Kolawole S. Okuyemi

Progression to established smoking: The influence of tobacco marketing

BACKGROUND Recent studies have shown that tobacco advertising leads to the onset of smoking among adolescents. However, much more still remains to be learned about the impact of tobacco advertising in the later transitions, mainly from experimentation to established smoking. In this study, we focused on the influence of tobacco advertising and promotions on the transition from experimentation to established smoking. METHODS Data were derived from a longitudinal survey of adolescents in California. Adolescents who were classified as experimenters at baseline were included in the analyses (N=965). Receptivity to tobacco advertising and promotions refers to the development of a positive affective response to the communication (e.g., having a favorite tobacco advertisement or being willing to use a promotional item). RESULTS Approximately 32% of adolescents who were experimenters at baseline in 1993, progressed to established smoking by follow-up in 1996. Progression was higher among Caucasian (37.3%) than Hispanic (21.9%) or African-American (17.6%) adolescents. Adolescents who perceived that most of their peers smoked, had poor relationships with family members, and were exposed to smoking friends and family members were more likely to progress to established smoking at follow-up in 1996. In addition, adolescents who were receptive to advertising and believed that they could quit anytime were more likely to progress to established smoking than those who did not think they could quit anytime. Adolescents who were willing to use a promotional item and who believed that they could quit anytime had the highest rate of progression to established smoking (52%). CONCLUSIONS This study provides evidence that receptivity to tobacco advertising and promotions is an important factor in progressing from experimentation to established smoking among adolescents. Because perceived ability to quit made adolescents more likely to progress, counter-tobacco marketing campaigns should incorporate messages about addiction and difficulties associated with quitting.

Association of nicotine metabolite ratio and CYP2A6 genotype with smoking cessation treatment in African-American light smokers

Cytochrome P450 2A6 (CYP2A6) is the main nicotine (NIC)‐metabolizing enzyme in humans. We investigated the relationships between CYP2A6 genotype, baseline plasma trans‐ 3′‐hydroxycotinine/cotinine (3HC/COT) (a phenotypic marker of CYP2A6 activity), and smoking behavior in African‐American light smokers. Cigarette consumption, age of initiation, and dependence scores did not differ among 3HC/COT quartiles or CYP2A6 genotype groups. Slow metabolizers (SMs; both genetic and phenotypic) had significantly higher plasma NIC levels, suggesting that cigarette consumption was not reduced to adjust for slower rates of NIC metabolism. Individuals in the slowest 3HC/COT quartile had higher quitting rates with both placebo and NIC gum treatments (odds ratio 1.85, 95% confidence interval (CI) 1.08–3.16, P = 0.03). Similarly, the slowest CYP2A6 genotype group had higher quitting rates, although this trend did not reach significance (odds ratio 1.61, 95% CI 0.95–2.72, P = 0.08). The determination of the 3HC/COT ratio, and possibly CYP2A6 genotype, may be useful in the future for personalizing the choice of smoking cessation treatment in African‐American light smokers.

Light smokers: Issues and recommendations

Although the overall prevalence of tobacco smoking in the United States is decreasing, the proportion of light smokers is increasing and is as high as 50% among some groups. There is growing evidence that light smokers experience significantly higher health risks compared to nonsmokers, and they are often unable to quit smoking on their own. The prevalence of light smoking differs among subpopulations in the US and is particularly common among adolescents, college students, pregnant women, and some ethnic minorities. Characteristics of light smokers in these subpopulations vary, as do the underlying reasons for smoking, barriers to cessation, and treatment issues. Unfortunately, the paucity of research to develop and test effective cessation aids is common across all groups of light smokers. Given the substantial portion of light smokers in these populations, development and dissemination of effective behavioral and pharmacological interventions for light smokers is likely to result in substantial smoking reduction rates in the general population.

Differences among African American light, moderate, and heavy smokers

This study examined differences in demography, behavior, attitude, and physician intervention among African American light, moderate, and heavy smokers. Data were derived from an intervention study designed to assess whether a smoking status stamp would increase screening for smoking status and cessation counseling by physicians. Current analysis included 879 African American smokers categorized into three groups: light (<10 cigarettes/day), moderate (10-19 cigarettes/day), or heavy (> or =20 cigarettes/day) smokers based on number of cigarettes per day smoked. Light smokers constituted 40% of study sample, 33% were moderate smokers, and 27% were heavy smokers. Light smokers were more likely to be female (p<0.001) and have a shorter smoking history (p<0.001). Light smokers were not different in age (p=0.334), or the number of previous quit attempts (p=0.551). Although light smokers were more likely than moderate and heavy smokers to be preparing to quit (p<0.001), they were less likely to be asked their smoking status (p=0.031) or told to arrange follow-up for smoking cessation (p=0.034) by their physicians. Many African American smokers are light smokers. Light smokers are more likely to be female and have a shorter smoking history. Despite their readiness to quit, compared to heavier smokers, African American light smokers are asked about smoking less often by their physicians. Programs are needed to enhance physician intervention in this understudied population of smokers.

Successful recruitment of minorities into clinical trials: The Kick It at Swope project

Ethnic minorities are often underrepresented in clinical trials, and their recruitment can challenge researchers. Developing and communicating effective and efficient recruitment strategies may help researchers enroll more minorities into research studies. Kick It at Swope was a double-blind, randomized trial that evaluated bupropion for smoking cessation among 600 adult African Americans who smoked 10 or more cigarettes a day. Proactive recruitment strategies (in-person appeals by study staff and health care providers) and reactive recruitment strategies (disseminating information that asked people to call a study hotline) were implemented sequentially in an additive fashion over 16 months. Resulting patterns of recruitment are described and the two phases are compared based on their relative effectiveness, efficiency, and cost. More enrollees were recruited in the reactive phase (n=534) than in the proactive phase (n=66). Those recruited in the reactive phase were more likely to be eligible (OR=4.8) and more likely to be enrolled (OR=4.2) than those recruited in the proactive phase. Participants recruited in the reactive phase reported significantly higher levels of education and income, better health, and significantly lower indicators of depression and life hassles, compared with those recruited in the proactive phase. The reactive recruitment phase was less expensive than the proactive recruitment phase (22 US Dollars/enrollee vs. 159 US Dollars/enrollee). Reactive recruitment strategies added to multiple proactive clinic-based recruitment strategies were more effective, more efficient, and less costly than proactive recruitment alone. Close monitoring combined with the use of multiple recruitment methods and flexible recruitment plans can lead to successful, efficient, and low-cost recruitment of minorities into clinical trials.

Racial/ethnic differences in menthol cigarette smoking, population quit ratios and utilization of evidence‐based tobacco cessation treatments

AIMS This study examines the relationship between menthol cigarette smoking and the population quit ratio and whether menthol smokers differ in utilization of evidence-based smoking cessation aids among a nationally representative sample of US adult smokers. DESIGN, SETTING AND PARTICIPANTS Secondary data analysis of cross-sectional data from the 2005 National Health Interview Survey (NHIS) Cancer Control Supplement. The NHIS is a nationally representative survey of US households conducted annually. MEASUREMENTS The main outcome variables of interest were (1) the population quit ratio and (2) use of smoking quit aids. All analyses were conducted using SAS version 9.2 with SUDAAN, which corrects for the complex sampling design of the study. Univariate analyses were used to determine variables that differed significantly by menthol status and utilization of types of quit aids. Multiple logistic regression analysis modeled the relationship between menthol smoking status, demographic characteristics and smoking-related characteristics on the population quit ratio and utilization of quit aids. FINDINGS We observed significant differences in the population quit ratio for menthol versus non-menthol among African American smokers (34% versus 49%, P < 0.001), but not among whites (52% versus 50%). In multiple logistic regression analysis, there was a significant interaction between race and menthol smoking status. African American menthol smokers were significantly less likely than white non-menthol smokers to have quit smoking (adjusted odds ratio: 0.72, 95% confidence interval: 0.53, 0.97) after controlling for age group, sex, marital status, region and average number of cigarettes smoked per day. Menthol smoking status was not associated with differences in utilization of quit aids. CONCLUSIONS African Americans have the highest rates of menthol cigarette smoking of all racial and ethnic groups in the United States. Menthol cigarette smoking is associated negatively with successful smoking cessation among African Americans.

Adherence to Principles of Motivational Interviewing and Client Within-Session Behavior

The purpose of this study was to examine whether counselor adherence to Motivational Interviewing (MI) principles was associated with more productive within-session client behavior in a smoking cessation trial for African American smokers. For these analyses 89 baseline counseling sessions of the trial were audiotaped and coded using the Motivational Interviewing Skill Code (MISC). Counselor adherence indicators included a global subjective rating of MI adherence and the frequency of MI-consistent and MI-inconsistent counselor behaviors described in the MISC. Indicators of productive client behaviors included global subjective ratings of within-session client functioning and counselor-client interaction, as well as the frequency of statements by the client favorable toward changing behavior (“change talk”) and resistant regarding changing behavior (“resist-change talk”). Results provided support for the principles of MI. Counselor adherence indexed by both the global subjective rating and MI-consistent behavior frequency was significantly positively associated with global ratings of within-session client functioning and counselor-client interaction, as well as more change talk.

Smoking Cessation in Homeless Populations: A Pilot Clinical Trial

This study, which tested two motivational interviewing treatment approaches, assessed the feasibility of conducting a community-based smoking cessation intervention among homeless smokers. Participants (N = 46) were recruited from multiple facilities in the Kansas City area and were randomized to two counseling conditions in which they received five individual motivational interviewing sessions, six group meetings, and their choice of 8 weeks of 21-mg nicotine patch or 4-mg nicotine lozenge. The two counseling conditions consisted of motivational interviewing targeted either to smoking behaviors exclusively (smoking only) or to smoking and other addictions or life events that could affect ability to quit (smoking plus). Group meetings were designed to provide educational information and social support. Measures of feasibility assessed included the proportion of participants who returned for randomization among those eligible, adherence to prescribed nicotine replacement therapies, retention rates at the week 26 final study visit, and biochemically verified 7-day abstinence at week 26. Most participants (69.6%) chose nicotine patches, and 32% of those participants reported using at least four patches per week. Carbon monoxide verified 7-day abstinence rates in the smoking-only and smoking-plus groups were 13.04% and 17.39% (ns), respectively, at week 8 and 8.70% and 17.39% (ns), respectively, at week 26. Participants who used at least four patches per week were more likely to have quit at 8 weeks than were those who used fewer patches (33.3% vs. 10.5%, p = .30). Results support the feasibility of conducting a smoking cessation intervention among homeless smokers. Findings also show promising effects for nicotine replacement therapy and counseling in this population. Developing programs to improve smoking cessation outcomes in underserved populations is an essential step toward achieving national health objectives and for ultimately reducing tobacco-related health disparities.

Pathways to Health: A Cluster Randomized Trial of Nicotine Gum and Motivational Interviewing for Smoking Cessation in Low-Income Housing

Despite high smoking rates among those living in poverty, few cessation studies are conducted in these populations. This cluster-randomized trial tested nicotine gum plus motivational interviewing (MI) for smoking cessation in 20 low-income housing developments (HDs). Intervention participants (10 HDs, n = 66) received educational materials, 8 weeks of 4 mg nicotine gum, and 5 MI sessions on quitting smoking. Comparison participants (10 HDs, n = 107) received 5 MI sessions and educational materials addressing fruit and vegetable consumption. Participants had a mean age of 46.3 years and were predominantly female (70%) and African American (83%). Biochemically-verified 7-day abstinence rates at 8 weeks were 6.1% and 5.6% in the intervention and comparison arms, respectively (p = ns); and at 26 weeks were 7.6% and 9.3%, respectively (p = ns). Results suggest that nicotine gum plus MI were not effective for smoking cessation in low-income housing. Programs are needed to enhance the effectiveness of pharmacotherapy and counseling in underserved populations.

Population-Based Analysis of Morbidity and Mortality Following Surgery for Intractable Temporal Lobe Epilepsy in the United States

OBJECTIVE To assess the morbidity of temporal lobe epilepsy (TLE) surgery on a nationwide level in order to address reservations regarding the morbidity of anterior temporal lobectomy (ATL) for TLE despite class I evidence demonstrating the superiority of ATL over continued medical therapy. DESIGN Retrospective cohort study. SETTING The Nationwide Inpatient Sample from 1988 to 2003 was used for analysis. PATIENTS Only patients who were admitted for ATL for TLE (International Classification of Diseases, Ninth Revision, Clinical Modification codes 345.41 and 345.51; primary procedure code, 01.53) were included. MAIN OUTCOME MEASURES Morbidity and mortality. Analysis was adjusted for several variables including patient age, race, sex, admission type, primary payer for care, income in zip code of residence, and hospital volume of care. RESULTS Multivariate analyses revealed that the overall morbidity (postoperative morbidity and/or adverse discharge disposition) following ATL for TLE was 10.8%, with no mortality. Private insurance decreased postoperative morbidity (odds ratio [OR] = 0.52; 95% confidence interval [CI] = 0.28-0.98; P = .04) and adverse discharge disposition (OR = 0.31; 95% CI = 0.12-0.81; P = .02). Increased patient age increased postoperative morbidity (OR = 1.04; 95% CI = 1.01-1.07; P = .03) and adverse discharge disposition (OR = 1.08; 95% CI = 1.02-1.13; P = .004). Neither sex, income, race, nor hospital volume was predictive of postoperative morbidity. The degree of medical comorbidity directly correlated with the incidence of postoperative morbidity. CONCLUSIONS Morbidity following ATL for TLE is low throughout the United States regardless of sex, race, insurance status, or income. Younger age and private insurance status are independently predictive of reduced postoperative morbidity. In patients with low medical comorbidity, ATL for TLE is safe, with low morbidity and no mortality.