Amy B. Lazev

Successes and failures of the teachable moment: Smoking cessation in cancer patients

Successful cancer treatment can be significantly compromised by continued tobacco use. Because motivation and interest in smoking cessation increase after cancer diagnosis, a window of opportunity exists during which healthcare providers can intervene and assist in the quitting process.

Smoking behavior in a low-income multiethnic HIV/AIDS population

The aim of this study was to describe smoking prevalence and smoking behavior in a multiethnic low-income HIV/AIDS population. A cross-sectional survey design was used. The study site was Thomas Street Clinic, an HIV/AIDS care facility serving a medically indigent and ethnically diverse population. Demographic, disease status, behavioral, and psychosocial variables were assessed by participant self-report. Surveys were collected from 348 study participants. Demographic composition of the sample was 78% male, 25% White, 44% Black, and 29% Hispanic. Study participants had a mean age of 40.2 years (SD=7.8). The HIV exposure profile of the sample was diverse: 46% men who have sex with men, 35% heterosexual contact, and 11% injection drug use. Prevalence of current cigarette smoking in the sample was 46.9%. Among participants with a lifetime history of smoking 100 or more cigarettes (62.8%), only 26.6% were currently abstinent, lower than the 48.8% rate seen in the general population. Multiple logistic regression analysis indicated that race/ethnicity, education level, age, and heavy drinking were significantly associated with smoking status. Hispanics were less likely than Whites were to smoke, younger participants were less likely than older participants were to be current smokers, and heavy drinkers were more likely to be current smokers than were those who were not heavy drinkers. As education level increased, the likelihood of smoking decreased and the likelihood of quitting increased. The high smoking prevalence in this HIV/AIDS population demonstrates the need for smoking cessation interventions targeted to the special needs of this patient group.

A randomized trial of a proactive cellular telephone intervention for smokers living with HIV/AIDS

Objective:To assess the efficacy of an innovative smoking cessation intervention targeted to a multiethnic, economically disadvantaged HIV-positive population. Design:A two-group randomized clinical trial compared a smoking cessation intervention delivered by cellular telephone with usual care approach. Methods:Current smokers from a large, inner city HIV/AIDS care center were recruited and randomized to receive either usual care or a cellular telephone intervention. The usual care group received brief physician advice to quit smoking, targeted self-help written materials and nicotine replacement therapy. The cellular telephone intervention received eight counseling sessions delivered via cellular telephone in addition to the usual care components. Smoking-related outcomes were assessed at a 3-month follow-up. Results:The trial had 95 participants and 77 (81.0%) completed the 3-month follow-up assessment. Analyses indicated biochemically verified point prevalence smoking abstinence rates of 10.3% for the usual care group and 36.8% for the cellular telephone group; participants who received the cellular telephone intervention were 3.6 times (95% confidence interval, 1.3-9.9) more likely to quit smoking compared with participants who received usual care (P = 0.0059). Conclusions:These results suggest that individuals living with HIV/AIDS are receptive to, and can be helped by, smoking cessation treatment. In addition, smoking cessation treatment tailored to the special needs of individuals living with HIV/AIDS, such as counseling delivered by cellular telephone, can significantly increase smoking abstinence rates over that achieved by usual care.

Increasing access to smoking cessation treatment in a low-income, HIV-positive population: the feasibility of using cellular telephones.

This study examined the feasibility of using cellular telephones to improve access to smoking cessation counseling in a low-income, HIV-positive population. Two pilot studies were conducted: (a). A survey of interest and barriers in participating in a smoking cessation intervention (n=49) and (b). a cellular telephone smoking cessation intervention in which participants were provided with free cellular telephones and received six telephone counseling sessions over a 2-week period (n=20). A primary care clinic serving a multiethnic, medically indigent, HIV-positive population served as the setting. Demographics and smoking status were assessed by self-report and expired-air carbon monoxide testing. In study 1, participants reported multiple barriers to participating in a smoking cessation intervention, including transportation, transience, and telephone availability. However, they also reported a high level of interest in participating in a smoking cessation intervention, with the greatest interest in a cellular telephone intervention. In study 2, 19 of the 20 participants successfully completed 2 weeks of smoking cessation counseling with a 93% (106 of 114 calls) contact rate. A total of 19 participants made a quit attempt, and the 2-week end of treatment point-prevalence abstinence rate was 75%. The provision of cellular telephones allowed for the implementation of a proactive telephone smoking cessation intervention providing an underserved population with access to care. Cellular telephones also may provide unique benefits because of the intensity of counseling and support provided as well as the ability to provide counseling in real-world, real-time situations (in vivo counseling).

The impact of email recruitment on our understanding of college smoking.

Email recruitment is growing in popularity; however, this convenience sampling method may yield very different results from prior convenience sampling methods. Participants in the current study were 825 undergraduate students, 446 recruited through a campus wide email and 379 recruited through Introductory Psychology courses, who completed an on-line survey on smoking and health. Outcomes varied significantly by group. Introductory Psychology students reported higher smoker self-concept, more pros of smoking, and were more likely to view smoking as a method of negative affect reduction. The current study suggests that recruitment method can bias our understanding of smoking behaviors among college students.

Predictors of Smoking Cessation Counseling Adherence in a Socioeconomically Disadvantaged Sample of Pregnant Women

Implementing and evaluating smoking cessation interventions in underserved populations has been found difficult due to high rates of non-adherence to the prescribed protocol. To understand better the barriers to cessation participation, we studied low-income inner-city pregnant women who were enrolled in either a standard or highly intensive quit smoking counseling program. The results showed that 1) in the prenatal phase, non-attendance was predicted by a greater number of cigarettes smoked per day; 2) in the postpartum follow-up phase, non-attendance was predicted by lower educational level and higher self-efficacy for quitting smoking; and 3) participants with more children living at home were at increased risk of rescheduling the postpartum follow-up session. These findings suggest that innovative delivery strategies are needed more effectively to assess and address risk factors for non-adherence to smoking cessation trials among underserved minority pregnant/postpartum smokers.

A tutorial on principal stratification-based sensitivity analysis: Application to smoking cessation studies

Background One problem with assessing effects of smoking cessation interventions on withdrawal symptoms is that symptoms are affected by whether participants abstain from smoking during trials. Those who enter a randomized trial but do not change smoking behavior might not experience withdrawal-related symptoms. Purpose We present a tutorial of how one can use a principal stratification sensitivity analysis to account for abstinence in the estimation of smoking cessation intervention effects. The article is intended to introduce researchers to principal stratification and describe how they might implement the methods. Methods We provide a hypothetical example that demonstrates why estimating effects within observed abstention groups is problematic. We demonstrate how estimation of effects within groups defined by potential abstention that an individual would have in either arm of a study can provide meaningful inferences. We describe a sensitivity analysis method to estimate such effects, and use it to investigate effects of a combined behavioral and nicotine replacement therapy intervention on withdrawal symptoms in a female prisoner population. Results Overall, the intervention was found to reduce withdrawal symptoms but the effect was not statistically significant in the group that was observed to abstain. More importantly, the intervention was found to be highly effective in the group that would abstain regardless of intervention assignment. The effectiveness of the intervention in other potential abstinence strata depends on the sensitivity analysis assumptions. Limitations We make assumptions to narrow the range of our sensitivity analysis estimates. While appropriate in this situation, such assumptions might not be plausible in all situations. Conclusions A principal stratification sensitivity analysis provides a meaningful method of accounting for abstinence effects in the evaluation of smoking cessation interventions on withdrawal symptoms. Smoking researchers have previously recommended analyses in subgroups defined by observed abstention status in the evaluation of smoking cessation interventions. We believe that principal stratification analyses should replace such analyses as the preferred means of accounting for post-randomization abstinence effects in the evaluation of smoking cessation programs. Clinical Trials 2010; 7: 286—298. http://ctj.sagepub.com

The use of university debit cards for purchasing cigarettes: An opportunity for tobacco use prevention on university campuses

Aims: Young adults have the highest smoking rate of any age group in the United States. However, little is known about how young adults, including college students, access and pay for cigarettes – important information for guiding policies and prevention and intervention efforts. This study examined students’ use of university debit cards, which provide money intended for school-related purchases and living expenses, to purchase cigarettes. Methods: Undergraduate students (N = 1302) at a large urban university completed an online survey during the spring 2009 semester. Students received a

E-35. Smoking and the sexes

10 gift card for completing at least 90% of the survey. Findings: Among past 30-day smokers (n = 367), 42% purchased cigarettes with university debit cards and were more likely to be daily smokers, smoked more cigarettes per day and tended to be younger than those who used other purchasing methods only. Conclusion: These data suggest that a significant number of students use their university debit cards to buy cigarettes, possibly increasing their access to cigarettes and contributing to their smoking behaviour. This trend may be more commonplace than parents or university administrators realize and should be considered when designing smoking prevention/intervention efforts as well as university policies.

The “Buzz” on Caffeine: Patterns of Caffeine Use in a Convenience Sample of College Students

Globally, smoking rates have traditionally been higher for men than for women. In recent decades, however, this sex difference has decreased. The impact of smoking is significant; there are now over 1 million deaths per year among women worldwide due to smoking. Since 1987 lung cancer has surpassed breast cancer as the leading cause of female cancer mortality in the U.S. and is responsible for 87% of all lung cancer deaths in this nation. In developing countries women’s smoking rates are increasing as they are targeted by the tobacco industry. In the U.S., men’s smoking rates have declined from over 50% in the 1950’s to 25.7% in 2002 while women’s smoking rates have declined by a much smaller percent (34% to 21%). The sex difference is even smaller among U.S. teens. While prevalence remains higher for men, the quit ratio, the proportion of ever smokers who are now former smokers (former smokers/ever smokers), is higher in men than women (52% vs. 47%, CDC 1994). In the past few decades smoking has clearly become a “women’s health issue” as defined by those issues “unique” to women or those that disproportionately affect women. To provide selected examples, consider the adverse impact of smoking on the fetus during pregnancy, the causal role of smoking in cervical cancer, and the potential complications of wound healing following reconstructive surgery for breast cancer. Each of these very different experiences creates a window of opportunity to target cessation efforts to women. However, the need for targeted interventions for women has been clouded by conflicting studies regarding sex differences that affect smoking initiation, maintenance of smoking, response to treatment, and relapse. Conflicting evidence exists for sex differences related to physiological, psychological, and behavioral factors. Studies suggest that there are sex differences in nicotine sensitivity, tolerance, and dependence. Women appear to be more dependent on nicotine, have reduced nicotine clearance, and experience greater withdrawal from nicotine. However, other studies suggest that women smoke fewer cigarettes and, while they self-report greater withdrawal symptoms than men, the actual withdrawal profile may be similar. Sex differences have also been found in response to NRT, with women receiving less cessation benefit. However, studies of pharmacological treatments such as bupropion tend to show equivalent results for men and women, perhaps negating the sex difference. At the behavioral level, psychological and social factors such as depression, weight gain concerns, social support, social pressure, self-efficacy, readiness to quit, cue-reactivity, coping styles, and expectancies may all affect initiation to smoking, treatment effectiveness, and relapse. Sex differences have been shown in all of these factors; however, the impact of these differences is not clear. For example, the rate of depression/negative affect is higher in women than men in population studies. While depression/negative affect is correlated with smoking rates, findings are mixed with some studies suggesting a causal role, and others suggesting only association. Weight concerns are also stronger in women than men. While smokers tend to weigh less than nonsmokers and quitting smoking often leads to an average 5-8 pound weight gain, it is not clear how these concerns differentially affect women’s smoking behavior. On the other hand, large population-based surveys have not shown sex differences in the ability to quit smoking and remain abstinent. While some treatment outcome studies have identified sex differences, methodological concerns have obscured the ability to draw firm conclusions. For example, the use of post-hoc analysis, lack of power to identify gender differences, and the lack of analysis of interactions of sex with etbnicity and SES are common methodological shortcomings. Furthermore, treatment outcome studies rely on convenience samples of volunteers and may not be representative of the general population. Over 20 years ago the Surgeon General reported that women may have more difficulty than men giving up smoking (U.S. Department of Health and Human Services, 1980). This controversy has not yet been resolved. Women’s smoking is increasingly a global problem. Increased awareness, funding, and advocacy is needed to reduce the rate of women who are smoking. However, in order to both target women and tailor interventions effectively, more research is needed to understand why women smoke, how to motivate them to quit, and how best to assist their quit attempts and prevent relapse. Finally, cultural differences in women’s smoking behavior, normative patterns and rapidly changing advertising and promotion tactics by the tobacco industry must be incorporated into ongoing and new research.