the real-world.

Assessing driving-relevant attentional impairment after a multiday drinking session: A two-phase pilot study.

BACKGROUND: The possibility of residual impairment of cognitive performance after multiday drinking sessions is particularly important given the potential for the deleterious effects of fatigue and hangover. This pilot study aimed to devise a methodology to compare sober performance on driving-relevant attentional tasks at the end of a 4-day music festival with performance at varying levels of the breath-alcohol curve. METHODS: Fifty-two participants completed selective and sustained attention tasks at a breath alcohol concentration (BrAC) of 0.00%, 0.05%, and 0.08% following acute dosing in a controlled laboratory setting. A subset of participants (n = 13) were then tested at the conclusion of a 4-day music festival at 0.00% BrAC, with task performance compared with laboratory results. RESULTS: During the laboratory phase, sustained attention was poorer at the 0.05% ascending timepoint only (compared to 0.00% BrAC). During the festival phase, participants made a greater number of errors on the selective attention task predeparture than at 0.00% and 0.05% BrAC in the laboratory. Sustained attention performance was poorer while intoxicated in the laboratory. CONCLUSIONS: Our findings suggest that the absence of blood alcohol acutely may not be indicative of unimpaired cognitive performance and that other factors related to multiday drinking may produce driving-related attentional deficits. The findings reinforce the need to measure attentional performance in real-world drinking contexts despite the methodological complexities of doing so. A larger study is warranted to replicate the findings and should include attentional measures that either are more sensitive to the effects of acute alcohol intoxication than those in our study or are based on a driving simulator.

Design of Financial Incentive Programs for Smoking Cessation: A Discrete Choice Experiment.

INTRODUCTION: Financial incentive programs promote smoking cessation. However, the incentive amount which should be provided-and how this may interact with other program characteristics-is unknown. The objective of this study was to evaluate the influence of the design of incentive programs for smoking cessation on current smokers' perceptions of programs and willingness to enroll. METHOD: An online discrete choice experiment was conducted amongst adult current smokers residing in the United Kingdom (N = 430). Hypothetical incentive programs were described using five attributes (incentive amount, incentive type, frequency of sessions, reward schedules, program location). Participants responded to a series of choice sets comprised of two hypothetical programs. For each set, participants selected their preferred program. They then specified whether they would enroll in their preferred program if it were available. Analyses also considered the effect of participant income on preferences. RESULTS: Overall, participants preferred higher amounts over lower amounts, cash over vouchers, healthcare settings over workplaces, and consistent amounts over an escalating schedule. One session per week was the most preferred session frequency. Willingness to enroll increased quadratically with the incentive amount, although this increase slowed for higher amounts. Although middle- and high-income smokers preferred slightly higher amounts (cf. low-income participants), enrollment choices did not differ by income. CONCLUSION: The characteristics of incentive programs influence smokers' perceptions of programs and willingness to enroll. Higher amounts may encourage greater enrollment rates, but there will likely be a ceiling point beyond which increasing the incentive amount does not meaningfully increase enrollments. IMPLICATIONS: There is increasing evidence incentive programs aid smoking cessation. Yet, the variety in previous program designs means how to best structure programs, including optimal incentive amount and the impact of the design on potential enrollment rates, remains unclear. This study suggests enrollments may be highest when incentive amounts are higher, rewards of a consistent amount in cash are provided, and sessions occur once per week in a healthcare setting. Although higher-income participants may desire higher incentive amounts compared to lower-income participants, this may not translate into differences in willingness to enroll.

Smokers' Perceptions of Incentivized Smoking Cessation Programs: Examining How Payment Thresholds Change With Income.

INTRODUCTION: Studies demonstrate that financial incentive programs increase smoking cessation. However, there is little guidance on which incentive magnitudes will ensure optimal enrollment and motivation levels. This study investigates current smokers' perceptions of varying incentive magnitudes to identify whether there is evidence for optimal amount(s) and whether perceptions differ by income group. METHODS: Studies 1 (N = 56) and 2 (N = 147) were conducted online via Prolific.co. Current smokers were randomly shown multiple hypothetical incentive programs that differed only in the incentive amount offered. For each program, smokers rated its appeal and their likelihood of enrolling and predicted their motivation to quit if enrolled. Growth models were used to investigate the relationship between perspectives and the incentive amount. RESULTS: An increasing quadratic trend in smokers' perceptions of programs as the incentive amount increased was identified. Incentive amounts beyond approximately £50-75 per week (£500-£750 total) did not significantly alter perceptions of programs. In Study 2, high-income smokers found programs significantly less appealing and motivating than low-income smokers, although no significant between-group differences were observed in the likelihood of enrollment. No significant differences were observed between low- and middle-income smokers. CONCLUSIONS: Increasing the incentive amount increased smoker's perceptions of programs. This relationship was curvilinear, meaning there may be a point beyond which further increasing the amount will not improve enrollment or motivation levels. Incentives appear equally appealing to low- and middle-income smokers; the population among whom smoking is most prevalent. Future research could explore other elements of program design and whether findings hold under real-world conditions. IMPLICATIONS: While acknowledging that they work, policymakers frequently request information about the monetary amount needed for incentive programs to be effective, and if this differs by income level. We investigated these questions using smokers' perceptions of hypothetical cessation programs that differed in the amount offered. An increasing quadratic trend in perceptions of programs by the amount and potential cut points was observed, suggesting a point may exist beyond which increasing the incentive will not improve perceptions of programs or enrollment levels. High-income smokers may not perceive incentives to be as appealing as other income groups, but appear equally willing to enroll.

Trends in Social Norms Towards Smoking Between 2002 and 2015 Among Daily Smokers: Findings From the International Tobacco Control Four Country Survey (ITC 4C).

OBJECTIVE: To assess trends in daily smokers' social norms and opinions of smoking between 2002 and 2015 in Canada, the United States, the United Kingdom, and Australia. METHOD: Data were from wave 1 (2002) to wave 9 (2013-2015) of the longitudinal International Tobacco Control Four Country Survey (Canada, the United States, the United Kingdom, Australia), involving 23 831 adult daily smokers. Generalized estimating equation logistic regression models, adjusted for demographics and survey design effects, assessed associations of wave and country with outcomes: (A) over half of five closest friends smoke, (B) agreeing that people important to you believe you should not smoke, (C) agreeing that society disapproves of smoking, and (D) negative opinion of smoking. RESULTS: Between 2002 and 2015, adjusting for covariates, (A) over half of five closest friends smoke did not change (56% vs. 55%; adjusted odds ratio [AOR] = 0.95 [95% Confidence Interval = 0.85-1.07]), (B) agreeing that people important to you believe you should not smoke generally decreased (89% vs. 82%; AOR = 0.54 [0.46-0.64]) despite an increase around 2006-2007, (C) agreeing that society disapproves of smoking increased between 2002 and 2006-2007 (83% vs. 87%; AOR = 1.38 [1.24-1.54]) then decreased until 2013-2015 (78%; AOR = 0.74 [0.63-0.88]), and (D) negative opinion of smoking decreased between 2002 and 2010-2011 (54% vs. 49%; AOR = 0.83 [0.75-0.91]) despite an increase around 2005-2006 and at the final wave (2013-2015). Except friend smoking, Canada had the greatest, and the United Kingdom the lowest, antismoking social norms and opinions. CONCLUSIONS: Except friend smoking and opinion of smoking, daily smokers' social norms became less antismoking between 2002 and 2015 despite increases around 2006-2007. Several potential explanations are discussed yet remain undetermined. IMPLICATIONS: Increasingly comprehensive tobacco control policies alongside decreasing smoking prevalence in Canada, the United States, the United Kingdom, and Australia have led to the assumption that smoking has become denormalized in these countries. Absent from the literature is any formal assessment of social norms towards smoking over time. Contrary to our hypotheses, this study found that the injunctive social norms of daily smokers became less antismoking between 2002 and 2015, despite increases around 2006-2007. There was no change over time in the proportion of daily smokers who report that over half of their five closest friends smoke.

Cigarette smokers' concurrent use of smokeless tobacco: dual use patterns and nicotine exposure.

BACKGROUND: The concurrent use of cigarettes with other tobacco products, such as smokeless tobacco (SLT), is increasingly common. Extant work with cigarette smokers who also use SLT is based heavily on retrospective reports and between-group comparisons. The purpose of this study was to assess prospectively the patterns of dual users' product use and nicotine exposure on days when cigarettes were smoked exclusively (single use) versus concurrently with SLT (dual use). DESIGN: Forty-six dual cigarette-SLT users recorded their product use in real time via ecological momentary assessment for a 2-week longitudinal design. They responded to questions about situational factors (eg, location, mood) using this same diary, and collected saliva samples each night for later cotinine measurement. At the end of this 2-week period, users reported on their reasons for and beliefs about SLT use. RESULTS: Cotinine levels were significantly higher on dual versus single use days (mean±SEM=374.48±41.08 ng/mL vs 300.17±28.13 ng/mL, respectively; p<0.01), and the number of cigarettes logged was higher on dual versus single use days (11.13±0.98 vs 9.13±1.11, respectively; p<0.01). Product use was distinguished by situational factors, with the strongest predictor being location of use. Moreover, the most common reason for initiating (56.52%) and continuing (67.39%) SLT use was to circumvent indoor smoking restrictions. CONCLUSIONS: Results support the idea of product supplementation rather than replacement among this convenience sample of dual users. For smokers whose primary motivation for SLT use involves situations where they would otherwise be tobacco free, the potential benefits of clean indoor air laws may be diminished.

Effect of Cytisine vs Varenicline on Smoking Cessation: A Randomized Clinical Trial.

Importance: Cytisine is more effective than placebo and nicotine replacement therapy for smoking cessation. However, cytisine has not been tested against the most effective smoking cessation medication, varenicline, which is associated with adverse events known to lead to discontinuation of therapy. Objective: To examine whether standard cytisine treatment (25 days) was at least as effective as standard varenicline treatment (84 days) for smoking cessation. Design, Setting, and Participants: This noninferiority, open-label randomized clinical trial with allocation concealment and blinded outcome assessment was undertaken in Australia from November 2017 through May 2019; follow-up was completed in January 2020. A total of 1452 Australian adult daily smokers willing to make a quit attempt were included. Data collection was conducted primarily by computer-assisted telephone interview, but there was an in-person visit to validate the primary outcome. Interventions: Treatments were provided in accordance with the manufacturers' recommended dosage: cytisine (n = 725), 1.5-mg capsules taken 6 times daily initially then gradually reduced over the 25-day course; varenicline (n = 727), 0.5-mg tablets titrated to 1 mg twice daily for 84 days (12 weeks). All participants were offered referral to standard telephone behavioral support. Main Outcomes and Measures: The primary outcome was 6-month continuous abstinence verified using a carbon monoxide breath test at 7-month follow-up. The noninferiority margin was set at 5% and the 1-sided significance threshold was set at .025. Results: Among 1452 participants who were randomized (mean [SD] age, 42.9 [12.7] years; 742 [51.1%] women), 1108 (76.3%) completed the trial. Verified 6-month continuous abstinence rates were 11.7% for the cytisine group and 13.3% for the varenicline group (risk difference, -1.62% [1-sided 97.5% CI, -5.02% to ∞]; P = .03 for noninferiority). Self-reported adverse events occurred less frequently in the cytisine group (997 events among 482 participants) compared with the varenicline group (1206 events among 510 participants) and the incident rate ratio was 0.88 (95% CI, 0.81 to 0.95; P = .002). Conclusions and Relevance: Among daily smokers willing to quit, cytisine treatment for 25 days, compared with varenicline treatment for 84 days, failed to demonstrate noninferiority regarding smoking cessation. Trial Registration: anzctr.org.au Identifier: ACTRN12616001654448.

Incentives for smoking cessation in a rural pharmacy setting: The Tobacco Free Communities program.

OBJECTIVE: Investigate the smoking-related outcomes and feasibility of a pharmacy-led financial incentive program for smoking cessation. DESIGN: Multi-site single-arm trial of the Tobacco Free Communities program. SETTING: Community pharmacies within the Glamorgan Spring Bay (Site 1) and George Town (Site 2) municipalities of Tasmania. PARTICIPANTS: Adult smokers. Based on funding, the recruitment target was 76 smokers. INTERVENTIONS: Pharmacy staff provided quitting advice through 7 sessions over 3 months. At 6 sessions, abstinent participants (no cigarettes in the previous week and expired carbon monoxide ≤4 ppm) were rewarded with AU$50 vouchers. MAIN OUTCOME MEASURES: Smoking-related outcomes were decreased smoking (self-reported cigarettes per day and carbon monoxide levels) and abstinence rates. Feasibility outcomes were meeting the recruitment target, participant retention and participants' views of the program (measured by interview data from Site 2). RESULTS: Ninety individuals enrolled. Sixty-two participants were included in analyses; remaining participants were excluded from analyses because they did not consent to use of their data within this study or had carbon monoxide ≤4 ppm at enrolment. Smoking (carbon monoxide and cigarettes per day) significantly decreased between enrolment and the first financial incentive session. Twelve participants (19.35%) were abstinent at the end of the program. Yet retention was poor; only 13 participants (20.97%) attended all sessions. Interviews suggested participants found the program beneficial. CONCLUSIONS: Providing financial incentive within rural community pharmacies could be a viable method of encouraging smoking reductions and quit attempts. Additional work is needed to increase retention and compare effects to usual care pharmacy practices.

Using Nicotine Gum to Assist Nondaily Smokers in Quitting: A Randomized Clinical Trial.

INTRODUCTION: Non-daily intermittent smokers (ITS) comprise 30% of US adult smokers. ITS smoke for nicotine and have trouble quitting, but tend to smoke in particular situations. This study tested the effect of nicotine gum, used to prevent or react to situational temptations, for helping ITS quit. METHODS: ITS (smoking 4-27 days/month) seeking help quitting were randomized to 2 mg nicotine gum (n = 181) or placebo (n = 188), to be used to anticipate or react to temptations to smoke, for 8 weeks. Participants received up to six sessions of behavioral counseling. The primary outcome was 6-month biochemically verified continuous abstinence; analyses also examined 14-day point-prevalence abstinence at multiple time points, and used event-history analyses to assess progression to abstinence, lapsing, and relapsing. Analyses adjusted for group differences in age and baseline smoking, and considered several potential moderators of treatment effects. RESULTS: Nicotine gum did not significantly improve outcomes on any measure. Biochemically verified 6-month continuous abstinence rates were 7.2% for active gum and 5.3% for placebo (AOR = 1.39, 0.58-3.29, p > .25). ITS with any degree of dependence (Fagerstrom Test of Nicotine Dependence scores >0) showed poorer outcomes on multiple endpoints, and did more poorly on active gum on some outcomes. Gum use was low, starting at 1 gum per day on average and declining over time. CONCLUSIONS: Nicotine gum (2 mg), used intermittently, did not improve cessation rates among ITS, including those demonstrating some degree of dependence. IMPLICATIONS: Nicotine replacement has been extensively tested with daily smokers, especially those who smoke relatively heavily. Nondaily smoking is now common, creating a need for treatment for ITS. Despite evidence that ITS' smoking is motivated by nicotine-seeking, a theoretically and empirically derived situational approach to using acute nicotine replacement was not successful at helping ITS quit. Gum use was low; whether higher or more frequent dosing is needed, or whether an entirely different approach is needed, is not clear. Effective treatment options are needed for ITS, especially those with some degree of dependence.

Body Mass Index and stimulus control: Results from a real-world study of eating behaviour.

BACKGROUND: Evidence suggests decisions about when, what, and how much to eat can be influenced by external (location, food outlet presence, food availability) and internal (affect) cues. Although the relationship between stimulus control and obesity is debated, it is suggested that individuals with higher BMIs are more driven by cues to eating than individuals in the healthy-weight range (HWR). This study investigates the influence of stimulus control on real-world food intake, and whether stimulus control differs by BMI. It was hypothesised that, compared to those in the HWR, eating among individuals with higher BMIs would be under greater stimulus control. METHOD: 74 participants (n = 34 BMI < 24.9, n = 40 BMI > 24.9) recorded food intake for 14 days using Ecological Momentary Assessment. Participants also responded to 4-5 randomly-timed assessments per day. Known external and internal eating cues were assessed during both assessment types. Within-person logistic regression analyses were used to predict eating vs. non-eating occasions from stimulus control domains. FINDINGS: Results support the hypothesis that eating was influenced by stimulus control: food availability, affect, time of day, and location significantly distinguished between eating and non-eating instances (AUC-ROC = 0.56-0.69, all p's < 0.001). The presence of food outlets was significantly better at distinguishing between eating and non-eating instances for those with higher BMIs (compared to individuals in the HWR). DISCUSSION: Results support the notion of stimulus control in shaping eating decisions. Differences in levels of stimulus control between participants in the HWR compared to those with a high BMI suggest that dietary improvement interventions may be more effective when they are tailored to the individual and consider environmental influences on eating behaviour.

Daily stress as link between disadvantage and smoking: an ecological momentary assessment study.

BACKGROUND: There is a well-established social gradient in smoking, but little is known about the underlying behavioral mechanisms. Here, we take a social-ecological perspective by examining daily stress experience as a process linking social disadvantage to smoking behavior. METHOD: A sample of 194 daily smokers, who were not attempting to quit, recorded their smoking and information about situational and contextual factors for three weeks using an electronic diary. We tested whether socioeconomic disadvantage (indicated by educational attainment, income and race) exerts indirect effects on smoking (cigarettes per day) via daily stress. Stress experience was assessed at the end of each day using Ecological Momentary Assessment methods. Data were analyzed using random effects regression with a lower-level (2-1-1) mediation model. RESULTS: On the within-person level lower educated and African American smokers reported significantly more daily stress across the monitoring period, which in turn was associated with more smoking. This resulted in a small significant indirect effect of daily stress experience on social disadvantage and smoking when using education and race as indicator for social disadvantage. No such effects were found when for income as indicator for social disadvantage. CONCLUSION: These findings highlight the potential for future studies investigating behavioral mechanisms underlying smoking disparities. Such information would aid in the development and improvement of interventions to reduce social inequality in smoking rates and smoking rates in general.

Effects of Pictorial Warning Labels for Cigarettes and Quit-Efficacy on Emotional Responses, Smoking Satisfaction, and Cigarette Consumption.

Background: Experimental research on pictorial warning labels for cigarettes has primarily examined immediate intentions to quit. Purpose: Here, we present the results of a clinical trial testing the impact on smoking during and after a 28-day period of naturalistic exposure to pictorial versus text-only warnings. Methods: Daily cigarette smokers (N = 244) at two sites in the USA were randomly assigned to receive their regular brand of cigarettes for 4 weeks with one of three warnings: (a) text-only, (b) pictures and text as proposed by FDA, or (c) the warnings proposed by FDA with additional text that elaborated on the risks of smoking. Analyses examined the effects of pictorial versus text-only warnings and self-efficacy for quitting on cigarette consumption during and 1 month after the trial as mediated by emotional and cognitive responses as well as satisfaction with smoking. Results: Stronger emotional responses to pictorial than text-only warnings predicted reduced satisfaction with smoking during the trial and lower cigarette consumption at follow-up among the majority of smokers who continued to smoke. Consistent with the efficacy-desire model, those with moderate efficacy reported the greatest reduction in consumption at follow-up. However, a small proportion of smokers (7%) who reported 7-day abstinence at follow-up did not exhibit a significant relation with self-efficacy. Conclusions: Pictorial warning labels proposed by FDA create unfavorable emotional reactions to smoking that predict reduced cigarette use compared to text alone, with even smokers low in self-efficacy exhibiting some reduction. Predictions that low self-efficacy smokers will respond unfavorably to warnings were not supported.

Using the Severity of Dependence Scale to screen for DSM-5 khat use disorder.

OBJECTIVE: This study aimed to determine the efficacy of the Severity of Dependence Scale (SDS) as a screening tool for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-defined khat use disorder. METHODS: Cross-sectional, purposive sample of past-year khat consumers aged 16 and above were recruited from khat markets and cafes from university and general community in Adama, Ethiopia. Participants self-completed a survey comprising current substance use disorder. RESULTS: The SDS formed a unifactorial structure, consistent with the dependence construct. Almost three quarters (73%) of the sample were identified as experiencing Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition khat use disorder. The SDS demonstrated excellent discrimination (area under the curve = 0.92) and an optimal cut-off as a score of 3 or greater, with sensitivity of 81% and specificity of 96%. This classification validly identified a group with more frequent and higher dose khat use than participants that did not screen positive. CONCLUSION: Although khat is a mild stimulant, there is clear evidence that some consumers are both concerned with their use and experience problems associated with their use. Consistent with its application for other drugs, the SDS is a brief and simple screening tool that appears to validly identify individuals experiencing a khat use disorder syndrome and experiencing high rates of adverse consequences in association with use.

Profile of Maternal Smokers Who Quit During Pregnancy: A Population-Based Cohort Study of Tasmanian Women, 2011-2013.

INTRODUCTION: Smoking remains the single-most significant preventable cause of poor pregnancy outcomes, yet around 12% of Australian women smoke during pregnancy. Many women are motivated to quit when they find out they are pregnant, yet few are successful. While previous studies have examined the profile of the maternal smoker compared to her nonsmoking counterpart (Aim 1), little is known about what differentiates women who quit during pregnancy to those who do not (Aim 2). Here, we present results from a study investigating the characteristics of women who were able to quit during pregnancy. METHODS: Data were drawn from the Tasmanian Population Health database of women who had received antenatal care between 2011 and 2013 (n = 14300). Data collected included age, relationship status and ethnicity of expectant mothers, antenatal details, mental health conditions, and drug use. Independent samples t tests were used to compare differences between women who had, and those who had not, quit during pregnancy. The 19.4% of women who self-reported as smoking in the first half (first 20 weeks) of their pregnancy were further grouped and analyzed comparing those who reported still smoking in the second half of their pregnancy (smokers: n = 2570, 92.4%) to those who quit (quitters: n = 211, 7.6%). RESULTS: Quitters (57.8%) were more likely to be in a relationship than their non-quitting counterparts (49.6%, p = .022) and were less likely to suffer from postnatal depression (2.4% vs. 6.0%, p = .029). No other differences between quitters and smokers were observed. CONCLUSIONS: Determining the profile of women who are able to quit during pregnancy may be important to improve the relatively poor cessation rates among maternal smokers and may assist in more effectively targeting at-risk women. IMPLICATIONS: Smoking cessation interventions have traditionally targeted socially disadvantaged women, for good reason: the majority of smoking pregnant women fall into this category. However, despite the significant attention and resources dedicated to antenatal smoking cessation interventions, most are ineffective with only 7.6% of the present sample quitting smoking during pregnancy. This paper may assist in developing more effective antenatal smoking cessation interventions by more clearly describing the profile of maternal smokers who successfully quit during pregnancy. Specifically, this paper highlights the need to acknowledge and address women's relationship status and mental health in order to promote smoking cessation in pregnancy.