Myra L. Muramoto

A controlled trial of sustained - Release bupropion, a nicotine patch, or both for smoking cessation

BACKGROUND AND METHODS Use of nicotine-replacement therapies and the antidepressant bupropion helps people stop smoking. We conducted a double-blind, placebo-controlled comparison of sustained-release bupropion (244 subjects), a nicotine patch (244 subjects), bupropion and a nicotine patch (245 subjects), and placebo (160 subjects) for smoking cessation. Smokers with clinical depression were excluded. Treatment consisted of nine weeks of bupropion (150 mg a day for the first three days, and then 150 mg twice daily) or placebo, as well as eight weeks of nicotine-patch therapy (21 mg per day during weeks 2 through 7, 14 mg per day during week 8, and 7 mg per day during week 9) or placebo. The target day for quitting smoking was usually day 8. RESULTS The abstinence rates at 12 months were 15.6 percent in the placebo group, as compared with 16.4 percent in the nicotine-patch group, 30.3 percent in the bupropion group (P<0.001), and 35.5 percent in the group given bupropion and the nicotine patch (P<0.001). By week 7, subjects in the placebo group had gained an average of 2.1 kg, as compared with a gain of 1.6 kg in the nicotine-patch group, a gain of 1.7 kg in the bupropion group, and a gain of 1.1 kg in the combined-treatment group (P<0.05). Weight gain at seven weeks was significantly less in the combined-treatment group than in the bupropion group and the placebo group (P<0.05 for both comparisons). A total of 311 subjects (34.8 percent) discontinued one or both medications. Seventy-nine subjects stopped treatment because of adverse events: 6 in the placebo group (3.8 percent), 16 in the nicotine-patch group (6.6 percent), 29 in the bupropion group (11.9 percent), and 28 in the combined-treatment group (11.4 percent). The most common adverse events were insomnia and headache. CONCLUSIONS Treatment with sustained-release bupropion alone or in combination with a nicotine patch resulted in significantly higher long-term rates of smoking cessation than use of either the nicotine patch alone or placebo. Abstinence rates were higher with combination therapy than with bupropion alone, but the difference was not statistically significant.

State-of-the-Art Interventions for Office-Based Parental Tobacco Control

Parental tobacco use is a serious health issue for all family members. Child health care clinicians are in a unique and important position to address parental smoking because of the regular, multiple contacts with parents and the harmful health consequences to their patients. This article synthesizes the current evidence-based interventions for treatment of adults and applies them to the problem of addressing parental smoking in the context of the child health care setting. Brief interventions are effective, and complementary strategies such as quitlines will improve the chances of parental smoking cessation. Adopting the 5 A’s framework strategy (ask, advise, assess, assist, and arrange) gives each parent the maximum chance of quitting. Within this framework, specific recommendations are made for child health care settings and clinicians. Ongoing research will help determine how best to implement parental smoking-cessation strategies more widely in a variety of child health care settings.

Efficacy of the nicotine inhaler in smoking reduction: A double-blind, randomized trial

Many smokers are not ready to quit but are interested in changing their smoking behavior, particularly if such a change is associated with a reduction in health risk. The present study evaluated the efficacy of the nicotine inhaler in reducing smoking. Exploratory studies assessed whether reduction in smoking was associated with reduction in markers of disease risk. A total of 429 healthy smokers (smoking at least 20 cigarettes/day) were randomly assigned to either nicotine-containing or placebo inhalers, which subjects were allowed to use ad libitum for up to 1 year. The nicotine inhaler was significantly superior to placebo in achieving reduction in daily cigarette consumption by at least 50% after 4 months, compared with baseline (18% vs. 8%, p = .004). Active treatment promoted smoking cessation: 8% of subjects in the nicotine group and 1% in the placebo group were abstinent at month 15. Throughout the study, smoking reduction, per se, independent of treatment group, was associated with a statistically significant decrease in exhaled carbon monoxide and serum cotinine and thiocyanate. Smoking reduction also improved established risk markers for cardiovascular disease over 4 months. The incidence of adverse events did not differ significantly between the active and placebo groups. The most common treatment-related adverse events were throat irritation and cough. In conclusion, the nicotine inhaler can help smokers who are unable or unwilling to quit to reduce daily cigarette consumption, which may be a health benefit on its own and may further promote quitting.

Prevalence of Intestinal Encephalitozoonosis in Mexico

Infections with Encephalitozoon (phylum Microspora) protozoa in immunodeficient patients have emerged worldwide. The prevalence of infections due to Encephalitozoon species in nonclinical populations remains unclear. We conducted a cross-sectional survey of two rural highland villages in Mexico by using monoclonal antibody 3B6 to Encephalitozoon in immunofluorescence to assess the prevalence of Encephalitozoon spores in human stools. We found that 20 (7.84%) of the 255 subjects were positive and that 15 (21.4%) of the 70 households had at least one member who was positive. These results suggest that Encephalitozoon species, most likely Encephalitozoon intestinalis, may be commonly present in community settings.

Smoking Among Low-Income Pregnant Women: An Ethnographic Analysis

This article presents findings from a qualitative study of 53 low-income women who were smokers at the onset of pregnancy. Study participants were interviewed during pregnancy to document smoking trajectories and factors contributing to, or undermining, harm reduction and quit attempts. Thirty percent of women quit smoking completely, 43% engaged in sustained harm reduction, and 26% reduced their smoking levels intermittently. Case studies of women are presented to illustrate reasons for quitting, harm reduction practices, and factors influencing relapse and smoking continuation. Womens motivations to quit are highlighted. Moral identity as a mother was found to be a key motivating factor behind womens quit attempts. Future programs targeting this population would do well to acknowledge moral identity as an issue and recognize the challenges of quitting for women with limited social support and little control over their immediate environment.

Physician assessment of patient smoking in Indonesia: a public health priority

Objective: To explore Indonesian physician’s smoking behaviours, their attitudes and clinical practices towards smoking cessation. Design: Cross-sectional survey. Setting: Physicians working in Jogjakarta Province, Indonesia, between October and December 2003. Subjects: 447 of 690 (65%) physicians with clinical responsibilities responded to the survey (236 men, 211 women), of which 15% were medical faculty, 35% residents and 50% community physicians. Results: 22% of male (n = 50) and 1% of female (n = 2) physicians were current smokers. Approximately 72% of physicians did not routinely ask about their patient’s smoking status. A majority of physicians (80%) believed that smoking up to 10 cigarettes a day was not harmful for health. The predictors for asking patients about smoking were being male, a non-smoker and a medical resident. The odds of advising patients to quit were significantly greater among physicians who perceived themselves as sufficiently trained in smoking cessation. Conclusions: Lack of training in smoking cessation seems to be a major obstacle to physicians actively engaging in smoking cessation activities. Indonesian physicians need to be educated on the importance of routinely asking their patients about their tobacco use and offering practical advice on how to quit smoking.

Methamphetamine suppression and route of administration: precursor regulation impacts on snorting, smoking, swallowing and injecting

AIMS The route of drug administration affects risk for dependence and medical harm. This study examines whether routes used by methamphetamine treatment participants were impacted by a major drug suppression policy-federal regulation of the methamphetamine precursor chemicals ephedrine and pseudoephedrine. DESIGN Autoregressive-integrated moving average (ARIMA) intervention time-series analysis. SETTING California (1992-2004). INTERVENTIONS Ephedrine single-ingredient products regulation, implemented August 1995; ephedrine with other active medicinal ingredients regulation, implemented October 1996; pseudoephedrine products regulation, implemented October 1997. MEASUREMENTS Monthly counts of non-coerced methamphetamine treatment admissions reporting snorting, smoking, swallowing or injecting. Findings After rising sharply, snorting, smoking, swallowing and injecting admissions dropped 50%, 43%, 26% and 26%, respectively, when the 1995 regulation was implemented. Snorting also dropped 38% at the time of the 1997 regulation. Snorting, swallowing and injecting remained at lower levels to the end of the study period. Smoking resurged (40%) at the time of the 1996 regulation and continued rising. CONCLUSIONS Precursor regulation was associated with changes in the administration of methamphetamine. Injecting, the route with the greatest health risk, entered a long-term reduction. So, too, did snorting and swallowing, two routes with lower risk for dependence. In contrast, smoking, which has a relatively high risk for dependence, dropped, then rebounded and entered a long-term rise. A possible explanation is that injecting, snorting and swallowing were largely linked with US domestic methamphetamine production, which has yet to recover from the regulations. While Mexican production, which was impacted only temporarily by the regulations and has supplanted domestic production, may have helped to diffuse smoking, a route with which it is historically correlated.

State-of-the-Art Office-Based Interventions to Eliminate Youth Tobacco Use: The Past Decade

Tobacco use and tobacco smoke exposure are among the most important preventable causes of premature disease, disability, and death and therefore constitute a major pediatric health concern. The pediatric primary care setting offers excellent opportunities to prevent tobacco use in youth and to deliver cessation-related treatment to youth and parents who use tobacco. This report updates a “state-of-the-art” article published a decade ago on office-based interventions to address these issues. Since then there has been marked progress in understanding the nature, onset, and trajectories of tobacco use and nicotine addiction in youth with implications for clinical practice. In addition, clinicians need to remain abreast of emerging nicotine delivery systems, such as electronic cigarettes, that may influence uptake or continuation of smoking. Although evidence-based practice guidelines for treating nicotine addiction in youth are not yet available, research continues to build the evidence base toward that goal. In the interim, practical guidelines are available to assist clinicians in addressing nicotine addiction in the pediatric clinical setting. This article reports current practices in addressing tobacco in pediatric primary care settings. It reviews our increasing understanding of youth nicotine addiction, summarizes research efforts on intervention in the past decade and additional research needed going forward, and provides practical guidelines for pediatric health care providers to integrate tobacco use prevention and treatment into their clinical practice. Pediatric providers can and should play an important role in addressing tobacco use and dependence, both in the youth they care for and in parents who use tobacco.

Breastfeeding and Smoking among Low-Income Women: Results of a Longitudinal Qualitative Study

BACKGROUND The benefits of breastfeeding for infants and mothers have been well established, yet rates of breastfeeding remain well below national recommendations in the United States and even lower for women who smoke during pregnancy. Primary goals of this study were to explore contextual factors that contribute to breastfeeding intentions and behavior and to examine how smoking status affected womens decision making about breastfeeding. METHODS This paper is based on a longitudinal qualitative study of smoking, pregnancy, and breastfeeding among 44 low-income women in the southwest U.S. who smoked during pregnancy. Each woman was interviewed 9 times; 6 times during pregnancy and 3 times postpartum using semistructured questionnaires. Interviews lasted 1 to 3 hours and were tape-recorded, transcribed, and analyzed. RESULTS Despite 36 (82%) respondents stating that they intended to breastfeed for an average duration of 8 months, rates of breastfeeding initiation and duration were much lower than intentions. By 6 months postpartum, only two women were breastfeeding exclusively. CONCLUSIONS Women perceived that a strong risk of harming the baby was posed by smoking while breastfeeding and received little encouragement to continue breastfeeding despite an inability to stop smoking. The perceptions of the toxic, addictive, and harmful effects of smoking on breastmilk constitution and quantity factored into reasons why women weaned their infants from breastfeeding much earlier than the recommended 6 months. The results indicate a need for more consistency and routine in educating women on the relationship between smoking and breastfeeding and in promoting breastfeeding in spite of smoking postpartum.

Tobacco cessation skills certification in Arizona: Application of a state wide, community based model for diffusion of evidence based practice guidelines

OBJECTIVE To describe the development and preliminary results from a community based certification model for training in tobacco cessation skills in Arizona. DESIGN A programme evaluation using both quantitative pre-post measures and qualitative methods. SETTING Arizonas comprehensive tobacco control programme of state funded, community based local projects and their community partners providing tobacco treatment services for geographically, socioeconomically, and ethnically diverse communities. INTERVENTION A three tiered model of skills based training emphasising Agency for Health Care Policy and Research guidelines, and utilising a training of trainers approach to build community capacity. Certification roles addressed basic tobacco cessation skills, tobacco cessation specialist, and tobacco treatment services manager. PARTICIPANTS Initial target audience was community based local project personnel and their community partners, with later adoption by community organisations unaffiliated with local projects, and the general public. MAIN EVALUATION MEASURES Process measures: participant satisfaction, knowledge, skills, and self-efficacy. Outcome: participant demographics, community organisations represented, post-training, cessation related activities. RESULTS During the models implementation year, 1075 participants attended certification training, 947 participants received basic skills certificates and 82 received specialist certificates. Pre, post, and three month measures of self efficacy showed significant and durable increases. Analysis of participant characteristics demonstrated broad community representation. At post-training follow up, 80.9% of basic skills trainees had performed at least one brief intervention and 74.8% had made a referral to intensive services. Among cessation specialists, 48.8% were delivering intensive services and 69.5% were teaching basic skills classes. CONCLUSIONS Initial experience with Arizonas state wide, community based model for certification of tobacco cessation skills training suggests this model may be a promising method for broad, population based diffusion of evidence based tobacco cessation guidelines.