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issn:1469-994
1.  Craving in Intermittent and Daily Smokers During Ad Libitum Smoking 
Nicotine & Tobacco Research  2014;16(8):1063-1069.
Introduction:
This study aimed to assess average and peak craving intensity among nondaily intermittent smokers (ITS) in smoking episodes and when not smoking compared to that of daily smokers (DS).
Methods:
Two hundred and twelve ITS and 194 DS monitored their smoking and craving for 3 weeks using Ecological Momentary Assessment methods. Craving was assessed (0–100 scale) when subjects lit a cigarette and at random times when not smoking; 48,469 observations were analyzed using generalized estimating equations.
Results:
ITS experienced craving, including intense craving; their 95th percentile intensity averaged 77.7±22.5 out of 100 (higher among DS: 89.1±14.5). ITS reported lower craving than DS, both when smoking and when not smoking. In both groups, craving was less intense when not smoking (DS: 71.1±20.7 vs. 59.83±21.97; ITS: 59.91±23.03 vs. 26.63±19.87), but the difference was significantly greater among ITS. Among ITS, the probability of smoking rose continuously as craving increased over the full range of the scale. In contrast, among DS the probability of smoking rose until the midpoint of the scale, after which the relationship flattened. Findings were mostly similar for ITS with and without a history of past daily smoking.
Conclusions:
ITS do experience craving, including intense craving. The relationship between craving and smoking is stronger among ITS because DS experience moderate craving even between cigarettes. In contrast, ITS appear to experience craving in limited situations associated with smoking, suggesting that their craving and smoking may be driven by transient cues rather than endogenous needs.
doi:10.1093/ntr/ntu023
PMCID: PMC4155421  PMID: 24619094
2.  Latent Classes of Young Adults Based on Use of Multiple Types of Tobacco and Nicotine Products 
Nicotine & Tobacco Research  2014;16(8):1056-1062.
Introduction:
New tobacco and nicotine products such as snus, hookah, and electronic cigarettes have risen in popularity in recent years. Use of these products among young adults is of particular interest given that experimentation with new products is common in young adulthood.
Methods:
We conducted latent class analysis among a population-based sample of young adults to identify separate classes based on use of 6 types of tobacco or nicotine products: snus, hookah, electronic cigarettes, cigarillos, snuff, and cigarettes. We then examined how identified classes differed on demographic characteristics and marijuana and alcohol use.
Results:
We identified 5 classes: the largest group (60%) was characterized as reporting no or limited use of any of the products, while the smallest group (7%) was characterized by use of many types of products (poly-users). Of the 3 middle classes, 2 were the same size (10%) and were characterized by primarily using 2 of the products: one class used snus and snuff, and the other used cigarillos and hookah; the third class (13%) was characterized by primarily cigarette smoking. Numerous differences were seen across classes, including the poly-users being less likely to be college students/graduates and more likely to be male and use marijuana and alcohol.
Conclusions:
We found that young adults can be grouped into 5 subgroups based on types of tobacco/nicotine products they do and do not use. A poly-use group that uses all types of tobacco products is concerning, particularly given high levels of marijuana and alcohol use reported in this group.
doi:10.1093/ntr/ntu024
PMCID: PMC4155422  PMID: 24604019
3.  Hostility and Cigarette Use: A Comparison Between Smokers and Nonsmokers in a Matched Sample of Adolescents 
Nicotine & Tobacco Research  2014;16(8):1085-1093.
Introduction:
We examined the association between hostility—a personality trait reflective of negativity and cynicism toward others—and smoking in adolescents by measuring (a) several subcomponents of hostility, and (b) facial emotion processing ability, which has been previously linked to hostility.
Methods:
Participants (N = 241 aged 14–19) were 95 smokers and 95 demographically matched nonsmokers as well as 51 nonmatched smokers. All participants completed the Cook–Medley (C-M) hostility scale, which provides a general hostility score and 3 component scores (cynicism, hypersensitivity, and aggressive responding), and a facial emotion processing task. This task, designed to assess emotion recognition, requires quickly identifying the emotion of faces that gradually morph from neutral to high-intensity happy, angry, or fearful.
Results:
Independent sample t tests indicated that matched smokers scored significantly higher in cynicism and aggressive responding than nonsmokers. Among smokers, age of smoking onset was negatively correlated with general hostility and aggressive responding. All hostility scales were positively correlated with the intensity needed to recognize happy faces. Counterintuitively, smokers required a greater intensity to recognize angry faces than nonsmokers. No other relations between hostility/smoking status and facial emotion processing were observed.
Conclusions:
Aspects of hostility, particularly aggressive responding, may be a risk factor for early onset smoking. Although hostile participants exhibited a deficiency in their ability to recognize happiness in facial pictures, these results did not translate to differences in smoking status. This study elucidates some of the complex interrelations between hostility, emotion processing, and adolescent smoking, which may have implications for teen smoking prevention.
doi:10.1093/ntr/ntu033
PMCID: PMC4155423  PMID: 24692670
4.  A Preliminary Randomized Controlled Trial of a Behavioral Exercise Intervention for Smoking Cessation 
Nicotine & Tobacco Research  2014;16(8):1094-1103.
Introduction:
Previous exercise intervention studies for smoking cessation have been challenged by a number of methodological limitations that confound the potential efficacy of aerobic exercise for smoking cessation.
Methods:
The preliminary efficacy of a behavioral exercise intervention that incorporated features designed to address prior limitations was tested in a randomized controlled trial (RCT). Sixty-one smokers (65.6% female, mean age = 47.3 years, smoked a mean of 19.7 cigarettes/day) were randomized to receive either a 12-week exercise intervention or a 12-week health education contact control. Participants in both conditions received an 8-week telephone-delivered, standard smoking cessation protocol (with the transdermal nicotine patch). Follow-ups were conducted at the end of treatment (EOT), 6- and 12-month timepoints.
Results:
There were no differences between conditions with respect to the number of weekly exercise or health education sessions attended (9.3±2.8 vs. 9.3±3.0, respectively). While not statistically significant, participants in the exercise condition demonstrated higher verified abstinence rates (EOT: 40% vs. 22.6%, odds ratio [OR] = 2.28; 6- and 12-month follow-ups: 26.7% vs. 12.9%, OR = 2.46). Irrespective of treatment condition, higher levels of moderate-to-vigorous exercise were associated with lower levels of depressive symptoms during the intervention.
Conclusions:
The results of this small RCT point toward the benefit of a behavioral exercise intervention designed to address previous methodological limitations for smoking cessation. Given the potential public health impact of the demonstrated efficacy of exercise for smoking cessation, the continued development and optimization of exercise interventions for smokers through larger RCTs merits pursuit.
doi:10.1093/ntr/ntu036
PMCID: PMC4155424  PMID: 24812023
5.  Smoking Cessation Is Followed by Increases in Serum Bilirubin, an Endogenous Antioxidant Associated With Lower Risk of Lung Cancer and Cardiovascular Disease 
Nicotine & Tobacco Research  2014;16(8):1145-1149.
Introduction:
Lower concentrations of serum bilirubin, an endogenous antioxidant, have been associated with risk of many smoking-related diseases, including lung cancer and cardiovascular disease, and current smokers are reported to have lower bilirubin levels than nonsmokers and past smokers. This study evaluates the effects of smoking cessation on bilirubin levels.
Methods:
In a secondary analysis of a 6-week placebo-controlled trial of naltrexone for smoking cessation, indirect and total bilirubin concentrations were evaluated at baseline and following smoking cessation. Individuals who were continuously abstinent for 6 weeks (n = 155) were compared to those who were not (n = 193). Participants reported smoking ≥20 cigarettes daily at baseline and received smoking cessation counseling, 21mg nicotine patch daily, and either placebo or 1 of 3 doses of naltrexone (25, 50, or 100mg) for 6 weeks. Change in indirect and total bilirubin following the quit date was measured at Weeks 1, 4, and 6 compared to baseline.
Results:
Individuals who were continuously abstinent from smoking, independent of naltrexone condition, showed a significantly greater mean increase in indirect (~unconjugated) bilirubin (0.06mg/dl, SD = 0.165) compared to those who did not (mean = 0.02, SD = 0.148, p = .015). Similar results were obtained for total bilirubin (p = .037).
Conclusions:
Smoking cessation is followed by increases in bilirubin concentration that have been associated with lower risk of lung cancer and cardiovascular disease.
doi:10.1093/ntr/ntu067
PMCID: PMC4155425  PMID: 24812024
6.  E-cigarette Availability and Promotion Among Retail Outlets Near College Campuses in Two Southeastern States 
Nicotine & Tobacco Research  2014;16(8):1150-1155.
Introduction:
E-cigarettes are relatively new products that simulate the smoking experience. This descriptive study assessed changes in e-cigarette availability and promotions among retailers in 11 college communities in North Carolina and Virginia during a 1-year period.
Methods:
During the spring of 2012 and 2013, observers completed assessments in 320 tobacco-selling retailers, including grocery and convenience stores, pharmacies, and tobacco shops. Assessors collected e-cigarette availability, advertising, price, and promotions.
Results:
E-cigarette availability increased among retailers from 24.7% in 2012 to 59.9% in 2013. They were available in the form of disposables and reusable kits and were most frequently available in tobacco shops, convenience stores, and pharmacies. The average price for disposables was $9.70 (SD = 1.07) in 2012 and $9.61 (SD = 2.10) in 2013; the average price for kits was $39.58 (SD = 15.79) in 2012 and $32.59 (SD = 18.65) in 2013. The presence of interior advertising increased from 12.7% to 50.6% (p < .0001), and the presence of exterior advertising increased from 7.6% to 22.8% (p = .0002). Convenience stores with gas (16.4%–70.4%; p < .0001) and without gas (6.0%–48.4%; p < .0001) had significant increases in the presence of interior advertising. Convenience stores with gas also had a significant increase in the presence of exterior advertising (8.2%–33.3%; p < .0001). Only 3% of retailers offered price promotions.
Conclusions:
Availability of e-cigarettes, including rechargeable kits and disposables, more than doubled during the study. The presence of interior and exterior advertising also significantly increased. Results underscore the need for further surveillance to understand how these environmental characteristics impact individual exposure and use of e-cigarettes.
doi:10.1093/ntr/ntu081
PMCID: PMC4155426  PMID: 24847099
7.  Monitoring Tobacco-Specific N-Nitrosamines and Nicotine in Novel Smokeless Tobacco Products: Findings From Round II of the New Product Watch 
Nicotine & Tobacco Research  2014;16(8):1070-1078.
Introduction:
Analysis of novel smokeless tobacco products purchased in Round I of the New Product Watch (NPW)—a national tobacco monitoring network—demonstrated that some tobacco constituents vary not only across various brands but also regionally and over time within the same product. In this study, we analyzed snus and dissolvable tobacco products that were purchased in Round II of the NPW.
Methods:
We analyzed tobacco-specific N-nitrosamines (TSNA) and nicotine in snus and dissolvable tobacco products that were purchased in various regions of the country during the spring and summer of 2011. The results were compared against the Round I data, across different U.S. regions, and among products.
Results:
A total of 216 samples were received from different states representing 6 regions of the country. Compared with the previous analyses, TSNA levels increased significantly in Marlboro and Camel Snus and some dissolvable Camel products. The levels of unprotonated nicotine in Marlboro Snus and Camel Snus in this study were not different from Round I but varied significantly by regions; the differences between the highest and the lowest average regional levels were ~3.2-fold in Marlboro Snus ~1.7-fold in Camel Snus.
Conclusions:
Our results indicate that some novel smokeless tobacco products contain TSNA at the levels found in the conventional moist snuff. Observation of regional variations in unprotonated nicotine content in both Round I and Round II of NPW suggest that manufacturers may tailor the levels of this constituent consistently to different regions.
doi:10.1093/ntr/ntu026
PMCID: PMC4110922  PMID: 24604020
8.  Secondhand Smoke Exposure Among Nonsmoking Pregnant Women in New York City 
Nicotine & Tobacco Research  2014;16(8):1079-1084.
Introduction:
Although secondhand smoke (SHS) exposure during pregnancy has detrimental effects on fetal health, little is known about levels of SHS in nonsmoking pregnant women. We examined disparities in SHS exposure among nonsmoking, ethnic minority pregnant women in New York City.
Methods:
We used self-reported smoking and serum cotinine collected from 244 pregnant women from the Bronx who self-identified as African American, Caribbean American, or Black Hispanic to examine smoking prevalence (>3ng/ml) and, in an adjusted logistic regression model, risk factors for SHS (≥0.05ng/ml and ≤3ng/ml).
Results:
Although only 4.1% of women self-reported they were smokers, 10.7% had serum cotinine levels indicating they were smokers. Among the 218 nonsmokers, 46.8% had serum cotinine levels indicating SHS exposure. Women at highest risk included those with less than a high school degree (66.7%) and those who were U.S.-born Black Hispanic (63.2%) or African American (63.0%). Women with more than 12 years of education were less likely to have detectable SHS exposure than women with fewer than 12 years (adjusted odds ratio 0.39, 95% CI = 0.17, 0.91). Compared with African American U.S.-born women, those who were African American foreign-born or Caribbean American and either U.S.-born or foreign-born were less likely to have detectable SHS exposure (all p ≤ .05).
Conclusions:
Nearly half of nonsmoking pregnant women in New York City had elevated cotinine levels despite living in a city with comprehensive tobacco control policies. Health professionals need to assess sources of SHS exposure during pregnancy and promote smoke-free environments to improve maternal and fetal health.
doi:10.1093/ntr/ntu034
PMCID: PMC4110923  PMID: 24642590
9.  The Predicted Impact of Reducing the Nicotine Content in Cigarettes on Alcohol Use 
Nicotine & Tobacco Research  2014;16(8):1033-1044.
Introduction:
Product standards reducing the level of nicotine in cigarettes could significantly improve public health by reducing smoking behavior and toxicant exposure. However, relatively little is known about how the regulatory strategy could impact alcohol use, a closely related health behavior that is also a major contributor to morbidity and mortality. The primary objective of this paper is to predict the effect of nicotine reduction on alcohol use, identify priorities for future research, and highlight areas for mitigating any adverse outcomes.
Methods:
We critically reviewed and integrated literatures examining the effects of very low nicotine content (VLNC) cigarettes on smoking-related outcomes (nicotine exposure, nicotine withdrawal, and smoking as a cue to drink) and, in turn, the effects of those outcomes on alcohol use.
Results:
Current evidence suggests reducing the nicotine content of cigarettes may benefit public health by reducing alcohol use and problematic drinking over time as a consequence of reduced exposure to nicotine and the smoking cues associated with drinking. Nicotine withdrawal could increase risk of drinking, although these effects should be short-lived and could be mitigated by other sources of nicotine. Gender, hazardous drinking, and psychiatric comorbidities are likely to be important moderators of the effects of VLNC cigarettes.
Conclusions:
It is imperative to broadly assess the public health impact of potential tobacco product regulations by including measures of closely related health behaviors that could be impacted by these interventions. Nicotine reduction in cigarettes may contribute to improved public health through reductions in alcohol use.
doi:10.1093/ntr/ntu037
PMCID: PMC4110924  PMID: 24647051
10.  Exploring the “Active Ingredients” of an Online Smoking Intervention: A Randomized Factorial Trial 
Nicotine & Tobacco Research  2014;16(8):1129-1139.
Introduction:
Research needs to systematically identify which components increase online intervention effectiveness (i.e., active ingredients). This study explores the effects of 4 potentially important design features in an Internet-based, population-level smoking intervention.
Methods:
Smokers (n = 1,865) were recruited from a large health care organization, regardless of readiness to quit. Using a full factorial design, participants were randomized to 1 of the 2 levels of each experimental factor (message tone [prescriptive vs. motivational], navigation autonomy [dictated vs. not], e-mail reminders [yes vs. no], and receipt of personally tailored testimonials [yes vs. no]) and provided access to the online intervention. Primary outcomes were self-reported 7-day point-prevalent smoking abstinence and confirmed utilization of adjunct treatment (pharmacotherapy or phone counseling) available through the health plan at 1 year. Outcomes were also assessed at 2 and 6 months and were examined among all enrolled participants (intent-to-treat [ITT]) and all who viewed the intervention (modified ITT).
Results:
At 1 year, 13.7% were abstinent and 26.0% utilized adjunct treatment. None of the contrasting factor levels differentially influenced abstinence or treatment utilization at 12 months. In the modified ITT sample, smokers receiving testimonials were less likely to use adjunct treatment at 6 months (odds ratio = 0.54, 95% confidence interval = 0.30–0.98, p = .04).
Conclusions:
None of the design features enhanced treatment outcome. The negative effect observed for testimonials is provocative, but it should be viewed with caution. This study offers a model for future research testing the “active ingredients” of online interventions.
doi:10.1093/ntr/ntu057
PMCID: PMC4110925  PMID: 24727369
11.  How U.S. Adults Find Out About Electronic Cigarettes: Implications for Public Health Messages 
Nicotine & Tobacco Research  2014;16(8):1140-1144.
Introduction:
Electronic cigarettes (e-cigarettes) are battery-powered nicotine delivery systems that have become increasingly popular in the United States. We sought to understand how U.S. adults hear about e-cigarettes.
Methods:
A national sample of 17,522 U.S. adults (≥18 years old) completed an online survey in March 2013 assessing their awareness of and sources of information about e-cigarettes.
Results:
Most respondents (86%) had heard of e-cigarettes. Current and former smokers were more likely to be aware of e-cigarettes than non-smokers. Males, younger adults, non-Hispanic Whites, and those with higher education were also more likely to have heard of e-cigarettes. The most commonly reported sources of information were another person, ads on television, and seeing e-cigarettes being sold, although the relative frequency of these sources differed for current, former, and never-smokers. Former and current smokers were more likely to have heard about e-cigarettes from e-cigarette users than were never-smokers. Adults age 30 years or younger were more likely than adults older than 30 years to have heard about e-cigarettes online.
Conclusions:
Nearly all U.S. adults had heard of e-cigarettes in 2013. By focusing on the most common channels of information, public health campaigns can more efficiently communicate information about e-cigarette safety and consider necessary regulations should companies use these channels for marketing that targets youth, non-tobacco users, and other at-risk groups.
doi:10.1093/ntr/ntu060
PMCID: PMC4110926  PMID: 24755397
12.  Interventions to Reduce Tobacco-Related Health Disparities 
Nicotine & Tobacco Research  2015;17(8):887-891.
doi:10.1093/ntr/ntv096
PMCID: PMC4502764  PMID: 26180213
13.  Familial Aggregation of Tobacco Use Behaviors Among Amish Men 
Nicotine & Tobacco Research  2014;16(7):923-930.
Introduction:
Tobacco use is a complex behavior. The Old Order Amish community offers unique advantages for the study of tobacco use because of homogenous ancestral background, sociocultural similarity, sex-specific social norms regarding tobacco use, and large family size. Tobacco use in the Old Order Amish community is almost exclusively confined to males.
Methods:
We examined characteristics of tobacco use and familial aggregation among 1,216 Amish males from cross-sectional prospectively collected data. Outcomes examined included ever using tobacco regularly, current use, quantity of use, duration of use, and frequency of use.
Results:
Sixteen percent of Amish men were current tobacco users, with the majority reporting cigar use only. Higher rates of tobacco use were found among sons of fathers who smoked compared with sons of fathers who did not smoke (46% vs. 22%, p < .001) as well as among brothers of index cases who smoked compared with brothers of index cases who did not smoke (61% vs. 29%, p < .001). After controlling for shared household effects and age, heritability accounted for 66% of the variance in ever smoking regularly (p = .045).
Conclusions:
The familial patterns of tobacco use observed among Amish men highlight the important role of family in propagating tobacco use and support the usefulness of this population for future genetic studies of nicotine addiction.
doi:10.1093/ntr/ntu006
PMCID: PMC4072896  PMID: 24583363
14.  Effects of Nicotine Deprivation and Replacement on BOLD-fMRI Response to Smoking Cues as a Function of DRD4 VNTR Genotype 
Nicotine & Tobacco Research  2014;16(7):939-947.
Introduction:
Reactivity to smoking cues is an important factor in the motivation to smoke and has been associated with the dopamine receptor 4 variable number tandem repeat (DRD4 exon III VNTR) polymorphism. However, little is known about the associated neural mechanisms.
Methods:
Non-treatment-seeking Caucasian smokers completed overnight abstinence and viewed smoking and neutral cues during 2 separate functional magnetic resonance imaging scans while wearing either a nicotine or placebo patch (order randomized) and were genotyped for the DRD4 VNTR. We conducted mixed-effects repeated-measures analyses of variance (within-subject factor: nicotine or placebo patch; between-subject factor: DRD4 long [L: ≥1 copy of ≥7 repeats] or short [S: 2 copies ≤6 repeats] genotype) of 6 a priori regions of interest.
Results:
Relative to neutral cues, smoking cues elicited greater activity in bilateral ventral striatum and left amygdala during nicotine replacement and deactivation in these regions during nicotine deprivation. A patch × DRD4 interaction was observed in the left amygdala, an area associated with appetitive reinforcement and relapse risk, such that S allele carriers demonstrated greater activation on active patch than on placebo patch.
Conclusions:
Brain systems associated with reward salience may become primed and overreactive at nicotine replacement doses intended for the first step of smoking cessation and may become inhibited during nicotine withdrawal in DRD4 S but not in DRD4 L carriers. These findings are consistent with the role of these regions in drug reinforcement and suggest a differential influence of nicotine replacement on amygdala activation in the association of incentive salience with smoking stimuli across DRD4 genotypes.
doi:10.1093/ntr/ntu010
PMCID: PMC4072897  PMID: 24659022
15.  Children’s Exposure to Secondhand and Thirdhand Smoke Carcinogens and Toxicants in Homes of Hookah Smokers 
Nicotine & Tobacco Research  2014;16(7):961-975.
Introduction:
We examined homes of hookah-only smokers and nonsmokers for levels of indoor air nicotine (a marker of secondhand smoke) and indoor surface nicotine (a marker of thirdhand smoke), child uptake of nicotine, the carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), and the toxicant acrolein by analyzing their corresponding metabolites cotinine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and NNAL-glucuronides (total NNAL) and 3-hydroxypropylmercapturic acid.
Methods:
Data were collected at 3 home visits during a 7-day study period from a convenience sample of 24 households with a child 5 years or younger. Three child urine samples and 2 air and surface samples from the living room and the child bedroom were taken in homes of nonsmokers (n = 5) and hookah-only smokers (n = 19) comprised of daily hookah smokers (n = 8) and weekly/monthly hookah smokers (n = 11).
Results:
Nicotine levels in indoor air and on surfaces in the child bedrooms in homes of daily hookah smokers were significantly higher than in homes of nonsmokers. Uptake of nicotine, NNK, and acrolein in children living in daily hookah smoker homes was significantly higher than in children living in nonsmoker homes. Uptake of nicotine and NNK in children living in weekly/monthly hookah smoker homes was significantly higher than in children living in nonsmoker homes.
Conclusions:
Our data provide the first evidence for uptake of nicotine, the tobacco-specific lung carcinogen NNK, and the ciliatoxic and cardiotoxic agent acrolein in children living in homes of hookah smokers. Our findings suggest that daily and occasional hookah use in homes present a serious, emerging threat to children’s long-term health.
doi:10.1093/ntr/ntu016
PMCID: PMC4072898  PMID: 24590387
16.  The LWDS-10J: Reliability and Validity of the Lebanon Waterpipe Dependence Scale Among University Students in Jordan 
Nicotine & Tobacco Research  2014;16(7):915-922.
Introduction:
While the Lebanon Waterpipe Dependence Scale (LWDS-11) has shown promise in assessing dependence on waterpipe tobacco smoking (WTS) in Lebanon among adult users, it would be valuable to identify WTS addiction earlier and to explore reliability and validity of these items in other populations.
Methods:
In 2010–2012, we conducted a multiyear survey of 5,853 students from 4 Jordanian universities. We measured WTS, sociodemographic data, and the LWDS-11 items. We conducted exploratory factor analysis with half of the sample and confirmed the resulting model using confirmatory factor analysis with the other half. We examined construct validity with regression models assessing associations between the modified scale and 5 constructs conceptually expected to be associated with dependence.
Results:
WTS rates were 35% in the past 30 days and 56% ever. Principal-components analysis of LWDS items in the first half of the sample yielded 10 items representing 3 factors labeled physical dependence, relaxation/pleasure, and social aspects. Cronbach’s α was .77 for the total scale and was .75, .70, and .67 for each individual subscale. Confirmatory factor analysis in a structural equation modeling framework confirmed good fit (root mean squared error of approximation = 0.068, and comparative fit index = 0.937). Dependence according to the resulting scale (LWDS-10J) was strongly associated with each of the 5 expected constructs, whether the dependent variable was treated as categorical or continuous.
Conclusions:
The LWDS-11 items exhibited a different factor structure in our sample. However, the modified scale (LWDS-10J) showed promising reliability and construct validity in this population.
doi:10.1093/ntr/ntu002
PMCID: PMC4133566  PMID: 24571810
17.  The Role of Cocoa as a Cigarette Additive: Opportunities for Product Regulation 
Nicotine & Tobacco Research  2014;16(7):984-991.
Introduction:
The 2009 Family Smoking Prevention and Tobacco Control Act prohibited the use of characterizing flavors in cigarettes; however, some of these flavors are still used in cigarettes at varying levels. We reviewed tobacco industry internal documents to investigate the role of one of these flavors, cocoa, with the objective of understanding its relationship to sensory and risk perception, promotion of dependence, and enhancement of attractiveness and acceptability.
Methods:
We used the Legacy Tobacco Documents Library to identify documents relevant to our research questions. Initial search terms were generated following an examination of published literature on cocoa, other cigarette additives, and sensory and risk perception. Further research questions and search terms were generated based on review of documents generated from the initial search terms.
Results:
Cocoa is widely applied to cigarettes and has been used by the tobacco industry as an additive since the early 20th century. Cocoa can alter the sensory properties of cigarette smoke, including by providing a more appealing taste and decreasing its harshness. The tobacco industry has experimented with manipulating cocoa levels as a means of achieving sensory properties that appeal to women and youth.
Conclusions:
Although cocoa is identified as a flavor on tobacco industry Web sites, it may serve other sensory purposes in cigarettes as well. Eliminating cocoa as an additive from tobacco products may affect tobacco product abuse liability by altering smokers’ perceptions of product risk, and decreasing product appeal, especially among vulnerable populations.
doi:10.1093/ntr/ntu017
PMCID: PMC4133567  PMID: 24610479
18.  Evaluating the Effect of Access to Free Medication to Quit Smoking: A Clinical Trial Testing the Role of Motivation 
Nicotine & Tobacco Research  2014;16(7):992-999.
Introduction:
Although the majority of smokers are ambivalent about quitting, few treatments specifically target smokers lacking motivation to quit in the near future. Most existing interventions are instead predicated on the belief that active treatments should only be distributed to smokers interested in quitting, a largely untested assumption.
Methods:
In the current clinical trial (N = 157), motivated smokers wanting to quit in the next 30 days were given a 2-week nicotine replacement therapy (NRT) sample and a referral to a quitline (Group MNQ), while unmotivated smokers were randomized to receive the same treatment (Group UNQ) or a quitline referral only (Group UQ). Participants were tracked via telephone for 3 months to assess quitting behaviors and smoking reduction.
Results:
Groups significantly differed across all comparisons with regard to incidence of any quit attempt (MNQ: 77%, UNQ: 40%, UQ: 18%, p < .05) and any 24-hr quit attempts (62%, 32%, 16%, p < .05). Clinically meaningful differences emerged in the rates of floating (19%, 17%, 6%) and point prevalence abstinence (17%, 15%, 5%). Compared to participants in Group UQ (11%), a greater proportion of participants in Group MNQ (48%, p = .01) and Group UNQ (31%, p = .01) reduced their daily cigarette consumption by at least half. Proxy measures of cessation readiness (e.g., motivation) favored participants receiving active forms of treatment.
Conclusions:
Providing NRT samples engaged both motivated and unmotivated smokers into the quitting process and produced positive changes in smoking outcomes. This suggests that motivation should not be considered a necessary precondition to receiving treatment.
doi:10.1093/ntr/ntu025
PMCID: PMC4133568  PMID: 24610399
19.  Families at Risk: Home and Car Smoking Among Pregnant Women Attending a Low-Income, Urban Prenatal Clinic 
Nicotine & Tobacco Research  2014;16(7):1020-1025.
Introduction:
Secondhand smoke exposure (SHSe) has been identified as a distinct risk factor for adverse obstetric and gynecological outcomes. This study examined the prevalence of SHSe reduction practices (i.e., home and car smoking bans) among pregnant women in a large U.S. prenatal clinic serving low-income women.
Methods:
Pregnant women (N = 820) attending a university-based, urban prenatal clinic in Houston, Texas, completed a prenatal questionnaire assessing bans on household and car smoking and a qualitative urine cotinine test as part of usual care. Data were collected from April 2011 to August 2012.
Results:
Nearly one-third (n = 257) of the sample reported at least 1 smoker living in the home. About a quarter of the women in the full sample did not have a total smoking ban in their home and car. Within smoking households, 44% of the pregnant women reported smoking, 56% reported smoking by another household member, and in 26% of smoking households both the pregnant woman and at least one other person were smoking. Only 43% of women with a household smoker reported a total ban on smoking, with higher rates among Hispanic women. Smoking bans were less common when the pregnant women smoked, when more than 1 smoker resided in the home, and when pregnant with her first child.
Conclusions:
SHSe among low-income pregnant women is high, and interventions to raise awareness and increase the establishment of smoking bans in homes and cars are warranted.
doi:10.1093/ntr/ntu049
PMCID: PMC4133569  PMID: 24692668
20.  Unplanned Quitting in a Triethnic Sample of U.S. Smokers 
Nicotine & Tobacco Research  2014;16(6):759-765.
Introduction:
Smokers who report quitting without prior planning have been shown to report longer abstinence compared with those who planned. Little is known about unplanned quitting (UQ) among U.S. smokers, minorities, or nondaily and light smokers.
Methods:
Using an online panel, we recruited equal numbers of Black, White, and Latino nondaily, light daily, and moderate/heavy daily smokers. Of the 1,127 who reported a past-year quit attempt, we queried whether it was planned and the maximum number of days abstinent.
Results:
Overall, 38% reported that their last quit attempt was unplanned. The impact of planned versus unplanned quitting interacted with smoking level and race. Among White moderate/heavy smokers, mean days abstinent was 99 for those who reported an unplanned quit attempt compared with 60 days for those who reported a planned attempt (p = .02). Among Black moderate/heavy smokers, the mean days abstinent was higher among those whose last attempt was planned, 92 days, compared with 56 days among those whose last attempt was unplanned (p = .09). The pattern among Latinos resembled Whites but was not significant. Results remained after adjusting for confounds such as age, gender, education, income, time to first cigarette, and menthol use. There were no significant differences in abstinence by quit type for light or nondaily smokers.
Conclusions:
Future studies are needed to elucidate why UQ appears to have differential effectiveness across racial/ethnic groups and different levels of cigarette use. Research examining the impact of UQ on long-term quitting, which is not addressed here, is needed.
doi:10.1093/ntr/ntt272
PMCID: PMC4064007  PMID: 24420329
21.  A Mobile-Phone-Based Breath Carbon Monoxide Meter to Detect Cigarette Smoking 
Nicotine & Tobacco Research  2014;16(6):766-773.
Introduction:
Mobile phones hold considerable promise for delivering evidence-based smoking cessation interventions that require frequent and objective assessment of smoking status via breath carbon monoxide (Breath CO) measurement. However, there are currently no commercially available mobile-phone-based Breath CO meters. We developed a mobile-phone-based Breath CO meter prototype that attaches to and communicates with a smartphone through an audio port. We then evaluated the reliability and the validity of Breath CO measures collected with the mobile meter prototype and assessed the usability and acceptability of the meter.
Methods:
Participants included 20 regular smokers (≥10 cigarettes/day), 20 light smokers (<10 cigarettes/day), and 20 nonsmokers. Expired air samples were collected 4 times from each participant: twice with the mobile meter and twice with a commercially available Breath CO meter.
Results:
Measures calculated by the mobile meter correlated strongly with measures calculated by the commercial meter (r = .96, p < .001). Additionally, the mobile meter accurately distinguished between smokers and nonsmokers. The area under the receiver-operating characteristic curve for the mobile meter was 94.7%, and the meter had a combined sensitivity and specificity of 1.86 at an abstinence threshold of ≤6 ppm. Responses on an acceptability survey indicated that smokers liked the meter and would be interested in using it during a quit attempt.
Conclusions:
The results of our study suggest that a mobile-phone-based Breath CO meter is a reliable, valid, and acceptable device for distinguishing between smokers and nonsmokers.
doi:10.1093/ntr/ntt275
PMCID: PMC4031569  PMID: 24470633
22.  Absolute and Comparative Cancer Risk Perceptions Among Smokers in Two Cities in China 
Nicotine & Tobacco Research  2014;16(6):899-903.
Introduction:
Knowledge about health effects of smoking motivates quit attempts and sustained abstinence among smokers and also predicts greater acceptance of tobacco control efforts such as cigarette taxes and public smoking bans. We examined whether smokers in China, the world’s largest consumer of cigarettes, recognized their heightened personal risk of cancer relative to nonsmokers.
Methods:
A sample of Chinese people (N = 2,517; 555 current smokers) from 2 cities (Beijing and Hefei) estimated their personal risk of developing cancer, both in absolute terms (overall likelihood) and in comparative terms (relative to similarly aged people).
Results:
Controlling for demographics, smokers judged themselves to be at significantly lower risk of cancer than did nonsmokers on the comparative measure. No significant difference emerged between smokers and nonsmokers in absolute estimates.
Conclusions:
Smokers in China did not recognize their heightened personal risk of cancer, possibly reflecting ineffective warning labels on cigarette packs, a positive affective climate associated with smoking in China, and beliefs that downplay personal vulnerability among smokers (e.g., I don’t smoke enough to increase my cancer risk; I smoke high-quality cigarettes that won’t cause cancer).
doi:10.1093/ntr/ntu028
PMCID: PMC4031570  PMID: 24668289
23.  Everyday Discrimination Is Associated With Nicotine Dependence Among African American, Latino, and White Smokers 
Nicotine & Tobacco Research  2013;16(6):633-640.
Introduction:
Discrimination is a commonly perceived stressor among African Americans and Latinos, and previous research has linked stress with substance dependence. Although studies have shown a link between discrimination and smoking, little is known about the relationship between discrimination and nicotine dependence.
Methods:
A total of 2,376 African American (33.4%; n = 794), Latino (33.1%; n = 786), and White (33.5%; n = 796) smokers completed an online survey. Everyday discrimination experiences were described in total and by race/ethnicity. Covariate-adjusted linear regression analyses were conducted to evaluate the associations between everyday discrimination and indicators of nicotine dependence.
Results:
Most participants (79.1%), regardless of race/ethnicity, reported experiencing everyday discrimination. However, total scores on the discrimination measure were higher among Latinos and African Americans than among Whites (p < .001). Race/ethnicity/national origin was the most commonly perceived reason for everyday discrimination among African Americans and Latinos, whereas physical appearance was the most commonly perceived reason among Whites. Regression analyses indicated that everyday discrimination was positively associated with indicators of nicotine dependence, including the Heaviness of Smoking Index (HSI; p < .001) and the Brief Wisconsin Inventory of Smoking Dependence Motives (WISDM) scales (all ps < .001). There was a significant interaction between race/ethnicity and discrimination, such that discrimination was associated with the HSI only among Latinos. Similarly, discrimination was most strongly associated with the WISDM scales among Latinos.
Conclusions:
Analyses indicated that discrimination is a common stressor associated with nicotine dependence. Findings suggest that greater nicotine dependence is a potential pathway through which discrimination may influence health.
doi:10.1093/ntr/ntt198
PMCID: PMC4015086  PMID: 24302634
24.  Knowledge, Attitudes, and Normative Beliefs as Predictors of Hookah Smoking Initiation: A Longitudinal Study of University Students 
Nicotine & Tobacco Research  2013;16(6):647-654.
Introduction:
While cross-sectional studies have shown that hookah tobacco smoking (HTS) is an increasingly popular behavior among university students, little is known about factors associated with initiation. This study sought to determine associations between knowledge, attitudes, and normative beliefs and initiation of HTS among university students.
Methods:
Data were from a prospective longitudinal cohort study of 569 randomly selected first- and second-year university students. Online questionnaires that were developed in accordance with our composite theoretical model were completed in September 2010 and April 2011.
Results:
About one-seventh (13%) of participants initiated HTS by follow-up. Positive attitudes and favorable normative beliefs were associated with increased adjusted odds of initiation (AOR = 4.12, 95% CI = 2.56, 6.59; and AOR = 2.01, 95% CI = 1.35, 2.99, respectively), while negative attitudes were associated with decreased adjusted odds (AOR = 0.62, 95% CI = 0.48, 0.80). Correct knowledge regarding toxicants associated with HTS was not significantly associated with initiation.
Conclusions:
While positive attitudes and favorable normative beliefs are associated with initiation of HTS in a cohort of never-users, increased knowledge about toxins is not associated with lower initiation. It may be particularly valuable for educational interventions to attempt to alter positive attitudes and normative beliefs related to HTS.
doi:10.1093/ntr/ntt201
PMCID: PMC4015087  PMID: 24323574
25.  Smoking Patterns and Their Relationship to Drinking Among First-Year College Students 
Nicotine & Tobacco Research  2014;16(6):743-752.
Introduction:
Unlike older smokers, young adult smokers frequently engage in light and intermittent smoking. It remains unclear how stable such smoking patterns are over time, as substantial variability exists between these smokers. This study identified subgroups of college student smokers based on the trajectory of their smoking frequency during the first year of college, thereby examining stability versus instability over time. We then tested if the interplay between drinking and smoking differed in the identified groups to determine the relative role drinking may play in intermittent versus more regular smoking.
Methods:
Incoming college students at 3 institutions completed online biweekly surveys of their daily substance use throughout the first year of college. Students who reported smoking at least 1 cigarette during this year (n = 266) were included in analyses (70% female, 74% White).
Results:
Group-based trajectory modeling identified 5 groups of smokers, 3 of which maintained their smoking frequency throughout the year (77%), and 2 groups of infrequent smokers showed significant trends (11% increasing, 12% decreasing). Notably, nondaily smoking was maintained at different specific frequencies (e.g., 1 vs. 3 days per week). Identified groups differed in the relationship between drinking and smoking, where cooccurrence was particularly strong among infrequent smokers, and trends in smoking quantity differed between groups.
Conclusions:
While there was a diversity of smoking patterns in the sample, patterns of intermittent smoking remain relatively stable for a majority of students throughout the year. Intervention messages targeting drinking and smoking should be tailored on the basis of smoking frequency.
doi:10.1093/ntr/ntt205
PMCID: PMC4015088  PMID: 24415586

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