Alicia M. Allen

Prenatal Smoking Prevalence Ascertained from Two Population-Based Data Sources: Birth Certificates and PRAMS Questionnaires, 2004

Objectives. This study provided a population-based estimate of the prevalence of smoking during pregnancy by combining information from two data sources: birth certificates (BCs) and a self-administered questionnaire. Methods. We analyzed data from 39,345 women who delivered live births in one of 24 states and responded to a questionnaire from the Pregnancy Risk Assessment Monitoring System (PRAMS), an ongoing, state- and population-based surveillance system. We compared prevalence of smoking during pregnancy based on the BC, the PRAMS questionnaire, and the two data sources combined. Data were weighted to represent all women delivering live births in each of the 24 states during 2004. Results. The combined estimate indicated that 15.1% of women reported smoking during pregnancy, whereas the BCs alone reported 10.4% and the PRAMS questionnaires alone reported 13.4%. Conclusions. Based on the combined BC and PRAMS questionnaire data, the number of infants exposed to tobacco in-utero may be 31% higher than is currently reported on the BCs. Combining the data from the two different sources led to higher ascertainment of prenatal smoking.

Postpartum Depressive Symptoms and Smoking Relapse

BACKGROUND Smokers with depressive symptoms are more likely to relapse after attempting to quit than those without depressive symptoms. Little is known about the relationship between depressive symptoms and relapse during the postpartum period; thus the aim of the present study is to assess the relationship between postpartum smoking relapse and depressive symptoms. METHODS Analysis of 2004 Pregnancy Risk Assessment Monitoring System (PRAMS) data from women in 16 states who reported smoking 3 months before pregnancy and reported abstinence from smoking during the last 3 months of pregnancy (n=2566). For women experiencing postpartum depressive symptoms, chi-square tests were computed for homogeneity of distribution between two groups (sustained abstinence versus relapsed) and an OR for relapsing during the postpartum period. Potential confounders, including demographic characteristics, intensity of smoking before pregnancy, and time since delivery, were computed. RESULTS Compared to women who did not experience postpartum depressive symptoms, women who did were 1.86 (95% CI=1.31, 2.65) times as likely to relapse during the postpartum period. After adjusting for demographic characteristics, intensity of smoking, and time since delivery, the association decreased slightly (adjusted OR=1.77, 95% CI=1.21, 2.59). CONCLUSIONS Women who quit smoking during pregnancy may be more likely to relapse if they experience depressive symptoms. Further research is needed into the screening and treatment of postpartum depressive symptoms as a possible method for preventing postpartum smoking relapse.

Influence of phase-related variability in premenstrual symptomatology, mood, smoking withdrawal, and smoking behavior during ad libitum smoking, on smoking cessation outcome.

Emerging evidence suggests that women have a more difficult time quitting smoking than men-possibly due, in part, to sex hormones. The present study characterized mood, premenstrual symptomatology, and smoking withdrawal, as well as smoking behavior, in the follicular and luteal phases during ad libitum smoking in 25 women intending to quit. We also investigated the possible influence of phase-related variability in these measures on likelihood of study adherence and smoking cessation. We found that premenstrual symptomatology, as well as some measures of mood and smoking withdrawal, were significantly higher during the luteal phase than in the follicular phase. Cigarettes/day did not vary by menstrual cycle phase. Phase-related variability in premenstrual symptomatology [F(3, 20)=2.82, p=0.0650)] and urge to smoke [F(2, 21)=4.85, p=0.0186)] were associated with relapse. These data support the inference that sex hormones influence smoking cessation outcome. This knowledge may contribute to the development of more rational and effective smoking cessation interventions for women.

Women and Smoking: The Effect of Gender on the Epidemiology, Health Effects, and Cessation of Smoking

Smoking is still the leading cause of premature morbidity and mortality. This paper examines new research on gender differences and the epidemiology of smoking, smoking-related morbidity and mortality, and factors that affect smoking cessation. The rate of decline in the prevalence of smoking has been slowing, especially among adolescent girls. New research suggests that, compared with men, women may be more susceptible to smoking-related morbidity and mortality. Gender-related barriers to smoking cessation include weight gain, sex hormones, and mood. Furthermore, the sensory aspects of smoking may have more of an effect on smoking treatment for women than for men. We discuss new studies that examine smoking-cessation interventions that may be particularly beneficial for women, including exercise (as an adjunct intervention), very low nicotine content cigarettes, and a variety of pharmacotherapy. Further research is needed to identify and target the gender-specific needs of smokers.

Patterns of self-selected smoking cessation attempts and relapse by menstrual phase

Clinical studies are emerging which suggest that sex hormones may play a role in quit attempts and relapse. The present study aim is to determine if menstrual phase plays a role on a second self-selected quit attempt and subsequent relapse during a twenty-six week follow-up. Participants (n=138) were 29.7+/-6.5 years old and smoked 16.1+/-4.8 cigarettes per day. Participants were more likely to self-select a second quit date during the Follicular (F) phase (59.4%) than Luteal (L) phase (40.6%, p=0.033) and were also more likely to relapse during the F phase than the L phase (59.7% vs. 40.3%, p=0.043, respectively). Those who self-selected to quit in the L phase experienced a significantly longer time to relapse than those who chose the F phase (median of 3 days vs. 2 days, respectively; Hazard Ratio=1.599, p-value=0.014). This confirms previous work suggesting quit dates in the F phase are associated with worse smoking cessation outcomes. Additional research is needed to investigate how this relationship may vary with the use of pharmacotherapy.

Severity of withdrawal symptomatology in follicular versus luteal quitters: The combined effects of menstrual phase and withdrawal on smoking cessation outcome

Women are at an increased risk of relapse after a smoking cessation attempt. While the reasons for this phenomenon are not fully understood, recent research indicates that both the menstrual cycle and negative symptomatology may play a role. The goal of this study was to describe the association between withdrawal symptoms during attempted smoking cessation, and to investigate the impact of these symptoms on smoking cessation outcomes as defined by 7-day point prevalence at 14 and 30 days. Negative symptoms associated with the premenstrual period were also assessed. Participants (n = 202) were 29.8 (SD +/- 6.6) years old and smoked 16.6 (SD +/- 5.6) cigarettes per day. They were randomly assigned to quit smoking in the follicular (n = 106) or luteal (n = 96) menstrual phase. We observed several significantly more severe premenstrual and withdrawal symptoms in the luteal phase. Regardless of quit phase, most withdrawal symptoms were associated with an increased risk of relapse at 14 and 30 days post quit date. Participants attempting to quit smoking in the follicular phase who had higher levels of Anger and Craving were more likely to relapse to smoking at 14-days (OR = 2.00, p-value = 0.026; OR = 2.63, p-value = 0.006; respectively). These data suggest that the menstrual cycle may play a role in smoking cessation outcome, as well as in the symptomatology experienced during a cessation attempt.

Determining menstrual phase in human biobehavioral research: A review with recommendations.

Given the volume and importance of research focusing on menstrual phase, a review of the strategies being used to identify menstrual phase and recommendations that will promote methodological uniformity in the field is needed. We conducted a literature review via Ovid Medline and PsycINFO. Our goal was to review methods used to identify menstrual phase and subphases in biobehavioral research studies with women who had physiologically natural menstrual cycles. Therefore, we excluded articles that focused on any of the following: use of exogenous hormones, the postpartum period, menstrual-related problems (e.g., polycystic ovarian syndrome, endometriosis), and infertility/anovulation. We also excluded articles on either younger (<18 years old) or older (>45 years old) study samples. We initially identified a total of 1,809 articles. After our exclusionary criteria were applied, 146 articles remained, within which our review identified 6 different methods used to identify menstrual phase and subphases. The most common method used was self-report of onset of menses (145/146 articles) followed by urine luteinizing hormone testing (50/146 articles) and measurement of hormones (estradiol and/or progesterone) in blood samples (49/146 articles). Overall, we found a lack of consistency in the methodology used to determine menstrual phase and subphases. We provide several options to improve accuracy of phase identification, as well as to minimize costs and burden. Adoption of these recommendations will decrease misclassification within individual studies, facilitate cross-study comparisons, and enhance the reproducibility of results.

Patterns of Cortisol and Craving by Menstrual Phase in Women Attempting to Quit Smoking

Research indicates stress, craving and menstrual phase may play a role in relapse to smoking. It remains unknown how these factors may interact during cessation. This study describes the relationship between craving and cortisol concentrations by menstrual phase during ad libitum smoking and investigates the impact of this relationship on time to relapse. Five assessments of cortisol concentrations and craving levels were collected the day before smoking cessation in female smokers (n=38) during either the follicular (n=21; F) or luteal (n=17; L) phase. Craving at wake-up was significantly greater in the F phase than the L phase (2.5+/-1.9 vs. 1.1+/-1.4; p=0.018; respectively). Decreased levels of morning cortisol concentrations and a greater decline from morning to the nadir levels in cortisol were associated with increased craving at bedtime in the L (r=-0.68, p=0.002; r=-0.67, p=0.003; respectively), but not in the F phase. Craving at wake-up was a significant predictor of time to relapse (p=0.008). Our results indicate that menstrual phase may play a role in the relationship among craving, cortisol concentrations, and risk for relapse.

Smoking- and menstrual-related symptomatology during short-term smoking abstinence by menstrual phase and depressive symptoms

Menstrual phase and depressive symptoms are known to minimize quit attempts in women. Therefore, the influence of these factors on smoking- and menstrual-related symptomatology during acute smoking cessation was investigated in a controlled cross-over lab-study. Participants (n=147) completed two six-day testing weeks during their menstrual cycle with testing order randomly assigned (follicular vs. luteal). The testing week consisted of two days of ad libitum smoking followed by four days of biochemically verified smoking abstinence. Daily symptomatology measures were collected. Out of the 11 total symptoms investigated, six were significantly associated with menstrual phase and nine were significantly associated with level of depressive symptoms. Two significant interactions were noted indicating that there may be a stronger association between depressive symptoms with negative affect and premenstrual pain during the follicular phase compared to the luteal phase. Overall, these observations suggest that during acute smoking abstinence in premenopausal smokers, there is an association between depressive symptoms and symptomatology whereas menstrual phase appears to have less of an effect. Further study is needed to determine the effect of these observations on smoking cessation outcomes, as well as to define the mechanism of menstrual phase and depressive symptoms on smoking-related symptomatology.

Effect of nicotine patch on energy intake and weight gain in postmenopausal women during smoking cessation

INTRODUCTION Post-cessation weight gain is a commonly cited barrier to smoking cessation. Some evidence suggests that nicotine replacement therapy may limit post-cessation weight gain by reducing energy intake. This project aims to assess differential changes in energy intake and body weight during smoking cessation in a sample of postmenopausal women randomized to receive 21 mg nicotine or placebo patch for 12 weeks. METHODS Postmenopausal women who smoked ≥10 cigarettes/day were enrolled in this double-blind randomized placebo-controlled study. Total energy intake (via four-day food diaries), body mass index (BMI; kg/m(2)), cigarettes/day and smoking status (self-report verified by exhaled carbon monoxide) were assessed at three time points: 2 weeks prior to quit date, 12 weeks after quit date, and 12 months after smoking cessation treatment. RESULTS Participants (n = 119) were, on average, 55.8 ± 6.7 years old with a baseline BMI of 27.0 ± 5.2 and average cigarette/day was 21.1 ± 8.6. At Week 12, participants randomized to nicotine patch increased their mean caloric intake by 146.4 ± 547.7 kcal/day whereas those on placebo patch decreased their caloric intake by 175.3 ± 463.2 (f-value = 10.1, p-value = 0.002). Despite the differences in caloric intake, body weight remained similar between groups. CONCLUSIONS The results of this study indicate that nicotine patch may increase energy intake during treatment, and does not prevent post-cessation weight gain in postmenopausal smokers. Additional research is needed to replicate these findings and assess whether different forms of nicotine replacement therapy influence caloric intake and post-cessation weight gain in postmenopausal smokers.