Bradley N. Collins

Do infants fed directly from the breast have improved appetite regulation and slower growth during early childhood compared with infants fed from a bottle

BackgroundBehavioral mechanisms that contribute to the association between breastfeeding and reduced obesity risk are poorly understood. The purpose of this study was to evaluate the hypothesis that feeding human milk from the breast (direct breastfeeding) has a more optimal association with subsequent child appetite regulation behaviors and growth, when compared to bottle-feeding.MethodsChildren (n = 109) aged 3- to 6- years were retrospectively classified as directly breastfed (fed exclusively at the breast), bottle-fed human milk, or bottle-fed formula in the first three months of life. Young childrens appetite regulation was examined by measuring three constructs (satiety response, food responsiveness, enjoyment of food) associated with obesity risk, using the Child Eating Behavior Questionnaire. Multinomial logistic regression analyses were used to test whether children bottle-fed either human milk or formula had reduced odds of high satiety and increased odds of high food responsiveness and high enjoyment of food compared to children fed directly from the breast. Current child weight status and growth trends from 6-36 months were also examined for their relation to direct breastfeeding and appetite regulation behaviors in early childhood.ResultsChildren fed human milk in a bottle were 67% less likely to have high satiety responsiveness compared to directly breastfed children, after controlling for child age, child weight status, maternal race/ethnicity, and maternal education. There was no association of bottle-feeding (either human milk or formula) with young childrens food responsiveness and enjoyment of food. There was neither an association of direct breastfeeding with current child weight status, nor was there a clear difference between directly breastfed and bottle-fed children in growth trajectories from 6- to 36-months. More rapid infant changes in weight-for-age score were associated with lower satiety responsiveness, higher food responsiveness and higher enjoyment of food in later childhoodConclusionWhile direct breastfeeding was not found to differentially affect growth trajectories from infancy to childhood compared to bottle-feeding, results suggest direct breastfeeding during early infancy is associated with greater appetite regulation later in childhood. A better understanding of such behavioral distinctions between direct breastfeeding and bottle-feeding may identify new pathways to reduce the pediatric obesity epidemic.

Gender differences in smoking cessation in a placebo-controlled trial of bupropion with behavioral counseling

Among smokers, women may be at greater risk than men for developing smoking-related diseases, perhaps because they have greater difficulty quitting smoking, as suggested by numerous studies. In the present study, we hypothesized that bupropion would reduce this gender disparity among 314 women and 241 men enrolled in a placebo-controlled, randomized trial using behavioral counseling plus 10 weeks of bupropion (300 mg). Prolonged abstinence and biochemically verified point prevalence outcomes were measured at end of treatment (8 weeks after the quit date) and at 6-month follow-up. A logistic regression model of 6-month prolonged abstinence and a Cox regression (survival analysis) model revealed a significant gender by smoking rate by drug interaction and a main effect for marital status. This three-way interaction suggests that bupropion particularly benefited men who smoked more than one pack of cigarettes per day at baseline and, conversely, women who smoked a pack or less. The point prevalence logistic regression model showed no evidence that either gender or smoking rate modified the effect of treatment. These results suggest that bupropion treatment may reduce the gender disparity in prolonged abstinence rates among lighter smokers.

Effect of bupropion on depression symptoms in a smoking cessation clinical trial.

Bupropion is an antidepressant shown to be efficacious for smoking cessation. This study examined the short- and long-term effects of bupropion (300 mg/day for 10 weeks) versus placebo on depression symptoms among 497 smokers attempting to quit in a randomized trial of bupropion plus behavioral counseling. Depression symptoms were assessed via the Center for Epidemiological Studies Depression Scale (L. Radloff, 1977) at baseline, end of treatment, and at 6-month follow-up. Baseline nicotine dependence level was assessed with the Fagerström Test for Nicotine Dependence (T. F. Heatherton, L. T. Kozlowski, R. C. Frecker, & K. O. Fagerstrom, 1991). A regression model of depression symptoms demonstrated a significant interaction between nicotine dependence and treatment for the treatment phase and during follow-up. Depression symptoms did not mediate the effects of bupropion on abstinence at either time point. Highly nicotine-dependent smokers who receive bupropion are more likely to experience a decrease in depressive symptoms during active treatment but are also more likely to experience a rebound in depressive symptoms when bupropion is discontinued.

Associations among breastfeeding, smoking relapse, and prenatal factors in a brief postpartum smoking intervention

Postpartum smoking contributes to child health problems and is a barrier to breastfeeding, which promotes child health. There is a risk of postpartum smoking relapse for smokers and they are less likely to breastfeed. Understanding of smoking–breastfeeding associations must be improved. Enhancing smoking cessation advice simultaneously with breastfeeding counseling could increase smoking abstinence and breastfeeding rates. A low income sample of 31 volunteer maternal smokers and ex‐smokers were recruited for this pilot intervention in an urban hospitals postpartum unit. Following pre‐intervention interview, participants received either smoking relapse prevention plus breastfeeding counseling, or smoking relapse prevention only counseling. At one‐month follow‐up, we hypothesized that breastfeeding duration would positively relate to 7‐day point prevalence abstinence rates and days to relapse and explored prenatal care and pregnancy smoking behavior associations with postpartum smoking and breastfeeding. Of the mothers, 75% completed follow‐up. Days to relapse was related to duration of breastfeeding (r = 0.92, p = 0.08); however, counseling group differences in one‐month smoking status were not significant. Earlier prenatal care initiation was associated with smoking abstinences at one month postpartum (χ2 = 4.87, p ≤ 0.05). Early prenatal care and breastfeeding is associated with postpartum smoking abstinence.

Smoking cue reactivity across massed extinction trials: Negative affect and gender effects.

Designing and implementing cue exposure procedures to treat nicotine dependence remains a challenge. This study tested the hypothesis that gender and negative affect (NA) influence changes in smoking urge over time using data from a pilot project testing the feasibility of massed extinction procedures. Forty-three smokers and ex-smokers completed the behavioral laboratory procedures. All participants were over 17 years old, smoked at least 10 cigarettes daily over the last year (or the year prior to quitting) and had expired CO below 10 ppm at the beginning of the ~4-hour session. After informed consent, participants completed 45 min of baseline assessments, and then completed a series of 12 identical, 5-minute exposure trials with inter-trial breaks. Smoking cues included visual, tactile, and olfactory cues with a lit cigarette, in addition to smoking-related motor behaviors without smoking. After each trial, participants reported urge and negative affect (NA). Logistic growth curve models supported the hypothesis that across trials, participants would demonstrate an initial linear increase followed by a decrease in smoking urge (quadratic effect). Data supported hypothesized gender, NA, and gender×NA effects. Significant linear increases in urge were observed among high and low NA males, but not among females in either NA subgroup. A differential quadratic effect showed a significant decrease in urge for the low NA subgroup, but a non-significant decrease in urge in the high NA group. This is the first study to demonstrate gender differences and the effects of NA on the extinction process using a smoking cue exposure paradigm. Results could guide future cue reactivity research and exposure interventions for nicotine dependence.

Reducing Underserved Children’s Exposure to Tobacco Smoke

INTRODUCTION Addressing maternal smoking and child tobacco smoke exposure is a public health priority. Standard care advice and self-help materials to help parents reduce child tobacco smoke exposure is not sufficient to promote change in underserved populations. We tested the efficacy of a behavioral counseling approach with underserved maternal smokers to reduce infants and preschoolers tobacco smoke exposure. DESIGN A two-arm randomized trial: enhanced behavior counseling (experimental) versus enhanced standard care (control). Assessment staff members were blinded. SETTING/PARTICIPANTS Three hundred randomized maternal smokers were recruited from low-income urban communities. Participants had a child aged <4 years exposed to two or more maternal cigarettes/day at baseline. INTERVENTION Philadelphia Family Rules for Establishing Smoke-free Homes (FRESH) included 16 weeks of counseling. Using a behavioral shaping approach within an individualized cognitive-behavioral therapy framework, counseling reinforced efforts to adopt increasingly challenging tobacco smoke exposure-protective behaviors with the eventual goal of establishing a smoke-free home. MAIN OUTCOME MEASURES Primary outcomes were end-of-treatment child cotinine and reported tobacco smoke exposure (maternal cigarettes/day exposed). Secondary outcomes were end-of-treatment 7-day point-prevalence self-reported cigarettes smoked/day and bioverified quit status. RESULTS Participation in FRESH behavioral counseling was associated with lower child cotinine (β=-0.18, p=0.03) and reported tobacco smoke exposure (β=-0.57, p=0.03) at the end of treatment. Mothers in behavioral counseling smoked fewer cigarettes/day (β=-1.84, p=0.03) and had higher bioverified quit rates compared with controls (13.8% vs 1.9%, χ(2)=10.56, p<0.01). There was no moderating effect of other smokers living at home. CONCLUSIONS FRESH behavioral counseling reduces child tobacco smoke exposure and promotes smoking quit rates in a highly distressed and vulnerable population. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02117947.

Coping and social problem solving correlates of asthma control and quality of life

In a sample of adults with asthma receiving care and medication in an outpatient pulmonary clinic, this study tested for statistical associations between social problem-solving styles, asthma control, and asthma-related quality of life. These variables were measured cross sectionally as a first step toward more systematic application of social problem-solving frameworks in asthma self-management training. Recruitment occurred during pulmonology clinic service hours. Forty-four adults with physician-confirmed diagnosis of asthma provided data including age, gender, height, weight, race, income, and comorbid conditions. The Asthma Control Questionnaire, the Mini Asthma Quality of Life Questionnaire (Short Form), and peak expiratory force measures offered multiple views of asthma health at the time of the study. Maladaptive coping (impulsive and careless problem-solving styles) based on transactional stress models of health were assessed with the Social Problem-Solving Inventory-Revised: Short Form. Controlling for variance associated with gender, age, and income, individuals reporting higher impulsive–careless scores exhibited significantly lower scores on asthma control (β = 0.70, p = 0.001, confidence interval (CI) [0.37–1.04]) and lower asthma-related quality of life (β = 0.79, p = 0.017, CI [0.15–1.42]). These findings suggest that specific maladaptive problem-solving styles may uniquely contribute to asthma health burdens. Because problem-solving coping strategies are both measureable and teachable, behavioral interventions aimed at facilitating adaptive coping and problem solving could positively affect patient’s asthma management and quality of life.

Kids Safe and Smokefree (KiSS): a randomized controlled trial of a multilevel intervention to reduce secondhand tobacco smoke exposure in children

BackgroundSecondhand smoke exposure (SHSe) harms children’s health, yet effective interventions to reduce child SHSe in the home and car have proven difficult to operationalize in pediatric practice. A multilevel intervention combining pediatric healthcare providers’ advice with behavioral counseling and navigation to pharmacological cessation aids may improve SHSe control in pediatric populations.Methods/designThis trial uses a randomized, two-group design with three measurement periods: pre-intervention, end of treatment and 12-month follow-up. Smoking parents of children < 11-years-old are recruited from pediatric clinics. The clinic-level intervention includes integrating tobacco intervention guideline prompts into electronic health record screens. The prompts guide providers to ask all parents about child SHSe, advise about SHSe harms, and refer smokers to cessation resources. After receiving clinic intervention, eligible parents are randomized to receive: (a) a 3-month telephone-based behavioral counseling intervention designed to promote reduction in child SHSe, parent smoking cessation, and navigation to access nicotine replacement therapy or cessation medication or (b) an attention control nutrition education intervention. Healthcare providers and assessors are blind to group assignment. Cotinine is used to bioverify child SHSe (primary outcome) and parent quit status.DiscussionThis study tests an innovative multilevel approach to reducing child SHSe. The approach is sustainable, because clinics can easily integrate the tobacco intervention prompts related to “ask, advise, and refer” guidelines into electronic health records and refer smokers to free evidence-based behavioral counseling interventions, such as state quitlines.Trial registrationNCT01745393 (clinicaltrials.gov).

Proactive recruitment predicts participant retention to end of treatment in a secondhand smoke reduction trial with low-income maternal smokers

Improving smoking intervention trial retention in underserved populations remains a public health priority. Low retention rates undermine clinical advancements that could reduce health disparities. To examine the effects of recruitment strategies on participant retention among 279 low-income, maternal smokers who initiated treatment in a 16-week behavioral counseling trial to reduce child secondhand smoke exposure (SHSe). Participants were recruited using either reactive strategies or methods that included proactive strategies. Logistic regression analysis was used to test associations among retention and recruitment method in the context of other psychosocial and sociodemographic factors known to relate to retention. Backwards stepwise procedures determined the most parsimonious solution. Ninety-four percent of participants recruited with proactive + reactive methods were retained through end of treatment compared to 74.7% of reactive-recruited participants. Retention likelihood was five times greater if participants were recruited with proactive + reactive strategies rather than reactive recruitment alone (odds ration [OR] = 5.36; confidence interval [CI], 2.31–12.45). Greater knowledge of SHS consequences (OR = 1.58; CI, 1.07–2.34) was another significant factor retained in the final LR model. Proactive recruitment may improve retention among underserved smokers in behavioral intervention trials. Identifying factors influencing retention may improve the success of recruitment strategies in future trials, in turn, enhancing the impact of smoking interventions.

Comparing intervention strategies among rural, low SES, young adult tobacco users.

OBJECTIVE To evaluate 3-month tobacco quit rates of young adult tobacco users randomized to 2 intervention conditions. METHODS Overall 192 non-treatment-seeking 18-to-24-year-old tobacco users received educational information and advice to quit smoking. Participants were then block randomized to 2 brief intervention conditions: (1) a telephone quitline (TQ) N = 90; or (2) a brief direct treatment intervention (BDTI) N = 102. RESULTS A 90-day follow-up evaluation found that 19.6% of BDTI and 10.2% of TQ participants reported 30-day point prevalence tobacco quit rates (chi-square = 2.37, P = .09). CONCLUSIONS BDTI can help non-treatment-seeking, low SES, young adult tobacco users quit smoking.