Philip H. Smith

The Impact of Cigarette Pack Design, Descriptors, and Warning Labels on Risk Perception in the U.S

BACKGROUNDnIn the U.S., limited evidence exists on the impact of colors and brand imagery used in cigarette pack design.nnnPURPOSEnThis study examined the impact of pack design, product descriptors, and health warnings on risk perception and brand appeal.nnnMETHODSnA cross-sectional mall-intercept study was conducted with 197 adult smokers and 200 nonsmokers in Buffalo NY from June to July 2009 (data analysis from July 2009 to December 2010). Participants were shown 12 sets of packs randomly; each set varied by a particular design feature (color, descriptor) or warning label style (text versus graphic, size, attribution, message framing). Packs were rated on criteria including risk perceptions, quit motivation, and purchase interest.nnnRESULTSnParticipants selected larger, pictorial, and loss-framed warning labels as more likely to attract attention, encourage thoughts about health risks, motivate quitting, and be most effective. Participants were more likely to select packs with lighter color shading and descriptors such as light, silver, and smooth as delivering less tar, smoother taste, and lower health risk, compared to darker-shaded or full-flavor packs. Additionally, participants were more likely to select the branded compared to plain white pack when asked which delivered the most tar, smoothest taste, was more attractive, appealed to youth aged <18 years, and contained cigarettes of better quality.nnnCONCLUSIONSnThe findings support larger, graphic health warnings that convey loss-framed messages as most effective in communicating health risks to U.S. adults. The results also indicate that color and product descriptors are associated with false beliefs about risks. Plain packaging may reduce many of the erroneous misperceptions of risk communicated through pack design features.

Gender Differences in Medication Use and Cigarette Smoking Cessation: Results From the International Tobacco Control Four Country Survey

INTRODUCTIONnThere is conflicting evidence for gender differences in smoking cessation, and there has been little research on gender differences in smoking cessation medication (SCM) use and effectiveness. Using longitudinal data from the International Tobacco Control Four Country Surveys (ITC-4) conducted in the United Kingdom, the United States, Canada, and Australia, we examined gender differences in the incidence of quit attempts, reasons for quitting, use of SCMs, reasons for discontinuing use of SCMs, and rates of smoking cessation.nnnMETHODSnData were analyzed from adult smokers participating in the ITC-4, annual waves 2006-2011 (n = 7,825), as well as a subsample of smokers (n = 1,079) who made quit attempts within 2 months of survey. Adjusted modeling utilized generalized estimating equations.nnnRESULTSnThere were no gender differences in the likelihood of desire to quit, plans to quit, or quit attempts between survey waves. Among quit attempters, women had 31% lower odds of successfully quitting (OR = 0.69; 95% CI = 0.51, 0.94). Stratified by medication use, quit success was lower among women who did not use any SCMs (OR = 0.59; 95% CI = 0.39, 0.90), and it was no different from men when medications were used (OR = 0.73; 95% CI = 0.46, 1.16). In particular, self-selected use of nicotine patch and varenicline contributed to successful quitting among women.nnnCONCLUSIONSnWomen may have more difficulty quitting than men, and SCMs use may help attenuate this difference.

Systematic and meta-analytic review of research examining the impact of menstrual cycle phase and ovarian hormones on smoking and cessation.

INTRODUCTIONnTo determine the effect of ovarian hormones on smoking, we conducted a systematic review of menstrual cycle effects on smoking (i.e., ad lib smoking, smoking topography, and subjective effects) and cessation-related behaviors (i.e., cessation, withdrawal, tonic craving, and cue-induced craving).nnnMETHODSnThirty-six papers were identified on MEDLINE that included a menstrual-related search term (e.g., menstrual cycle, ovarian hormones), a smoking-related search term (e.g., smoking, nicotine), and met all inclusion criteria. Thirty-two studies examined menstrual phase, 1 study measured hormone levels, and 3 studies administered progesterone.nnnRESULTSnSufficient data were available to conduct meta-analyses for only 2 of the 7 variables: withdrawal and tonic craving. Women reported greater withdrawal during the luteal phase than during the follicular phase, and there was a nonsignificant trend for greater tonic craving in the luteal phase. Progesterone administration was associated with decreased positive and increased negative subjective effects of nicotine. Studies of menstrual phase effects on the other outcome variables were either small in number or yielded mixed outcomes.nnnCONCLUSIONSnThe impact of menstrual cycle phase on smoking behavior and cessation is complicated, and insufficient research is available upon which to conduct meta-analyses on most smoking outcomes. Future progress will require collecting ovarian hormone levels to more precisely quantify the impact of dynamic changes in hormone levels through the cycle on smoking behavior. Clarifying the relationship between hormones and smoking-particularly related to quitting, relapse, and medication response-could determine the best type and timing of interventions to improve quit rates for women.

Concordant and discordant alcohol, tobacco, and marijuana use as predictors of marital dissolution

This study examined concordant and discrepant alcohol, tobacco, and marijuana use among couples to determine whether they predicted marital separation or divorce over 9 years. The study recruited 634 couples as they applied for their marriage licenses; we assessed them at that time and reassessed them with mailed questionnaires at their first, second, fourth, seventh, and ninth wedding anniversaries. Approximately 60% of the men and women were European American, and approximately 33% were African American. The frequency of drinking to intoxication and binge drinking (more than 5 drinks in an occasion) was assessed, as was the use of cigarettes and marijuana. At each assessment, each member of the couple was asked about the occurrence of marital separations and divorce. Bivariate analyses indicated that tobacco and marijuana use, whether discrepant or concordant, were associated with marital disruptions. However, discrepant heavy drinking was associated with disruptions, but concordant heavy drinking was not. Concordant and discordant marijuana use were not associated with divorce when analyses controlled for alcohol and tobacco use. Concordant and discordant tobacco use was not associated with divorce when analyses controlled for sociodemographic and personality factors. However, discrepant alcohol use was related to divorce after controlling for the other substances in 1 analysis and after controlling for the sociodemographic factors in a separate analysis. Tobacco and marijuana use were related to divorce through their associations with other variables. However, results suggest that discrepant alcohol use may lead to marital disruptions and should be addressed with couples seeking marital treatment.

Sex Differences in Varenicline Efficacy for Smoking Cessation: A Meta-Analysis

INTRODUCTIONnWomen have lower rates of quitting than men with both bupropion and nicotine replacement. It is unknown whether varenicline demonstrates differential efficacy for men and women. The purpose of this study was to conduct the first comprehensive meta-analysis of clinical trial data examining sex differences in the efficacy of varenicline for smoking cessation.nnnMETHODSnSearching MEDLINE, EMBASE, and PsychINFO, 17 of 43 clinical trials of varenicline for smoking cessation published through December 31, 2014 were low-bias randomized double-blind placebo-controlled trials. Data (n = 6710 smokers, 34% female, n = 16 studies, 96% of available data) was analyzed with Metafor program in R. Outcome endpoints were 7-day point-prevalence (PP) and continuous-abstinence (CA) at week 12 (end of treatment), week 24 (6-month follow-up), and week 52 (12-month follow-up).nnnRESULTSnUsing placebo, women were less likely than men to quit (PP-12, CA-24; P < .05 for sex). Using varenicline, similar rates of abstinence for men and women were demonstrated for all six outcomes (eg, PP-12 abstinence rates were 53% in both women and men). Varenicline versus placebo outcomes demonstrated that varenicline was more effective for women for short and intermediate outcomes (PP-12, CA-12, CA-24; P < .05 sex × medication interaction). For end-of-treatment PP, varenicline was 46% more effective for women. For continuous abstinence, varenicline was 34% (CA-12) and 31% (CA-24) more effective for women.nnnCONCLUSIONSnUnlike other smoking cessation medications, varenicline demonstrated greater efficacy among women smokers for short and immediate-term outcomes and equal efficacy for 1-year outcomes. Varenicline may be particularly useful for reducing the sex disparity typically seen in rates of smoking cessation.nnnIMPLICATIONSnVarenicline is currently the most effective FDA-approved smoking cessation medication and this is the first demonstration that women compared with men have a preferred therapeutic response for a smoking cessation medication when considering short-term outcomes. Importantly, this is also the first demonstration that women have similar rates of quitting to men when considering longer-term, 1-year outcomes.

Cigarette Smoking and Mental Illness: A Study of Nicotine Withdrawal

OBJECTIVESnWe compared prevalence, severity, and specific symptom profiles for nicotine withdrawal across categories of mental illness. We also examined the influence of nicotine withdrawal on efforts to quit smoking among those with mental illness.nnnMETHODSnWe analyzed data from 2 sources: wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions, limiting the sample to current smokers (2001-2002; nu2009=u20099913); and a 2-wave cohort telephone survey of a national sample of adult smokers (2004-2006; nu2009=u2009751).nnnRESULTSnMental illness was associated with a substantially greater likelihood of nicotine withdrawal syndrome; approximately 44% of nicotine withdrawal syndrome diagnoses were attributable to mental illness. Symptom profiles were highly comparable between mental illness categories, although anxiety-related symptoms were better markers of withdrawal for those with an internalizing disorder. Smokers with mental illness were motivated to quit but were less likely to be successful in their quit attempts, and both dependence and withdrawal independently accounted for this lower likelihood of success.nnnCONCLUSIONSnNicotine withdrawal may be a particularly important target for intervention among those with mental illness who smoke cigarettes.

Correcting over 50 years of tobacco industry misinformation.

BACKGROUNDnIn 2006, a U.S. Federal Court ruled that the major domestic cigarette manufacturers were guilty of conspiring to deny, distort, and minimize the hazards of cigarette smoking to the public and ordered corrective statements to correct these deceptions.nnnPURPOSEnThis study evaluates the effectiveness of different versions of corrective statements that were proposed to the Court.nnnMETHODSn239 adult smokers (aged 18-65 years) were randomized to view one of five different versions of corrective statements on five topics (health risks, addiction, low-tar cigarettes, product manipulation, and secondhand smoke); change in knowledge and beliefs were measured before and after viewing the statements, as well as 1 week later. Three of the versions were text-based statements recommended by different parties in the case (Philip Morris, U.S. Department of Justice [DOJ], Interveners), whereas two others were developed at Roswell Park Cancer Institute (RPCI) for this study and utilized pictorial images (emotive and neutral). Data collection and analysis were conducted in Buffalo NY from 2008 to 2009.nnnRESULTSnRegardless of which corrective statement was seen, exposure resulted in a consistent pattern of increased level of knowledge and corrected misperceptions about smoking, although the effects were not large and diminished back toward baseline levels within 1 week. The DOJ, Interveners, and emotive statements elicited a stronger affective response and were rated by respondents as more persuasive (p-value<0.05). The emotive statement was better recalled and drew the respondents attention in the shortest amount of time.nnnCONCLUSIONSnEach of the proposed corrective statements tested helped correct false beliefs about smoking, but sustained impact will likely require repeated exposures to the message.

Targeting the Noradrenergic System for Gender- Sensitive Medication Development for Tobacco Dependence

INTRODUCTIONnTobacco use remains the leading cause of morbidity and mortality for both women and men in the United States, and women often experience poorer smoking cessation outcomes than men. Preliminary evidence suggests there are sex differences in medication effectiveness for smoking cessation. However, current medications do not take into account gender-sensitive treatment development and efficacy, underscoring the importance of this underdeveloped area of research.nnnMETHODSnWe reviewed preclinical and clinical evidence for gender differences in the inability to quit smoking by examining (a) the effect of increased negative affect and stress reactivity on smoking outcomes in women and (b) smoking for nicotine reinforcement in men. We also reviewed the current literature targeting the noradrenergic system as a novel gender-sensitive treatment strategy for tobacco dependence.nnnRESULTSnWe hypothesize that noradrenergic agents that normalize noradrenergic activity may differentially attenuate stress reactivity in women and nicotine-related reinforcement in men, indicating that targeting the noradrenergic system for smoking cessation may be effective for both genders, with benefits operating through sex-specific mechanisms.nnnCONCLUSIONSnConverging lines of preclinical and clinical evidence suggest that gender-sensitive approaches to medication development for smoking cessation are a critical next step for addressing low quit rates and exacerbated health risks among women. Evidence reviewed indicates that smoking activates different brain systems modulated by noradrenergic activity in women versus men, and noradrenergic compounds may preferentially target these gender-sensitive systems.

Childhood sexual abuse, distress, and alcohol-related problems: Moderation by drinking to cope

Previous studies have found relationships between childhood sexual abuse (CSA) and problem alcohol use. However, few studies have explored mechanisms that may explain this relationship. The present study examined whether (a) distress mediated the relationship between CSA and both heavy drinking and alcohol consequences, (b) coping motives for drinking moderated the paths between distress and both heavy drinking and alcohol consequences, and (c) these relationships remained significant after controlling for other forms of abuse/trauma. Three hundred ninety-five undergraduate women completed survey measures of childhood abuse/trauma, alcohol use/consequences, distress, and drinking motives. Data were analyzed using path analyses. Results supported a moderated-mediation model in which distress mediated the relationship between CSA and alcohol consequences, but only among those who endorsed coping motives for drinking. After controlling for other forms of abuse/maltreatment, the moderated-mediated pathway was no longer significant, but there remained a direct path between CSA and alcohol consequences. The present study provides support for tension-reduction models of alcohol use among CSA-exposed women and demonstrates the moderating role of coping motives. The present study also highlights the need for future studies to control for other forms of abuse/trauma and suggests that other mechanisms and contextual variables need to be explored to explain the CSA/alcohol-use pathway.

Couples' marijuana use is inversely related to their intimate partner violence over the first 9 years of marriage

Research on the association between marijuana use and intimate partner violence (IPV) has generated inconsistent findings, and has been primarily based on cross-sectional data. We examined whether husbands and wives marijuana use predicted both husbands and wives IPV perpetration over the first 9 years of marriage (Wave 1, n = 634 couples). We also examined moderation by antisocial behavior, the spouses marijuana use, and whether IPV was reported during the year before marriage. These predictive associations were calculated using a time-lagged multivariate generalized multilevel model, simultaneously estimating predictors of husband and wife IPV. In fully adjusted models, we found that more frequent marijuana use by husbands and wives predicted less frequent IPV perpetration by husbands. Husbands marijuana use also predicted less frequent IPV perpetration by wives. Moderation analyses demonstrated that couples in which both spouses used marijuana frequently reported the least frequent IPV perpetration. There was a significant positive association between wives marijuana use and wives IPV perpetration, but only among wives who had already reported IPV perpetration during the year before marriage. These findings suggest there may be an overall inverse association between marijuana use and IPV perpetration in newly married couples, although use may be associated with greater risk of perpetration among women with a history of IPV perpetration.