A growing geographic disparity: Rural and urban cigarette smoking trends in the United States.

Rural areas of the United States have a higher smoking prevalence than urban areas. However, no recent studies have rigorously examined potential changes in this disparity over time or whether the disparity can be explained by demographic or psychosocial characteristics associated with smoking. The present study used yearly cross sectional data from the National Survey on Drug Use and Health from 2007 through 2014 to examine cigarette smoking trends in rural versus urban areas of the United States. The analytic sample included 303,311 respondents. Two regression models were built to examine (a) unadjusted rural and urban trends in prevalence of current smoking and (b) whether differences remained after adjusting for demographic and psychosocial characteristics. Results of the unadjusted model showed disparate and diverging cigarette use trends during the 8-year time period. The adjusted model also showed diverging trends, initially with no or small differences that became more pronounced across the 8-year period. We conclude that differences reported in earlier studies may be explained by differences in rural versus urban demographic and psychosocial risk factors, while more recent and growing disparities appear to be related to other factors. These emergent differences may be attributable to policy-level tobacco control and regulatory factors that disproportionately benefit urban areas such as enforcement of regulations around the sale and marketing of tobacco products and treatment availability. Strong federal policies and targeted or tailored interventions may be important to expanding tobacco control and regulatory benefits to vulnerable populations including rural Americans.

Treatment adherence in a lay health adviser intervention to treat tobacco dependence.

Lay health advisers (LHAs) are increasingly used to deliver tobacco dependence treatment, especially with low-socioeconomic status (SES) populations. More information is needed about treatment adherence to help interpret mixed evidence of LHA intervention effectiveness. This study examined adherence to behavioral counseling and nicotine patches in an LHA intervention with 147 Ohio Appalachian female daily smokers. Participants were randomly selected from clinics and randomized to the intervention condition of a randomized controlled trial. Overall, 75.5% of participants received all seven planned LHA visits, 29.3% used patches for >7 weeks and approximately half received high average ratings on participant responsiveness. Depressive symptoms and low nicotine dependence were associated with lower patch adherence while high poverty-to-income ratio was associated with high responsiveness. Compared with those with fewer visits, participants who received all visits were more likely to be abstinent (22.5 versus 2.8%, P=0.026) or have attempted quitting (85.0 versus 47.4%, P=0.009) at 3 months. High participant responsiveness was associated with 12-month abstinence. LHA interventions should focus on improving adherence to nicotine patches and managing depression because it is an independent risk factor for low adherence.

Cigarette and waterpipe smoking associated knowledge and behaviour among medical students in Lebanon.

As future physicians capable of controlling tobacco dependence in the population, medical students are considered a main target for tobacco control interventions. This cross-sectional study reported on the prevalence of tobacco use (cigarettes and waterpipes) and associated knowledge and behaviour among 6th-year medical students in 2009-2010 from 6 medical schools in Lebanon. The self-administered questionnaire based on the Global Health Professional Survey (GHPSS) core questions also enquired about training in tobacco cessation approaches. All enrolled students were asked to participate; the response rate was 191/354 (54.3%). The prevalence of tobacco use was 26.3% for cigarettes and 29.5% for waterpipes. Smoking waterpipes was the only significant predictor for cigarette smoking and there was no difference by sex and socioeconomic status. A minority reported ever receiving any formal training in treatment approaches for tobacco dependence. Medical schools should include tobacco dependence treatment training programmes in their curriculum and discourage tobacco use.

Regional Rural-Urban Differences in E-Cigarette Use and Reasons for Use in the United States.

PURPOSE: To determine whether there are rural/urban differences in e-cigarette use and reasons for use that vary across the 10 Health & Human Services (HHS) regions. METHODS: Age-adjusted bivariate and multivariable analyses were conducted for n = 225,413 respondents to the 2014-2015 Tobacco Use Supplement-Current Population Survey to estimate the prevalence of e-cigarette use. Reasons for e-cigarette use were collected from n = 16,023 self-respondents who reported ever using e-cigarettes. FINDINGS: While nationally rural residents appeared more likely to use e-cigarettes, adjusted results indicated that current e-cigarette use was significantly less likely across the northern and western regions (New England, East North Central, Heartland, North Central Mountain, Northwest, and Southwest Pacific regions). Reasons for e-cigarette use differed by urban/rural status and region; for example, the rationale to use e-cigarettes as a smoking cessation aid was significantly more common among rural compared to urban adults in the New England and New York/New Jersey regions, but less common in the Southeast. CONCLUSIONS: For several regions, there were no significant rural/urban differences in e-cigarette use and reasons for use. Yet those regions that present differences face the need to develop public health approaches to minimize urban/rural disparities in health education, services, and outcomes related to tobacco use, particularly where access to health care is limited. Public health campaigns and guidance for clinical care within HHS regions should be tailored to reflect regional differences in beliefs about e-cigarettes.

Tobacco policy in American prisons, 2007.

OBJECTIVE: To examine current tobacco policy in US prisons and explore changes in prison tobacco policies over time. DATA SOURCE: Telephone survey of the 52 US departments of correction. MAIN OUTCOME MEASURES: Current tobacco policy; distribution of free tobacco; availability of smoking cessation programming and cessation aids. PARTICIPANTS: Complete responses were received from 51 of 52 (98%) departments, while one provided partial information. RESULTS: The majority of correctional systems (60%) reported total tobacco bans on prison grounds, with most remaining facilities (27%) having an indoor ban on tobacco use. No prisons distributed free tobacco. No major violence was reported relating to the implementation of stricter tobacco policies; however many respondents noted that tobacco became a major contraband item following the implementation of a total ban. While most prison systems with an indoor tobacco ban (86%) reported having tobacco cessation programmes, few of those with total bans (39%) continued such programmes after the initial transition period. CONCLUSION: Total tobacco bans have often been accompanied by the termination of tobacco cessation programmes. Such actions undermine efforts to promote long-term cessation resulting in a missed public health opportunity.

Smoking behavior, dysphoric states and the menstrual cycle: results from single smoking sessions and the natural environment.

A 2-way factorial repeated measures design examined the effects of menstrual cycle phase and smoking on: 1) smoking behavior, 2) mood state, 3) nicotine withdrawal symptomatology, and 4) menstrual symptomatology. Female smokers, aged 20-39, were followed for two consecutive menstrual cycles with two data collection sessions per cycle, which were conducted in the University's General Clinical Research Center (GCRC). Participants were randomly assigned to order of smoking condition, which included: 1) smoking ad libitum, and 2) 24-hour abstinence prior to data collection. Data were collected in the mid-to-late follicular (MLF) phase (between days 6 through to 11) and the four days prior to menses in late luteal (LL) phase. Participants completed the Profile of Mood States and Menstrual Symptom Severity List and recorded daily cigarette smoking rate in the natural environment during MLF and LL phases. Nicotine boost and carbon monoxide (CO) boost were measured and the Shiffman-Jarvick Tobacco Withdrawal Questionnaire was administered during GCRC data collection sessions. Results indicated that subjects smoked more cigarettes per day during the LL phase and CO boost was greater during MLF. No difference was noted in nicotine boost by condition or phase. No difference in mood state was noted by either condition or phase. Withdrawal symptomatology and craving for cigarettes were increased after 24 hours of abstinence. No difference was noted in menstrual symptoms by condition or phase. Further investigations are still needed to characterize the importance of cycle phase in the design of smoking cessation interventions for women of reproductive age.

Naltrexone administration affects ad libitum smoking behavior.

Endogenous opioid peptides have been implicated in the reinforcement of smoking and opioid antagonists have been examined to determine their role in smoking behavior. To date, the relationship between smoking behavior and chronic opiate antagonist administration during ad libitum smoking has not been investigated. The purpose of this study was to examine the relationships between naltrexone, an opiate antagonist administered orally, and smoking behavior and mood states during ad libitum smoking. A repeated measures experimental design was used. Normal adult male and female volunteers, admitted to the Clinical Research Center, were randomly assigned to naltrexone-treated (n = 22) or placebo-control (n = 21) groups in a double-blind manner. Day 1 was considered acclimation to the unit and day 2 was baseline, or pre-drug administration. On days 3, 4, and 5, subjects received 50 mg naltrexone or a placebo at 0700 and 1600 hours. Plasma nicotine and expired air carbon monoxide levels were measured daily at 1900 hours. Number of cigarettes smoked, mood states, withdrawal symptomatology and self-reported satisfaction with smoking were also quantified daily. Results indicated that plasma nicotine levels (P = 0.005), number of cigarettes smoked daily (P = 0.003) and self-reported satisfaction with smoking (P = 0.043) were significantly lower among those treated with naltrexone, compared to the placebo-control group. Expired air carbon monoxide levels did not differ between the two groups. In addition, mood states and withdrawal symptoms did not differ between groups. These findings suggest that endogenous opioid peptides influence specific smoking behavior variables.

Plasma nicotine, plasma beta-endorphin and mood states during periods of chronic smoking, abstinence and nicotine replacement.

Nicotine is known to release neuroendocrine substances which may subsequently reinforce smoking behavior by improving mood states. The purpose of this study was to examine changes in plasma beta-endorphin and mood states during periods of chronic smoking, abstinence from smoking, and abstinence while chewing nicotine gum. A modified A-B-A-C design was used. Normal male volunteers were randomly assigned to an experimental or control group. Over a 12-day protocol, experimental subjects smoked ad libitum for 2 days, were abstinent for 4 days, resumed smoking for 2 days, and then chewed nicotine gum for the final 4 days. Control subjects smoked ad libitum throughout the entire protocol. Results indicated that changes in plasma beta-endorphin levels were not related to changes in the four smoking conditions. Plasma nicotine and mood states were related, such that dysphoric moods increased during abstinence from smoking in comparison to the control group. To investigate further the relationships between nicotine, beta-endorphin and reinforcement for smoking, it may be necessary to characterize endogenous opioid peptide release in the central nervous system during smoking.

The effect of chronic administration of nicotine on antinociception, opioid receptor binding and met-enkelphalin levels in rats.

The effect of chronic nicotine administration on (1) antinociception; (2) opioid receptor binding; and (3) met-enkelphalin levels in discrete brain regions in rats was investigated. Male and female Sprague-Dawley rats were treated with nicotine 0.3 mg/kg, 0.1 mg/kg, or saline three times a day subcutaneously during a 14-day protocol. Antinociception was measured by hotplate (HP) test on days 1, 2, 7, 10 and 14. After completion of the protocol, mu-opioid receptors were analyzed by [3H]-DAMGO binding studies and met-enkelphalin levels were determined by radioimmunoassay. Results indicated that hot-plate latency increased during the first 2 days of nicotine administration for male and female rats who were treated with 0.3 mg/kg nicotine. There was an up-regulation of mu-receptors (increased Bmax) in the striatum of rats treated with 0.3 mg/kg nicotine, compared to 0. 1 mg/kg nicotine and saline groups. An interaction effect of group by gender was noted. After 14 days of chronic nicotine administration, met-enkelphalin levels were significantly lower in striatum and midbrain of animals treated with 0.3 mg/kg nicotine, as compared to controls. These results suggest that chronic nicotine administration, in doses representative of human smoking, produces antinociception initially, and is accompanied by an upregulation of micro-opioid receptors in the striatum of rats. In addition, nicotine-induced tolerance to antinociception may be associated with a decrease in met-enkelphalin level over a period of time.

Gender differences in tobacco use.

Gender differences in overall tobacco use clearly exist. In general, men are more likely to use tobacco products than are women. However, this simple generalization, ignoring type of tobacco products, time, and culture, masks many more interesting gender differences in tobacco use. There are pronounced gender differences in tobacco use of specific tobacco products within some cultures but not others. Yet these differences have changed across time, including narrowing and widening of this gender gap, depending on culture and tobacco product. This article addresses these issues and presents possible psychosocial, biological, and psychobiological explanations for these phenomena. In addition, the implications of these differences and ways to learn more about these important differences are discussed.

The role of postcessation factors in tobacco abstinence: stressful events and coping responses.

Postcessation factors of stressful events and coping responses used when tempted to smoke, were examined to determine their contribution to relapse among ex-smokers. Subjects from smoking cessation clinics (N = 150) were contacted at three months after quitting. Questionnaires that measured: (a) current smoking behavior, (b) stressful events that occurred since quitting, and (c) coping responses used when tempted to smoke, were administered. Results indicated that abstinent subjects reported fewer work-related stressful events than both partially or totally relapsed subjects. Abstinent subjects used more problem-focused coping responses and fewer emotion-focused coping responses than partially and totally relapsed subjects. It was concluded that work-related stressful events, as well as the use of problem-focused coping responses when tempted to smoke, play important roles in determining smoking behavior during the immediate postcessation period.

Processes of change across five stages of smoking cessation.

A cross-sectional design with 190 smokers and exsmokers selected by random digit dialing was used to determine differences in processes individuals use to modify behavior across five stages of smoking cessation. Five stages of cessation are: precontemplation, contemplation, recent quitting, long-term quitting, and relapse. Ten processes of change (POC) or ways individuals modify behavior were assessed. Examples of POCs are: consciousness raising, self-liberation, reinforcement management, and stimulus control. Biochemical validation of smoking abstinence was performed on a random subset of exsmoker subjects. Individuals in five stages of smoking cessation used processes of change differently as reflected by a significant MANOVA, F (40,590) = 5.02, p = .0001. It is important to assess an individual's stage of smoking cessation when planning interventions related to POCs.

Evaluation of a mass media community smoking cessation campaign.

The effectiveness of a smoking cessation campaign that included both printed and televised materials was evaluated in registrant and randomly acquired samples of smokers during the first month postcampaign and again at 3 months. Registrant and random samples differed on several sociodemographic variables. Registrants had much higher rates of abstinence at both times compared to the randomly acquired group. Nicotine gum replacement was used more frequently among the registrant group. Fifteen percent of registrants who had not attempted to quit at Time 1 were abstinent 3 months postcampaign. Registering to participate in print and televised cessation programs may be related to a change in smoking behavior.

A smoking cessation intervention with hospitalized surgical cancer patients: a pilot study.

The purpose of this pilot study was to examine the effect of a structured smoking cessation intervention during hospitalization on short-term smoking abstinence. Hospitalized surgical oncology patients who smoked (n = 26) and were diagnosed with cancer were randomly assigned to either an experimental or control group. Experimental group subjects (n = 12) received a structured smoking cessation intervention during hospitalization followed by five weekly phone calls after discharge. Control group subjects (n = 14) received usual care from their health-care providers during hospitalization. Abstinence from smoking, as determined by saliva cotinine, the primary metabolite of nicotine, was measured at first postdischarge visit. Subjects with a saliva cotinine level of < 10 ng/ml were classified as abstinent. At first postdischarge visit, 75% of experimental group subjects were abstinent compared with 42.9% in the usual care group, a 32% difference. These preliminary findings will assist in the design and further evaluation of cancer rehabilitation strategies promoting cessation in hospitalized postoperative cancer patients who continue to smoke.

A nurse-delivered smoking cessation intervention among hospitalized postoperative patients--influence of a smoking-related diagnosis: a pilot study.

OBJECTIVE: To examine the effect of a nurse-delivered smoking cessation intervention on short-term smoking abstinence among hospitalized postoperative patients. DESIGN: Prospective, experimental, random assignment. SETTING: Midwestern university-affiliated tertiary medical center. PATIENTS: Postoperative smokers (n = 80) from cardiovascular, oncology, and general surgical units. OUTCOME MEASURE: Self-reported smoking status and saliva cotinine level at 5 to 6 weeks after hospitalization. INTERVENTION: Three structured smoking cessation sessions during hospitalization, followed by phone calls once a week for 5 weeks after discharge. RESULTS: Of the experimental group patients, 37.8% were abstinent as compared to 25.6% in the usual care group. Abstinence rates of experimental group patients from cardiovascular (40%) and oncology (64.3%) units were higher than that of GS (13.3%) unit patients. Regardless of group assignment, 100% of cardiovascular and oncology patients abstained during hospitalization, compared to only 10.7% of GS patients. CONCLUSIONS: Preliminary results indicate that a nurse-delivered cessation intervention may be effective postoperatively among smokers with an identified smoking-related diagnosis.

Cigarette craving and subsequent coping responses among smoking cessation clinic participants.

Withdrawal symptoms, including craving, have been cited as common reasons for relapse into smoking. This study looked at 29 subjects enrolled in a community-based smoking cessation clinic to determine their levels of craving at 48 hours and end-of-clinic, as well as to determine those situational factors that precipitated a craving episode and the subsequent coping responses used during the first 48 hours post-cessation. Subjects completed the Shiffman-Jarvik Craving Subscale (SJCS) and the Visual Analogue Scale of Craving (VAS) to measure the severity of their cigarette craving. Data obtained from both tools were analyzed via paired t-tests. Mean difference scores on the SJCS (D = 1.42, t = 4.58, p less than 0.0002) and the VAS (D = 36.39, t = 4.46, P less than 0.0003) indicated that all subjects experienced craving during the first 48 hours after quitting, and that craving decreased significantly over a two-week period, corresponding with the end-of-clinic. Situational factors related to craving included: being at work, negative affect, and late afternoon hours. Coping responses to craving were categorized as either affective- or problem-oriented, with the former cited by subjects 73% of the time.

A nurse-managed smoking cessation intervention during diagnostic testing for lung cancer.

PURPOSE/OBJECTIVES: To determine the effectiveness of a nurse-managed smoking cessation intervention. DESIGN: Prospective, descriptive, one-group, pretest/post-test. SETTING: Urban, academic, tertiary-care setting. SAMPLE: Fifteen adult male and female smokers with a suspected diagnosis of lung cancer who were admitted to an inpatient thoracic surgery unit for diagnostic testing. METHODS: Subjects received a nurse-managed smoking cessation intervention during hospitalization with subsequent verification of smoking status at a clinic visit six weeks postintervention. MAIN RESEARCH VARIABLES: Self-reported smoking status and saliva cotinine levels at six weeks postintervention. FINDINGS: Eighty-seven percent of subjects reported an intent to quit smoking within the month. At six weeks postintervention, 93% of the subjects reported at least one cessation attempt, and 40% were confirmed, via saliva cotinine analysis, as abstinent from smoking during the prior week. CONCLUSIONS: A nurse-managed smoking cessation intervention was successful in achieving short-term cessation. IMPLICATIONS FOR NURSING PRACTICE: Hospitalization for diagnostic testing associated with lung cancer may represent an opportunity for nurses to deliver a smoking-cessation intervention.

The effectiveness of a nurse-managed minimal smoking-cessation intervention among hospitalized patients with cancer.

PURPOSE/OBJECTIVES: To determine the effectiveness of a nurse-managed minimal smoking-cessation intervention among hospitalized patients with cancer. DESIGN: Prospective, two-group, randomized clinical trial. SETTING: Urban, academic, tertiary-care setting. SAMPLE: 28 adult male and female smokers with a diagnosis of cancer who are hospitalized for a surgical procedure. METHODS: During hospitalization, subjects were assigned to a minimal smoking-cessation intervention group (n = 14) or a usual care group (n = 14). Verification of smoking status was performed at a clinic visit six weeks postintervention. Nonsmoking status was defined as self-report of zero cigarettes/day during the prior week and confirmed by saliva cotinine analysis. MAIN RESEARCH VARIABLES: One-time, Inpatient, nurse-managed, minimal smoking-cessation intervention, self-reported smoking status, and saliva cotinine level of < or = 14 ng/ml. FINDINGS: Upon hospital admission, 64% of the intervention group and 71% of the usual care group reported their intention to quit smoking. At six weeks postintervention, only 21% and 14% of the intervention and usual care group, respectively, were classified as abstinent from smoking. More than 90% of the intervention group members who resumed smoking did so within first week of discharge. IMPLICATIONS FOR NURSING PRACTICE: A more intensive intervention may be necessary to assist hospitalized surgical patients in achieving smoking cessation. Additional contact prior to discharge or within the first few days postdischarge may be necessary to reinforce strategies for remaining abstinent.

Implementing the Agency for Health Care Policy and Research's Smoking Cessation Guideline in a lung cancer surgery clinic.

PURPOSE/OBJECTIVES: To determine the effectiveness of a nurse-managed smoking cessation intervention based on the Agency for Health Care Policy and Research's (AHCPR's) Smoking Cessation Guideline in a lung cancer surgery clinic. DESIGN: Quasi-experimental. SETTING: Urban, Midwest, academic, and tertiary care. SAMPLE: 25 adult male and female smokers with a confirmed diagnosis of lung cancer that had been surgically managed. Subjects were assigned to an intervention group (n = 14) or a usual-care group (n = 11). METHODS: Participants in the intervention group received a nurse-delivered, AHCPR-based smoking cessation intervention that included face-to-face and phone follow-up contact beginning with the first preoperative clinic consultation. Usual-care participants received routine care provided at the institution. MAIN RESEARCH VARIABLES: Self-reported smoking status with expired air carbon monoxide confirmation six months postsurgery. FINDINGS: Seventy-one percent of the intervention group was biochemically confirmed to be abstinent by expired air carbon monoxide, as compared to 55% in the usual-care group. CONCLUSIONS: Smokers diagnosed with lung cancer desired to quit smoking and may benefit from an intensive smoking cessation intervention at time of diagnosis. IMPLICATIONS FOR NURSING PRACTICE: Further research should include continuing evaluation of an intensive smoking cessation intervention with this population, and all clinicians should be trained to implement AHCPR's Smoking Cessation Guideline in practice.

Tobacco-control attitudes, advocacy, and smoking behaviors of oncology nurses.

PURPOSE/OBJECTIVES: To describe oncology nurses' attitudes, smoking behaviors, and involvement in tobacco-control policy and legislation. DESIGN: Descriptive, cross-sectional survey. SAMPLE: Responses from 1,508 (38% return) of 4,000 randomly selected members of the Oncology Nursing Society (ONS). The typical respondent was female, age 44, a staff nurse, had practiced as an oncology nurse for 12 years, and was certified as an OCN. METHODS: A mailed survey with specific questions about smoking status and the importance of nursing involvement in healthcare policy and legislation for tobacco control. MAIN RESEARCH CONCEPTS: Attitudes about tobacco-control policies and legislation; sociodemographic, professional, and institutional variables; and tobacco use. FINDINGS: The majority (85%) of members stated that nursing involvement in tobacco-control healthcare policy and legislation was important. More than 90% of respondents supported prevention of youth access to tobacco and providing information about health effects of tobacco and cessation. Seven percent (n = 106) were current smokers. Significantly fewer smokers valued involvement in tobacco-control activities. Respondents with personal experience of tobacco-related illnesses were more likely to value involvement in advocacy activities. Educational programs to prevent tobacco use among youth and to help patients stop smoking received the most support (80%). IMPLICATIONS FOR NURSING PRACTICE: This sample of ONS members strongly supported involvement in tobacco-control policies and legislation. Smoking was associated with more negative attitudes about the importance of actively engaging in tobacco control. These oncology nurses recognized the need for additional educational programs to prevent tobacco initiation by youth.