Sophie Orton

Predictors of Children's Secondhand Smoke Exposure at Home: A Systematic Review and Narrative Synthesis of the Evidence

Background Childrens exposure to secondhand smoke (SHS) has been causally linked to a number of childhood morbidities and mortalities. Over 50% of UK children whose parents are smokers are regularly exposed to SHS at home. No previous review has identified the factors associated with childrens SHS exposure in the home. Aim To identify by systematic review, the factors which are associated with childrens SHS exposure in the home, determined by parent or child reports and/or biochemically validated measures including cotinine, carbon monoxide or home air particulate matter. Methods Electronic searches of MEDLINE, EMBASE, PsychINFO, CINAHL and Web of Knowledge to July 2014, and hand searches of reference lists from publications included in the review were conducted. Findings Forty one studies were included in the review. Parental smoking, low socioeconomic status and being less educated were all frequently and consistently found to be independently associated with childrens SHS exposure in the home. Children whose parents held more negative attitudes towards SHS were less likely to be exposed. Associations were strongest for parental cigarette smoking status; compared to children of non-smokers, those whose mothers or both parents smoked were between two and 13 times more likely to be exposed to SHS. Conclusion Multiple factors are associated with child SHS exposure in the home; the best way to reduce child SHS exposure in the home is for smoking parents to quit. If parents are unable or unwilling to stop smoking, they should instigate smoke-free homes. Interventions targeted towards the socially disadvantaged parents aiming to change attitudes to smoking in the presence of children and providing practical support to help parents smoke outside the home may be beneficial.

Longitudinal cohort survey of women's smoking behaviour and attitudes in pregnancy: study methods and baseline data

Objectives To report the methods used to assemble a contemporary pregnancy cohort for investigating influences on smoking behaviour before, during and after pregnancy and to report characteristics of women recruited. Design Longitudinal cohort survey. Setting Two maternity hospitals, Nottingham, England. Participants 3265 women who attended antenatal ultrasound scan clinics were offered cohort enrolment; those who were 8–26 weeks pregnant and were currently smoking or had recently stopped smoking were eligible. Cohort enrollment took place between August 2011 and August 2012. Primary and secondary outcome measures Prevalence of smoking at cohort entry and at two follow-up time points (34–36 weeks gestation and 3 months postnatally); response rate, participants’ sociodemographic characteristics. Results 1101 (33.7%, 95% CI 32.1% to 35.4%) women were eligible for inclusion in the cohort, and of these 850 (77.2%, 95% CI 74.6% to 79.6%) were recruited. Within the cohort, 57.4% (N=488, 95% CI 54.1% to 60.7%) reported to be current smokers. Current smokers were significantly younger than ex-smokers (p<0.05), more likely to have no formal qualifications and to not be in current paid employment compared to recent ex-smokers (p<0.001). Conclusions This contemporary cohort, which seeks very detailed information on smoking in pregnancy and its determinants, includes women with comparable sociodemographic characteristics to those in other UK cross-sectional studies and cohorts. This suggests that future analyses using this cohort and aimed at understanding smoking behaviour in pregnancy may produce findings that are broadly generalisable.

Socio-economic and Psychosocial Determinants of Smoking and Passive Smoking in Older Adults

OBJECTIVE To determine the associations of socio-economic and psychosocial factors with active and passive smoking in older adults. METHODS Using a standard interview method, we examined random samples of 6071 people aged⋝60 years in 5 provinces of China during 2007-2009. RESULTS World age-standardised prevalence for current and former smoking in men was 45.6% and 20.5%, and in women 11.1% and 4.5%. Current smoking reduced with older age but increased with men, low socioeconomic status (SES), alcohol drinking, being never-married, pessimistic and depressive syndromes. Former smoking was associated with men, secondary school education, a middle-high income, being a businessman, being widowed, less frequencies of visiting children/relatives and friends, and worrying about children. Among 3774 never-smokers, the prevalence of passive smoking was 31.5%, and the risk increased with women, low SES, alcohol drinking, being married, having a religious believe, and daily visiting children/relatives. There were sex differences in the associations, and an interaction effect of education and income on smoking and passive smoking. CONCLUSION Older Chinese had a higher level of smoking and passive smoking than those in high income countries, reflecting Chinas failures in controlling smoking. The associations with low SES and different psychosocial aspects and sex differences suggest preventative strategies for active and passive smoking.

Association of Passive Smoking With Cognitive Impairment in Nonsmoking Older Adults A Systematic Literature Review and a New Study of Chinese Cohort

Association of passive smoking with cognitive impairment in older adults is unclear. We carried out a systematic literature review and a new study to determine the association. There were 3 cross-sectional studies published, showing a significant association of passive smoking with cognitive impairment (a relative risk (RR) of about 1.30-1.90). In the new cohort study, we interviewed 1081 never-smoking participants aged ≥ 65 years in China using a standard method of the Geriatric Mental State–Automated Geriatric Examination for Computer Assisted Taxonomy and found a significant association with dose response; multivariate adjusted RR was 1.02 (95% confidence interval 0.67-1.55) in >0 to 49 exposure level years of passive smoking, 1.57 (1.00-2.47) in 50 to 99, and 2.12 (1.24-3.63) in ≥100, trend P = .008. The relationship seems not to be a reverse causality of the effect. Passive smoking could be considered an important risk factor for cognitive impairment in older adults. Avoiding exposure to passive smoking would help to preserve cognitive decline in later life.

Smoking and quit attempts during pregnancy and postpartum: a longitudinal UK cohort

Objectives Pregnancy motivates women to try stopping smoking, but little is known about timing of their quit attempts and how quitting intentions change during pregnancy and postpartum. Using longitudinal data, this study aimed to document women’s smoking and quitting behaviour throughout pregnancy and after delivery. Design Longitudinal cohort survey with questionnaires at baseline (8–26 weeks’ gestation), late pregnancy (34–36 weeks) and 3 months after delivery. Setting Two maternity hospitals in one National Health Service hospital trust, Nottingham, England. Participants 850 pregnant women, aged 16 years or over, who were current smokers or had smoked in the 3 months before pregnancy, were recruited between August 2011 and August 2012. Outcome measures Self-reported smoking behaviour, quit attempts and quitting intentions. Results Smoking rates, adjusting for non-response at follow-up, were 57.4% (95% CI 54.1 to 60.7) at baseline, 59.1% (95% CI 54.9 to 63.4) in late pregnancy and 67.1% (95% CI 62.7 to 71.5) 3 months postpartum. At baseline, 272 of 488 current smokers had tried to quit since becoming pregnant (55.7%, 95% CI 51.3 to 60.1); 51.3% (95% CI 44.7 to 58.0) tried quitting between baseline and late pregnancy and 27.4% (95% CI 21.7 to 33.2) after childbirth. The percentage who intended to quit within the next month fell as pregnancy progressed, from 40.4% (95% CI 36.1 to 44.8) at baseline to 29.7% (95% CI 23.8 to 35.6) in late pregnancy and 14.2% (95% CI 10.0 to 18.3) postpartum. Postpartum relapse was lower among women who quit in the 3 months before pregnancy (17.8%, 95% CI 6.1 to 29.4) than those who stopped between baseline and late pregnancy (42.9%, 95% CI 24.6 to 61.3). Conclusions Many pregnant smokers make quit attempts throughout pregnancy and postpartum, but intention to quit decreases over time; there is no evidence that smoking rates fall during gestation.

Nicotine preloading for smoking cessation: the Preloading RCT.

BACKGROUND Nicotine preloading means using nicotine replacement therapy prior to a quit date while smoking normally. The aim is to reduce the drive to smoke, thereby reducing cravings for smoking after quit day, which are the main cause of early relapse. A prior systematic review showed inconclusive and heterogeneous evidence that preloading was effective and little evidence of the mechanism of action, with no cost-effectiveness data. OBJECTIVES To assess (1) the effectiveness, safety and tolerability of nicotine preloading in a routine NHS setting relative to usual care, (2) the mechanisms of the action of preloading and (3) the cost-effectiveness of preloading. DESIGN Open-label randomised controlled trial with examination of mediation and a cost-effectiveness analysis. SETTING NHS smoking cessation clinics. PARTICIPANTS People seeking help to stop smoking. INTERVENTIONS Nicotine preloading comprised wearing a 21 mg/24 hour nicotine patch for 4 weeks prior to quit date. In addition, minimal behavioural support was provided to explain the intervention rationale and to support adherence. In the comparator group, participants received equivalent behavioural support. Randomisation was stratified by centre and concealed from investigators. MAIN OUTCOME MEASURES The primary outcome was 6-month prolonged abstinence assessed using the Russell Standard. The secondary outcomes were 4-week and 12-month abstinence. Adverse events (AEs) were assessed from baseline to 1 week after quit day. In a planned analysis, we adjusted for the use of varenicline (Champix®; Pfizer Inc., New York, NY, USA) as post-cessation medication. Cost-effectiveness analysis took a health-service perspective. The within-trial analysis assessed health-service costs during the 13 months of trial enrolment relative to the previous 6 months comparing trial arms. The base case was based on multiple imputation for missing cost data. We modelled long-term health outcomes of smoking-related diseases using the European-study on Quantifying Utility of Investment in Protection from Tobacco (EQUIPT) model. RESULTS In total, 1792 people were eligible and were enrolled in the study, with 893 randomised to the control group and 899 randomised to the intervention group. In the intervention group, 49 (5.5%) people discontinued preloading prematurely and most others used it daily. The primary outcome, biochemically validated 6-month abstinence, was achieved by 157 (17.5%) people in the intervention group and 129 (14.4%) people in the control group, a difference of 3.02 percentage points [95% confidence interval (CI) -0.37 to 6.41 percentage points; odds ratio (OR) 1.25, 95% CI 0.97 to 1.62; p = 0.081]. Adjusted for use of post-quit day varenicline, the OR was 1.34 (95% CI 1.03 to 1.73; p = 0.028). Secondary abstinence outcomes were similar. The OR for the occurrence of serious AEs was 1.12 (95% CI 0.42 to 3.03). Moderate-severity nausea occurred in an additional 4% of the preloading group compared with the control group. There was evidence that reduced urges to smoke and reduced smoke inhalation mediated the effect of preloading on abstinence. The incremental cost-effectiveness ratio at the 6-month follow-up for preloading relative to control was £710 (95% CI -£13,674 to £23,205), but preloading was dominant at 12 months and in the long term, with an 80% probability that it is cost saving. LIMITATIONS The open-label design could partially account for the mediation results. Outcome assessment could not be blinded but was biochemically verified. CONCLUSIONS Use of nicotine-patch preloading for 4 weeks prior to attempting to stop smoking can increase the proportion of people who stop successfully, but its benefit is undermined because it reduces the use of varenicline after preloading. If this latter effect could be overcome, then nicotine preloading appears to improve health and reduce health-service costs in the long term. Future work should determine how to ensure that people using nicotine preloading opt to use varenicline as cessation medication. TRIAL REGISTRATION Current Controlled Trials ISRCTN33031001. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 41. See the NIHR Journals Library website for further project information.

Views on and experiences of electronic cigarettes: a qualitative study of women who are pregnant or have recently given birth

BackgroundElectronic cigarettes (ECs) are increasingly used for reducing or stopping smoking, with some studies showing positive outcomes. However, little is known about views on ECs during pregnancy or postpartum and previous studies have nearly all been conducted in the US and have methodological limitations, such as not distinguishing between smokers and ex/non-smokers. A greater understanding of this topic will help to inform both clinicians and EC interventions. We elicited views and experiences of ECs among UK pregnant or recently pregnant women.MethodsWe conducted semi-structured telephone interviews, using topic guides, with pregnant or recently pregnant women, who were current or recent ex-smokers. To ensure broad views of ECs were obtained, recruitment was from several geographical locations and via various avenues of recruitment. This included stop smoking services, antenatal and health visitor clinics, a pregnancy website and an informal network. Participants were 15 pregnant and 15 postpartum women, including nine current EC users, 11 ex-users, and 10 never-users. Five women who were interviewed in pregnancy were later interviewed in postpartum to explore if their views had changed. Audio data was transcribed verbatim and framework analysis was applied.ResultsFive main themes emerged: motivations for use (e.g., for stopping or reducing smoking), social stigma (e.g., avoiding use in public, preferring ‘discrete’ NRT), using the EC (e.g., mostly used at home); consumer aspects (e.g., limited advice available), and harm perceptions (e.g., viewed as less harmful than smoking; concerns about safety and addiction).ConclusionsECs were viewed positively by some pregnant and postpartum women and seen as less harmful than smoking and useful as aids for reducing and stopping smoking. However, due to perceived social stigma, some women feel uncomfortable using ECs in public, especially during pregnancy, and had concerns about safety and nicotine dependence. Health professionals and designers of EC interventions need to provide women with up-to-date and consistent information and advice about safety and dependence, as well as considering the influence of social stigma.

Using qualitative interviews with nihr crn research midwives to refine trial recruitment methods

Background Smoking during pregnancy increases the risks of many pregnancy-related complications. MiQuit is a tailored, self-help, text-message intervention developed to help pregnant smokers to stop. A pilot RCT investigated feasibility of recruitment of women attending hospital antenatal clinics by using NIHR Clinical Research Network (CRN) research midwives (RMs); findings will be used to plan a future definitive trial to investigate MiQuit efficacy. We aimed to describe the facilitators and barriers to trial recruitment that RMs perceived, and relate these to key recruitment processes.

Smoking in the home after childbirth: prevalence and determinants in an English cohort.

Objectives Childrens exposure to secondhand smoke (SHS) is causally linked to childhood morbidity and mortality. Over 38% of English children (aged 4–15) whose parents are smokers are exposed to SHS in the home. Little is known about the prevalence of SHS exposure in the homes of young infants (≤3 months). This study aimed to estimate maternal self-reported prevalence of SHS exposure among infants of women who smoked just before or during pregnancy, and identify factors associated with exposure. Setting Primary Care, Nottingham, England. Participants Current and recent ex-smoking pregnant women (n=850) were recruited in Nottingham, England. Women completed questionnaires at 8–26 weeks gestation and 3 months after childbirth. Data on smoking in the home 3 months after childbirth was available for 471 households. Primary and secondary outcome measures Maternal-reported smoking in the home 3 months after childbirth. Results The prevalence of smoking in the home 3 months after childbirth was 16.3% (95% CI 13.2% to 19.8%) and after multiple imputation controlling for non-response 18.2% (95% CI 14.0% to 22.5%). 59% of mothers were current smokers; of these, 24% reported that smoking occurred in their home compared to 4.7% of non-smokers. In multivariable logistic regression, mothers smoking ≥11 cigarettes per day were 8.2 times (95% CI 3.4 to 19.6) more likely to report smoking in the home. Younger age, being of non-white ethnicity, increased deprivation and less negative attitudes towards SHS were also associated with smoking in the home. Conclusions This survey of smoking in the home 3 months after childbirth found a lower prevalence than has been reported in older children. Interventions to support smoking mothers to quit, or to help them restrict smoking in the home, should target attitudinal change and address inequality relating to social disadvantage, younger age and non-white ethnic groups.