Rebecca L. Emery

Religiosity and substance use among Asian American college students: Moderated effects of race and acculturation

BACKGROUND Religiosity is a well-established protective factor against substance use among Caucasians, but limited research has examined its role among Asian Americans. The purposes of this study were (1) to examine whether the associations between religiosity and substance use outcomes differed across Caucasians and Asian Americans, and (2) to test whether acculturation moderated the associations between religiosity and substance use outcomes among Asian Americans. METHOD We utilized a large and diverse cross-sectional sample of 839 college students to test whether race moderated the associations between religiosity and substance use outcomes (Study 1). We then replicated and extended our findings in a separate college sample of 340 Asian Americans, and examined the moderating role of acculturation on the associations between religiosity and substance use outcomes (Study 2). RESULTS Controlling for age, gender, and paternal education, religiosity was protective against alcohol use, alcohol problems, and marijuana use among Caucasians but was unrelated to these outcomes among Asian Americans in Study 1. In Study 2, religiosity was protective against alcohol problems only at high levels of acculturation. Moreover, religiosity was protective against marijuana use at both high and mean levels of acculturation, but not at low levels of acculturation. CONCLUSIONS The protective effects of religiosity on alcohol use and problems varied across Caucasian and Asian American college students, and religiosity protected against alcohol problems and marijuana use only among more acculturated Asian Americans. These findings underscore the need to examine culturally-specific correlates of substance use outcomes among Asian Americans.

Questionnaire and behavioral task measures of impulsivity are differentially associated with body mass index: A comprehensive meta-analysis.

Although impulsivity has been implicated in the development and maintenance of obesity, evidence linking impulsivity to obesity has been mixed. These mixed findings may be related to differences in the type of impulsivity measures used and the varied domains of impulsivity assessed by each measure. The present meta-analysis aimed to examine the impact of measurement selection on the relationship between impulsivity and body mass index (BMI). A total of 142 articles met inclusion criteria and were comprised of 315,818 participants. Effect sizes consisted of Fisher’s z-transformed correlation coefficients, which were weighted by the inverse variance to establish the grand mean estimate of the relationship between impulsivity and BMI. Overall weighted mean effect sizes also were computed for each type and domain of impulsivity measure. Moderator analyses were conducted using a mixed-effects approach to determine if the relationship between impulsivity and BMI varied between the types of impulsivity measures used. On average, participants were 32.25 (SD = 12.41) years of age, with a BMI of 26.63 (SD = 5.73) kg/m2. The overall relationship between impulsivity and BMI was small but significant (r = .07). Behavioral task measures of impulsivity produced significantly larger effect sizes (r = .10) than did questionnaire measures of impulsivity (r = .05). Domains of impulsivity that assessed disinhibited behaviors (r = .10), attentional deficits (r = .11), impulsive decision-making (r = .10), and cognitive inflexibility (r = .17) produced significant effect sizes. These meta-analytic findings demonstrate that impulsivity is positively associated with BMI and further document that this association varies by the type of impulsivity measure used and the domain of impulsivity assessed.

Examining the effect of binge eating and disinhibition on compensatory changes in energy balance following exercise among overweight and obese women.

Some women behaviorally compensate for the energy expended during exercise by increasing their energy intake or becoming more sedentary, thereby decreasing their energy expenditure. Although behavioral compensation can attenuate or even reverse the energy deficit generated by exercise, few data are available on predictors of compensatory responses to exercise. The present study aimed to identify eating-related predictors of compensatory changes in energy balance following exercise. Overweight and obese, physically inactive women (N=48) completed self-report measures of disinhibition and binge eating and participated in two experimental conditions, exercise and rest, in counterbalanced order. Energy intake and expenditure were measured for 24-hours following each experimental condition to estimate energy balance. On average, women were 21.33±2.09years old and 63% were white. Of the sample, 63% compensated for the energy expended during exercise by increasing their energy intake or decreasing their energy expenditure. Linear mixed effects modeling with repeated measurement showed that disinhibition was not predictive of behavioral compensation. However, there was a significant difference between the negative energy balance observed following the rest condition and the positive energy balance observed following the exercise condition among women who reported binge eating, which was driven by a tendency to spend less time being physically active and more time being sedentary following exercise. These findings indicate that women who binge eat may be at greatest risk of compensating for exercise. Future research is needed to better understand psychosocial predictors and common mechanisms through which behavioral compensation is promoted.

Prevalence and correlates of a lifetime cannabis use disorder among pregnant former tobacco smokers.

BACKGROUND Following tobacco and alcohol, cannabis is the most commonly used substance during pregnancy. Given the high prevalence of concurrent cannabis and tobacco use as well as the health consequences associated with prenatal substance use, we sought to document the relative contributions of psychosocial and psychiatric factors commonly associated with cannabis use in predicting a lifetime cannabis use disorder (CUD) among women who had quit smoking tobacco as a result of pregnancy. METHODS Pregnant former tobacco smokers (n=273) enrolled in a larger randomized controlled trial for postpartum tobacco relapse prevention completed semi-structured psychiatric interviews and self-reported demographic, pregnancy, health, psychosocial, and tobacco use factors during their third trimester of pregnancy. RESULTS In total, 14% (n=38) of women met criteria for a lifetime CUD. The strongest predictors of a lifetime CUD were a history of having multiple psychiatric disorders (OR=36.44; 95% CI=5.03-264.27; p<0.001) followed by a lifetime alcohol use disorder (OR=3.54; 95% CI=1.27-9.87; p<0.05). In addition, more frequent attempts to quit smoking tobacco (OR=1.12; 95% CI=1.01-1.25; p<0.05) and lower self-efficacy about weight management after quitting smoking tobacco (OR=0.78; 95% CI=0.62-0.97; p<0.05) also were significantly associated with a lifetime CUD. CONCLUSIONS Women with a history of both cannabis and tobacco dependence may represent a subset of women who need more specialized treatment during the perinatal period to improve substance use outcomes.

The Influence of Smoking on Breast feeding Among Women Who Quit Smoking During Pregnancy

Introduction Understanding factors related to breast-feeding intention, initiation, duration, and weaning among women who quit smoking as a result of pregnancy may inform interventions to increase breast-feeding rates among women who smoke. Methods Women (N = 300) who quit smoking as a result of pregnancy and enrolled in a postpartum relapse prevention trial were interviewed about breast-feeding intention prior to delivery. Breast-feeding initiation, duration, reasons for weaning, and relapse to smoking were assessed at 12-weeks postpartum. Results The majority of pregnant former smokers intended to breastfeed (68%), and actual rates of breast feeding were higher (74%). Among women who initiated breast feeding, weaning before 2 months was common (41%). For most women (69%), smoking had no effect on breast-feeding decisions. Among the 31% of women who reported that smoking influenced their feeding decisions, 83% indicated that they did not smoke or decreased smoking frequency in order to breastfeed while 17% did not breastfeed or quit breast feeding in order to smoke. Women who decided to forgo breast feeding to smoke were significantly more likely to have a high school education or less (p < .001) and to be African American (p < .0001) than those who had other reasons not to breastfeed. Conclusions Most women who quit smoking during pregnancy initiate breast feeding, and the majority report smoking did not influence feeding decisions. Importantly, among women for whom smoking did influence feeding decisions, most reported changing smoking behavior to enable breast feeding. Interventions to increase breast-feeding initiation and duration may decrease postpartum relapse and improve maternal and infant health. Implications This study extends the literature on womens perception of the influence of smoking on breast feeding by assessing breast-feeding intent, initiation, duration, and reasons for weaning longitudinally among women who quit smoking as a result of pregnancy. The results support a need for additional research to determine the effectiveness of breast feeding supports as a component of interventions to reduce postpartum smoking relapse.

Loss of control over eating before and during early pregnancy among community women with overweight and obesity

OBJECTIVE This study examined the prevalence of and changes in loss of control over eating (LOC) among pregnant women with overweight/obesity, along with associations between LOC and depressive symptoms and stress. METHOD Community women (N = 200; body mass index ≥ 25; 12-20 weeks gestation) reported LOC before and during early pregnancy using the Eating Disorder Examination, which was adapted for administration in pregnancy. Women self-reported depressive symptoms and stress during early pregnancy. RESULTS Twenty-eight percent (n = 56) of women reported LOC before or during early pregnancy: 14.5% (n = 29) reported LOC incidence during early pregnancy, 9.5% (n = 19) reported LOC persistence from prepregnancy to early pregnancy, and 4.0% (n = 8) reported LOC prepregnancy only. Women with LOC reported more depressive symptoms and stress than did those without. Women with LOC persistence reported clinically significant depressive symptoms and elevated stress. Levels of depressive symptoms and stress differed between women with LOC persistence and those without LOC (ps < 0.05). DISCUSSION LOC during pregnancy was prevalent and associated with distress, particularly when present before and during pregnancy. Among women with LOC, few reported remission, but one-half reported onset during early pregnancy. Longitudinal studies are needed among mothers with overweight/obesity to identify patterns of LOC throughout pregnancy and how LOC affects perinatal outcomes.

Change in Body Weight Does Not Mediate the Relationship Between Exercise and Smoking Cessation Among Weight-Concerned Women Smokers.

INTRODUCTION Exercise has received attention as a method to prevent or reduce postcessation weight gain. However, little is known about how weight changes following quit attempts contribute to the relationship between exercise and smoking cessation. The present study assessed how exercise relates to cessation and whether initial changes in exercise after quitting smoking promote cessation through attenuated weight gain. METHODS Weight-concerned women smokers (N = 342) receiving cessation treatment provided biochemical validation of cessation, reported weekly exercise activities, and were weighed at 1, 3, and 6 months following treatment initiation. Survival analyses were used to determine time to and risk of relapse among women who reported engaging in varied levels of exercise at baseline. A mediation analysis was used to examine whether the effect of initial changes in exercise on longer-term cessation was driven by change in weight. All analyses were adjusted for relevant covariates. RESULTS Women smokers who reported high levels of exercise at baseline were less likely to relapse and returned to smoking more gradually than did women who reported low levels of exercise. Change in weight did not mediate the relationship between exercise and cessation. CONCLUSIONS Cessation interventions utilizing an exercise component may have to develop exercise regimens of either higher duration or greater intensity to produce beneficial cessation outcomes, particularly when targeting sedentary smokers. Given that change in weight did not mediate the relationship between exercise and cessation, it is likely that other mediational processes are involved.

Adapting the eating disorder examination for use during pregnancy: Preliminary results from a community sample of women with overweight and obesity

OBJECTIVE The Eating Disorder Examination (EDE) is a structured clinical interview that is widely used for assessing disordered eating. Although the EDE has been used in pregnant women, no standard pregnancy version has been developed. Accordingly, the present study aimed to document adaptations made to a pregnancy version of the EDE (EDE-PV) and to describe the internal reliability of this adapted version. METHOD Three major modifications were made in the development of the EDE-PV. First, disordered eating was assessed during and prior to pregnancy to account for changes across the perinatal period. Second, items were adapted and rules governing ratings were altered to distinguish eating attitudes and behaviors that are considered normative during pregnancy from disordered eating. Third, several items were omitted. RESULTS The EDE-PV was administered to 129 women with overweight and obesity who were between 12 and 20 weeks gestation. Women were 27.25 (SD = 5.48) years of age and 56% were African American. Women endorsed low levels of disordered eating on the EDE-PV, and the internal reliability was similar to previous reports. CONCLUSION These findings provide support for use of the EDE-PV to assess disordered eating among pregnant women with overweight and obesity.

Optimal Carbon Monoxide Criteria to Confirm Smoking Status Among Postpartum Women

INTRODUCTION Although expired-air carbon monoxide (CO) is a well characterized biomarker of cigarette smoking, limited research has assessed whether the standard clinical CO cutoffs need to be altered for postpartum women and whether these cutoffs remain constant across the postpartum year. Accordingly, the present study evaluated the effectiveness of using CO as a method to confirm smoking status relative to salivary cotinine among postpartum women and assessed optimal CO criteria to confirm smoking status across the postpartum year. Differences in optimal CO criteria to confirm smoking status also were examined between black and white postpartum women. METHODS Women (N = 208) for the present study had quit smoking for their current pregnancy and were enrolled in a larger postpartum relapse prevention intervention. Smoking status was assessed at 12, 24, and 52 weeks postpartum using both expired-air CO and salivary cotinine. RESULTS Receiver-operating characteristic analyses indicated that CO provided moderately high diagnostic accuracy to distinguish between women who were and were not smoking when using salivary cotinine as the reference criterion to confirm smoking status. CO cutoffs of 2 and 3 parts per million (ppm) had the highest overall efficiency and combined sensitivity and specificity across the postpartum year. Results were consistent for black and white women. CONCLUSIONS These findings indicate that optimal CO criteria to confirm smoking status remains stable throughout the postpartum year and support a need to utilize CO cutoffs much lower than the standard clinical CO criterion of 8 ppm to confirm abstinence among postpartum women. IMPLICATIONS Findings from the present study confirm the value of CO as a biomarker of smoking status among postpartum women. Results indicate that CO cutoffs of 2 and 3 ppm were optimal for confirming smoking status across the entire postpartum year in both black and white women. These findings offer a replication and extension of previous work and indicate that optimal CO criteria to confirm smoking status remain stable throughout the postpartum period and further support a need to utilize CO cutoffs much lower than the standard clinical criterion of 8 ppm to confirm smoking status among postpartum women.

Do Psychiatric Disorders or Measures of Distress Moderate Response to Postpartum Relapse Prevention Interventions

Introduction Most women who quit smoking during pregnancy will relapse postpartum. Interventions for sustained postpartum abstinence can benefit from understanding prenatal characteristics associated with treatment response. Given that individuals with psychiatric disorders or elevated depressive symptoms have difficulty quitting smoking and that increases in depressive symptoms prenatally are common, we examined the relevance of psychiatric diagnoses, prenatal depressive symptoms, and stress to postpartum relapse prevention intervention response. Methods Pregnant women (N = 300) who quit smoking during pregnancy received intervention (with specialized focus on mood, weight, and stress [STARTS] or a comparison [SUPPORT]) to prevent postpartum relapse. As previously published, nearly one-third and one-quarter of women achieved biochemically-confirmed sustained abstinence at 24- and 52-weeks postpartum, with no difference in abstinence rates between the interventions. Women completed psychiatric interviews and questionnaires during pregnancy. Smoking was assessed in pregnancy, and 24- and 52-weeks postpartum. Results Psychiatric disorders did not predict sustained abstinence or treatment response. However, treatment response was moderated by end-of-pregnancy depressive symptoms (χ2 = 9.98, p = .002) and stress (χ2 = 6.90, p = .01) at 24- and 52-weeks postpartum and remained significant after including covariates. Women with low distress achieved higher abstinence rates in SUPPORT than in STARTS (37% vs. 19% for depressive symptoms; 36% vs. 19% for stress), with no difference for women with high symptoms. Conclusions Prenatal depressive symptoms and stress predicted differential treatment efficacy in women with low symptoms, not in women with high symptoms. Diagnostic history did not predict treatment differences. Future research to address prenatal distress may help tailor postpartum relapse prevention interventions. Implications We examined prenatal history of psychiatric disorders and psychiatric distress as moderators of response to postpartum smoking relapse prevention intervention that either included or did not include added content on mood, stress, and weight concerns. For women with lower psychiatric distress, the added focus is not necessary, as these women achieved greater sustained abstinence in the less-intensive treatment. Understanding which women need which level of care to sustain abstinence can help allocate resources for all postpartum former smokers. These findings underscore the importance of perinatal symptom monitoring and promoting behavioral health more broadly in pregnant and postpartum women.