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1.  Erratum 
Nicotine & Tobacco Research  2013;15(5):999.
PMCID: PMC3870767
2.  Protecting the World From Secondhand Tobacco Smoke Exposure: Where Do We Stand and Where Do We Go From Here? 
Nicotine & Tobacco Research  2012;15(4):789-804.
Article 8 of the Framework Convention on Tobacco Control mandates all signatory countries to “protect citizens from exposure to tobacco smoke in workplaces, public transport and indoor public places.” Even though there has been great progress in the implementation of Article 8, still most of the world population remains exposed to secondhand smoke (SHS). In this article, we sought to summarize the research that supports Article 8, where do we stand, and current research gaps and future directions.
Secondhand smoke is an established cause of heart disease and several types of cancer. Additional research is needed to reach final conclusions for diseases where evidence is only suggestive of causality. The only solution to SHS exposure in public places is banning smoking indoors. Research on the gaming industry and nightclubs, particularly in developing countries, needs to be disseminated to support their inclusion in smoke-free laws. Aside from indoor bans, additional research is needed for outdoor and multiunit housing bans and in support of measures that protect children and other vulnerable populations. The impact of smoke-free laws on other health outcomes, besides heart disease and respiratory outcomes, is another area where further research is needed. Thirdhand smoke assessment and health effects are also likely to be a topic of further research. As new tobacco products emerge, evaluating SHS exposure and effects will be vital.
Furthering research in support of Article 8 can contribute to reach the final goal of protecting everyone from SHS exposure.
PMCID: PMC3601911  PMID: 23072872
3.  Tobacco Packaging and Mass Media Campaigns: Research Needs for Articles 11 and 12 of the WHO Framework Convention on Tobacco Control 
Nicotine & Tobacco Research  2012;15(4):817-831.
Communicating the health risks of smoking remains a primary objective of tobacco-control policy. Articles 11 and 12 of the World Health Organization’s Framework Convention on Tobacco Control establish standards for two important forms of communication: packaging regulations (Article 11), and mass media campaigns (Article 12).
A narrative review approach was used to identify existing evidence in the areas of package labeling regulations (including health warnings, constituent and emission messages, and prohibitions on misleading information) and communication activities (including mass media campaigns and news media coverage). When available, recent reviews of the literature were used, updated with more recent high-quality studies from published literature.
Implementation of Articles 11 and 12 share several important research priorities: (a) identify existing consumer information needs and gaps, (b) research on the message source to identify effective types of content for health warnings and media campaigns, (c) research on how messages are processed and the extent to which the content and form of messages need to be tailored to different cultural and geographic groups, as well as subgroups within countries, and (d) research to identify the most cost-effective mix and best practices for sustaining health communications over time.
A unifying theme of effective health communication through tobacco packaging and mass media campaigns is the need to provide salient, timely, and engaging reminders of the consequences of tobacco use in ways that motivate and support tobacco users trying to quit and make tobacco use less appealing for those at risk of taking it up.
PMCID: PMC3601912  PMID: 23042986
4.  Research Priorities for Article 14—Demand Reduction Measures Concerning Tobacco Dependence and Cessation 
Nicotine & Tobacco Research  2012;15(4):805-816.
Tobacco dependence treatment (TDT) interventions are often seen as expensive with little impact on the prevalence of tobacco use. However, activities that promote the cessation of tobacco use and support abstinence have an important role in any comprehensive tobacco control program and as such are recognized within Article 14 (A14) of the Framework Convention on Tobacco Control.
To review current evidence for TDT and recommend research priorities that will contribute to more people being helped to stop tobacco use.
We used the recommendations within the A14 guidelines to guide a review of current evidence and best practice for promotion of tobacco cessation and TDT, identify gaps, and propose research priorities.
We identified nine areas for future research (a) understanding current tobacco use and the effect of policy on behavior, (b) promoting cessation of tobacco use, (c) implementation of TDT guidelines, (d) increasing training capacity, (e) enhancing population-based TDT interventions, (f) treatment for different types of tobacco use, (g) supply of low-cost pharmaceutical devices/ products, (h) investigation use of nonpharmaceutical devices/ products, and (i) refinement of current TDTs. Specific research topics are suggested within each of these areas and recognize the differences needed between high- and low-/middle-income countries.
Research should be prioritized toward examining interventions that (a) promote cessation of tobacco use, (b) assist health care workers provide better help to smokers (e.g., through implementation of guidelines and training), (c) enhance population-based TDT interventions, and (d) assist people to cease the use of other tobacco products.
PMCID: PMC3601913  PMID: 23139406
5.  Implementation and Research Priorities for FCTC Articles 13 and 16: Tobacco Advertising, Promotion, and Sponsorship and Sales to and by Minors 
Nicotine & Tobacco Research  2013;15(4):832-846.
Article 13 of the Framework Convention on Tobacco Control (FCTC) calls for a comprehensive ban on tobacco advertising, promotion, and sponsorship (TAPS), and Article 16 calls for prohibition of tobacco sales to and by minors. Although these mandates are based on sound science, many countries have found provision implementation to be rife with challenges.
This paper reviews the history of tobacco marketing and minor access restrictions in high-, middle-, and low-income countries, identifying past challenges and successes. We consider current challenges to FCTC implementation, how these barriers can be addressed, and what research is necessary to support such efforts. Specifically, we identify implementation and research priorities for FCTC Articles 13 and 16.
Although a solid evidence base underpins the FCTC’s call for TAPS bans and minor access restrictions, we know substantially less about how best to implement these restrictions. Drawing on the regulatory experiences of high-, middle-, and low-income countries, we discern several implementation and research priorities, which are organized into 4 categories: policy enactment and enforcement, human capital expertise, the effects of FCTC marketing and youth access policies, and knowledge exchange and transfer among signatories. Future research should provide detailed case studies on implementation successes and failures, as well as insights into how knowledge of successful restrictions can be translated into tobacco control policy and practice and shared among different stakeholders.
Tobacco marketing surveillance, sales-to-minors compliance checks, enforcement and evaluation of restriction policies, and capacity building and knowledge transfer are likely to prove central to effective implementation.
PMCID: PMC3601914  PMID: 23291641
6.  Research Priorities for FCTC Articles 20, 21, and 22: Surveillance/Evaluation and Information Exchange 
Nicotine & Tobacco Research  2013;15(4):847-861.
Framework Convention on Tobacco Control (FCTC) Articles 20, 21, and 22 call for strong monitoring and reporting of tobacco use and factors influencing use and disease (Articles 20 and 21) and for collaboration among the Parties and relevant organizations to share resources, knowledge, and expertise on all relevant tobacco control strategies (Article 22).
This paper provides background information and discusses research strategies that would strengthen these efforts and better inform the Parties. By necessity, Articles 20 and 21 are discussed separately from Article 22, although 1 example that relates to both 20/21 and 22 is discussed at the end.
Twelve important research opportunities on surveillance and evaluation are recognized, along with 4 on collaboration. The authors believe that the 6 most important areas for research would study (a) possible underreporting of tobacco use among certain demographic groups in some countries, (b) measures of industry activities, (c) optimal sampling strategies, (d) sentinel surveillance, (e) networks of tobacco companies and their partners as they promote tobacco use and interfere with implementation of the FCTC, and (f) network/relationship factors that impact diffusion of knowledge and decision making on the implementation of the FCTC. In addition, we call for a review process of existing surveillance and evaluation strategies to coordinate activities to make optimal use of existing resources. This activity would involve networking as prescribed in Article 22.
Studies and activities such as these would facilitate control of the tobacco epidemic.
PMCID: PMC3601915  PMID: 23335488
7.  Converging Research Needs Across Framework Convention on Tobacco Control Articles: Making Research Relevant to Global Tobacco Control Practice and Policy 
Nicotine & Tobacco Research  2012;15(4):761-766.
Much of the research used to support the ratification of the WHO Framework Convention on Tobacco Control (FCTC) was conducted in high-income countries or in highly controlled environments. Therefore, for the global tobacco control community to make informed decisions that will continue to effectively inform policy implementation, it is critical that the tobacco control community, policy makers, and funders have updated information on the state of the science as it pertains to provisions of the FCTC. Following the National Cancer Institute’s process model used in identifying the research needs of the U.S. Food and Drug Administration’s relatively new tobacco law, a core team of scientists from the Society for Research on Nicotine and Tobacco identified and commissioned internationally recognized scientific experts on the topics covered within the FCTC. These experts analyzed the relevant sections of the FCTC and identified critical gaps in research that is needed to inform policy and practice requirements of the FCTC. This paper summarizes the process and the common themes from the experts’ recommendations about the research and related infrastructural needs. Research priorities in common across Articles include improving surveillance, fostering research communication/collaboration across organizations and across countries, and tracking tobacco industry activities. In addition, expanding research relevant to low- and middle-income countries (LMIC), was also identified as a priority, including identification of what existing research findings are transferable, what new country-specific data are needed, and the infrastructure needed to implement and disseminate research so as to inform policy in LMIC.
PMCID: PMC3693497  PMID: 22990225
8.  Research Required for the Effective Implementation of the Framework Convention on Tobacco Control, Articles 9 and 10 
Nicotine & Tobacco Research  2012;15(4):777-788.
This paper is part of a series of articles intended to set out the research questions that are relevant to the successful implementation of the various provisions of the Framework Convention on Tobacco Control (FCTC). This paper focuses on issues affecting Articles 9 and 10 of the FCTC. This paper focuses on the research that is most important for most countries, rather than on what is desirable in countries with high levels of research capacity.
Articles 9 and 10 of the FCTC address the regulation of contents and emissions of tobacco products and regulation of tobacco product disclosure. Such regulation will be essential if the long-term objective of reducing the danger of tobacco products is to be achieved. There are many components of tobacco and tobacco smoke that are excessively toxic and dangerous to the user. Many of these components are carcinogenic and addictive and can be removed or reduced substantially with current known technology. The fact that these components remain in tobacco and tobacco smoke at levels that are unnecessarily dangerous is precisely the reason why the successful implementation of Articles 9 and 10 of the FCTC is important to tobacco control. This paper discusses the scientific challenges involved in successfully implementing Articles 9 and 10 of the FCTC, which focuses on regulating carcinogens and toxins in tobacco and tobacco smoke, the abuse liability of tobacco products, and the additives and engineering features in tobacco products that make tobacco products appealing to future consumers.
The research issues we focus on are those required to support the early stages of regulation. As regulation proceeds, new and more sophisticated research questions will undoubtedly emerge.
PMCID: PMC3693498  PMID: 23024247
9.  Price and Tax Measures and Illicit Trade in the Framework Convention on Tobacco Control: What We Know and What Research Is Required 
Nicotine & Tobacco Research  2012;15(4):767-776.
Article 6 of the Framework Convention on Tobacco Control commits Parties to use tax and price policies to reduce tobacco use, whereas Article 15 commits Parties to implement measures to eliminate the illicit trade in tobacco products. This paper identifies research gaps/needs, especially in low- and middle-income countries, which, if adequately addressed, would help in implementing Articles 6 and 15.
Based on a recent comprehensive review on the impact of tax and price on tobacco consumption and a summary of reviews and narratives about the illicit tobacco market, research gaps are identified.
Countries have highly diverse research needs, depending on the stage of the tobacco epidemic, previous research and data availability, and making a ranking of research needs infeasible. Broad issues for further research are the following: (1) monitoring tobacco consumption, prices, and taxes, (2) assessing the effectiveness of the tax structure in generating revenue and reducing tobacco use, (3) strengthening the tax administration system in order to reduce tax evasion and tax avoidance, (4) improving our understanding of the political economy of tobacco tax policy, and (5) employing a multidisciplinary approach to assessing the magnitude of illicit tobacco trade.
At a technical level, the case for increasing excise taxes to improve public health and increase government revenue is easily made, but the political and policy environment is often not supportive. In order to effectively impact policy, the required approach would typically make use of rigorous economic techniques, and be cognizant of the political economy of raising excise taxes.
PMCID: PMC3693499  PMID: 22987785
10.  Perceptions of Smoking-Related Risk and Worry Among Dual-Smoker Couples 
Nicotine & Tobacco Research  2012;15(3):734-738.
Quit rates are lower and relapse rates are higher for people in close relationships with a partner who smokes. Although desire to quit is often related to health concerns for one’s self, much less is known about psychosocial factors associated with quitting in dual-smoker couples. This study investigated relations among beliefs about smoking and desire to quit from both partners’ perspectives.
We recruited 63 couples in which both partners smoke daily. Participants were aged 21–67 (M = 43.0, SD = 11.3) and had been smoking for 4–51 years (M = 22.9, SD = 11.3).
Individuals’ desire to quit related to worry about partner’s health (r = .29, p < .01), perceived risk of partner getting a disease if the partner continues to smoke (r = .39, p < .001), and belief that own smoking has caused partner physical harm (r = .38, p < .001). Within couples, partners were modestly concordant with regard to worry about harm of smoking for oneself (r = .30, p < .05) and partner (r = .30, p < .05), perceived risk of disease for oneself (r = .26, p < .05) and partner (r = .24, p < .05), and desire that partner quit (r = .34, p < .01). Participants had an extremely strong desire (78% = 7 on 1–7 scale) for their partner’s help if they attempt to quit.
Dual-smoker couples are at heightened health risks due to exposure to passive smoke and their own smoking. Partners’ perceived risk and worry about the harms of smoking could be important leverage points for smoking cessation efforts. Interventions can be informed by considering both partners’ beliefs and by helping partners develop plans for quitting and supporting each other.
PMCID: PMC3572873  PMID: 22990222
11.  Smoking Status, Physical Health–Related Quality of Life, and Mortality in Middle-Aged and Older Women 
Nicotine & Tobacco Research  2012;15(3):662-669.
Women who smoke, particularly older women, have been relatively neglected in smoking research. There is a lack of knowledge concerning the relation of level of smoking to quality of life and mortality among middle-aged and older women smokers.
This study examined the relation of smoking status to physical health–related quality of life (PHRQL) and total mortality in women in the Women’s Health Initiative (WHI) Observational Study. Participants were 90,849 postmenopausal women, who were an average age of 63.6 years at baseline. Analyses used multiple linear and Cox proportional hazards regression and controlled for age, educational level, and ethnicity. Never-smokers were the reference group.
We found that smoking status was significantly related to PHRQL cross-sectionally at baseline and prospectively at a 3-year follow-up, with those who smoked having lower PHRQL. Heavier smokers showed large, clinically meaningful associations with PHRQL and light smokers showed small associations. In addition, we found that the smoking status at baseline was significantly related to 10-year total mortality. Both light and heavier smoking at baseline significantly correlated with higher mortality risk; however, the relationship of smoking to mortality was dose dependent. Among former smokers, those who had smoked longer showed significantly lower PHRQL and significantly increased mortality risk.
Findings suggest that the risks of smoking may not be evident to light smokers and that educational interventions targeted to middle-aged and older women stressing the consequences of light smoking may be particularly beneficial.
PMCID: PMC3611990  PMID: 22965789
12.  Impact of Smoking Exposure Change on Infant Birth Weight Among a Cohort of Women in a Prenatal Smoking Cessation Study 
Nicotine & Tobacco Research  2012;15(3):685-692.
Despite the known harmful effects of smoking during pregnancy, the highly addicted find it difficult to quit. Decreased smoking may be regarded as a means of harm reduction. There is limited information on the benefits of smoking reduction short of quitting. This study used salivary cotinine to assess the impact of change in smoking exposure on birth weight in full-term infants.
In a prenatal smoking cessation study, smoking status was validated by saliva cotinine at baseline and end of pregnancy (EOP). Salivary cotinine ≥15ng/ml defined active smoking. Based on salivary cotinine, women were grouped as nonsmoking/quit, light exposure (<150ng/ml), and heavy exposure (≥150ng/ml) at baseline and EOP. EOP and baseline smoking status were stratified to form smoking exposure change groups. Mean birth weight was compared among those who quit, reduced, maintained, and increased.
Smoking cessation was associated with a 299g increase in birth weight compared with sustained heavy smoking, p = .021. Reduced exposure from heavy to light was associated with a 199g increase in birth weight compared with sustained heavy exposure, a 103g increase compared with increased exposure, and a 63g increase compared with sustained light exposure. Differences among continuing smokers were not statistically significant.
Although not statistically significant, the increase in infant birth weight associated with reduction from heavy to light exposure suggests potential for benefit. The only statistically significant comparison was between quitters and sustained heavy smokers, confirming that smoking cessation should remain the goal for pregnant women.
PMCID: PMC3611991  PMID: 22990216
13.  Enhancing Tobacco Quitline Effectiveness: Identifying a Superior Pharmacotherapy Adjuvant 
Nicotine & Tobacco Research  2012;15(3):718-728.
: Telephone tobacco quitlines are effective and are widely used, with more than 500,000 U.S. callers in 2010. This study investigated the clinical effectiveness and cost-effectiveness of 3 different quitline enhancements: combination nicotine replacement therapy (NRT), longer duration of NRT, and counseling to increase NRT adherence.
: In this study, 987 quitline callers were randomized to a combination of quitline treatments in a 2×2 × 2 factorial design: NRT duration (2 vs. 6 weeks), NRT type (nicotine patch only vs. patch plus nicotine gum), and standard 4-call counseling (SC) versus SC plus medication adherence counseling (MAC). The primary outcome was 7-day point-prevalence abstinence (PPA) at 6 months postquit in intention-to-treat (ITT) analyses.
: Combination NRT for 6 weeks yielded the highest 6-month PPA rate (51.6%) compared with 2 weeks of nicotine patch (38.4%), odds ratios [OR] = 1.71 (95% confidence interval [CI]:1.20–2.45). A similar result was found for 2 weeks of combination NRT (48.2%), OR = 1.49 (95% CI: 1.04–2.14) but not for 6 weeks of nicotine patch alone (46.2%), OR = 1.38 (95% CI: 0.96–1.97). The MAC intervention effect was nonsignificant. Cost analyses showed that the 2-week combination NRT group had the lowest cost per quit ($442 vs. $464 for 2-week patch only, $505 for 6-week patch only, and $675 for 6-week combination NRT).
: Combination NRT for 2 or 6 weeks increased 6-month abstinence rates by 10% and 13%, respectively, over rates produced by 2 weeks of nicotine patch when offered with quitline counseling. A 10% improvement would potentially yield an additional 50,000 quitters annually, assuming 500,000 callers to U.S. quitlines per year.
PMCID: PMC3611992  PMID: 22992296
14.  Modeling Nicotine Dependence: An Application of a Longitudinal IRT Model for the Analysis of Adolescent Nicotine Dependence Syndrome Scale 
Nicotine & Tobacco Research  2012;15(2):326-333.
Measures of nicotine dependence typically use the item average or total score from rating scales, such as the Nicotine Dependence Syndrome Scale (NDSS). Alternatively, item response theory (IRT) methods can provide useful item-specific information. IRT methods developed for longitudinal data can additionally provide information about item-specific changes over time.
We describe a longitudinal 2-parameter ordinal IRT model, and compare the results from this model with those from an IRT model for only the baseline item responses, and a conventional longitudinal analysis of the item-average NDSS score. We examined a 10-item, adolescent version of the NDSS at baseline, 6, 15, and 24 months for 1,097 9th or 10th graders.
IRT analysis of the baseline data revealed that the items “willing to go out of the house in a storm to find a cigarette,” “choose to spend money on cigarettes than lunch,” “function better after morning cigarette,” and “worth smoking in cold or rain,” were good items at distinguishing individuals’ levels of nicotine dependency. While the analysis of the averaged NDSS score indicated linear growth over time, the longitudinal IRT method revealed that only 5 out of the 10 items showed statistical increase over time.
Infrequently endorsed NDSS items were generally better able to distinguish higher levels of dependency. The endorsement of such items increased over time. Items that changed significantly over time reflected the general drive concept of dependence, as well as the total first overarching dimension of dependence.
PMCID: PMC3545713  PMID: 22585539
15.  Counseling Nondaily Smokers about Secondhand Smoke as a Cessation Message: A Pilot Randomized Trial 
Nicotine & Tobacco Research  2012;15(2):334-342.
Nondaily smoking represents a substantial and growing fraction of smokers, many of whom do not consider themselves smokers or at risk of tobacco-related diseases and, so, may be less responsive to counseling content contained in traditional cessation interventions. This study compares the effects brief counseling interventions (<20 min) focused on the harm smoking does to themselves (harm to self, HTS) versus the harm their secondhand smoke (SHS) does to others (harm to others, HTO) among nondaily smokers.
Randomized trial of 52 nondaily smokers (smoked in the past week, but not daily) recruited between September 2009 and June 2010; 40 completed the study. We measured changes in motivation and smoking status at 3 months postintervention.
There was a difference in quitting between the two groups, with 9.5% (2 out of 21) for HTS and 36.8% (7 out of 19) for HTO subjects reporting not smoking any cigarettes in the prior week (p = .06 by Fisher exact test and .035 by likelihood-ratio chi-square). Motivation and self-efficacy increased from baseline to 3-month follow-up, but not differentially by intervention group.
Consistent with findings from research conducted by the tobacco industry as early as the 1970s that concluded that social smokers feel immune from the personal health effects of tobacco but are concerned about the consequences of their SHS on others, educating nondaily smokers about the dangers of SHS to others appears to be a more powerful cessation message than traditional smoking cessation counseling that emphasizes the harmful consequences to the smoker.
PMCID: PMC3545714  PMID: 22592447
16.  High Dose Transdermal Nicotine for Fast Metabolizers of Nicotine: A Proof of Concept Placebo-Controlled Trial 
Nicotine & Tobacco Research  2012;15(2):348-354.
Smokers with a faster rate of nicotine metabolism, estimated using the ratio of 3′-hydroxycotinine (3-HC) to cotinine, have lower plasma nicotine levels and are more likely to relapse with 21 mg nicotine patch therapy, than smokers with slower rates of nicotine metabolism. Thus, faster metabolizers of nicotine may require a higher nicotine patch dose to achieve cessation.
This proof of concept randomized placebo-controlled trial evaluated the efficacy and safety of 8 weeks of 42 mg transdermal nicotine versus 21 mg, among 87 fast metabolizers of nicotine (3-HC/cotinine ≥ 0.18).
After 1 week of treatment, an intent-to-treat (ITT) analysis showed that participants treated with 42 mg nicotine had significantly higher expired-air carbon monoxide (CO)-confirmed 24-hr abstinence (75% vs. 58.1%; OR = 3.21; 95% CI: 1.12–9.24, p = .03) but not 7-day abstinence (50% vs. 34.9%; OR = 2.02; 95% CI: 0.82–4.94, p = .13). After 8 weeks of treatment, ITT analysis showed that participants treated with 42 mg nicotine had marginally higher rates of CO-confirmed 24-hr abstinence (45.5% vs. 30.2%; OR = 2.32; 95% CI: 0.92–5.92, p = .08) but not 7-day abstinence (29.6% vs. 23.3%; OR = 1.52, 95% CI: 0.57–4.07, p = .41). Percent nicotine and cotinine replacement were significantly greater for 42 mg nicotine versus 21 mg (p < .005). There were no significant differences between treatment arms in the frequency of severe side effects and serious adverse events or blood pressure during treatment (p > .10).
Further examination of the efficacy of 42 mg nicotine patch therapy for fast metabolizers of nicotine is warranted.
PMCID: PMC3545715  PMID: 22589423
17.  Osmotic Release Oral System Methylphenidate Prevents Weight Gain during a Smoking-Cessation Attempt in Adults with ADHD 
Nicotine & Tobacco Research  2012;15(2):583-587.
Adults with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for both cigarette smoking and being overweight or obese. Although smoking cessation tends to result in weight increase, potentially initiating or exacerbating weight problems, adults with ADHD who are treated with osmotic release oral system methylphenidate (OROS-MPH) tend to lose weight. It is unclear how the use of OROS-MPH during a smoking-cessation attempt might affect the typical weight gain that accompanies cessation.
We examined changes in weight and hunger during a smoking-cessation attempt in 215 adults with ADHD who completed a multisite, randomized, controlled trial and were randomized to either OROS-MPH (n = 107) or placebo (n = 108) (NCT #00253747). Both groups also received open-label transdermal nicotine replacement and counseling.
Participants who received OROS-MPH lost an average of 1.6% of their body weight during the 11-week study, whereas those who received placebo gained an average of 1.3% of their weight (p < .001). Hunger ratings were lower in the OROS-MPH group (M = 1.1, SD = 0.8) than in the placebo group (M = 1.6, SD = 0.9; p < .001).
The use of OROS-MPH during a smoking-cessation attempt prevents weight gain in adults with ADHD who substantially reduce or quit smoking. The potential utility of OROS-MPH in individuals with ADHD who are attempting to quit smoking and for whom weight gain would be problematic warrants further research.
PMCID: PMC3545716  PMID: 22955246
18.  Effectiveness of Antismoking Media Messages and Education Among Adolescents in Malaysia and Thailand: Findings From the International Tobacco Control Southeast Asia Project 
Nicotine & Tobacco Research  2012;15(2):482-491.
Finding ways to discourage adolescents from taking up smoking is important because those who begin smoking at an earlier age are more likely to become addicted and have greater difficulty in quitting. This article examined whether anti smoking messages and education could help to reduce smoking susceptibility among adolescents in two Southeast Asian countries and to explore the possible moderating effect of country and gender.
Data came from Wave 1 of the International Tobacco Control Southeast Asia Project (ITC-SEA) survey conducted in Malaysia (n = 1,008) and Thailand (n = 1,000) where adolescents were asked about receiving antismoking advice from nurses or doctors, being taught at schools about the danger of smoking, noticing antismoking messages, knowledge of health effects of smoking, beliefs about the health risks of smoking, smoking susceptibility, and demographic information. Data were analyzed using chi-square tests and logistic regression models.
Overall, significantly more Thai adolescents reported receiving advice from their nurses or doctors about the danger of smoking (p < .001), but no country difference was observed for reported antismoking education in schools and exposure to antismoking messages. Multivariate analyses revealed that only provision of antismoking education at schools was significantly associated with reduced susceptibility to smoking among female Malaysian adolescents (OR = 0.26). Higher knowledge of smoking harm and higher perceived health risk of smoking were associated with reduced smoking susceptibility among Thai female (OR = 0.52) and Malaysian male adolescents (OR = 0.63), respectively.
Educating adolescents about the dangers of smoking in schools appears to be the most effective means of reducing adolescents’ smoking susceptibility in both countries, although different prevention strategies may be necessary to ensure effectiveness for male and female adolescents.
PMCID: PMC3545717  PMID: 22949569
19.  Effects of Smoking Cues and Argument Strength of Antismoking Advertisements on Former Smokers’ Self-efficacy, Attitude, and Intention to Refrain From Smoking 
Nicotine & Tobacco Research  2012;15(2):527-533.
This study examines the impact of smoking cues employed in antismoking advertisements on former smokers. Previous findings indicate that visual smoking cues in antismoking advertisements with weak antismoking arguments can elicit smoking urges in smokers and undermine message effectiveness. This study extends these observations to former smokers asking whether smoking cues in antismoking advertisements influence former smokers’ self-efficacy, attitudes, and intention to refrain from smoking, along with smoking urges and perceived message effectiveness.
The study was a mixed 2 (smoking cues; present vs. absent) × 2 (argument strength [AS]; high vs. low) design where smoking cue was a between-subject factor and AS was a within-subject factor. Potential participants recruited via online ads were screened in a phone interview for their eligibility. A total of 105 former smokers (aged 21–65) participated in the study, which was conducted in a laboratory setting. Repeated measure ANOVA and MANOVA were used for the analyses.
The results showed that the presence of smoking cues in antismoking ads undermines former smokers’ behavioral self-efficacy, attitude, and intention about smoking abstinence, which increased as AS for the ads increased. Former smokers’ reports of smoking urge were not affected by smoking cues or AS. However, consistent with previous findings for smokers, the presence of cues weakened perceived message effectiveness of antismoking ads rated by former smokers.
The effect of smoking cues on former smokers’ self-efficacy, attitude, and intention to refrain from smoking is problematic. Inclusion of smoking cues in antismoking ads should be undertaken only when accompanied by strong arguments.
PMCID: PMC3545718  PMID: 22949578
20.  Effects of Abstinence in Adolescent Tobacco Smokers: Withdrawal Symptoms, Urge, Affect, and Cue Reactivity 
Nicotine & Tobacco Research  2012;15(2):457-464.
The aim of this study was to evaluate abstinence effects in adolescent daily smokers by examining the effects of experimentally manipulated acute smoking abstinence on measures including: (a) withdrawal symptoms, (b) reactive irritability, (c) smoking urges, (d) affect, and (e) responses to smoking cues.
Participants (ages 13–19, 74 daily smokers, and 22 nonsmokers) completed baseline questionnaires and laboratory assessments (Session 1) and returned 1–4 days later to repeat the laboratory assessments (Session 2); half of the smokers were randomly assigned to overnight tobacco abstinence preceding Session 2.
During Session 2, abstinent smokers reported significantly greater increases in withdrawal symptoms, smoking urges, and negative affect compared with smokers who did not abstain and compared with nonsmokers. Although there was not a significant effect of abstinence on differential reactivity to smoking versus neutral cues, abstinence did result in significantly increased peak provoked urges and negative effect. There was not a significant effect of abstinence on positive affect or reactive irritability,
Our results suggest that adolescents experience increases in withdrawal symptoms, smoking urges (un-cued and peak provoked), and negative affect (un-cued and peak provoked) after acute smoking abstinence, but do not experience the increases in reactive irritability or decreases in positive affect that have been shown in adult smokers. Overall findings support the withdrawal relief and negative reinforcement models of smoking maintenance in adolescents and point to withdrawal, urge, and negative affect as important targets for treatment.
PMCID: PMC3611993  PMID: 22949582
21.  Smoking During Consecutive Pregnancies Among Primiparous Women in the Population-Based Norwegian Mother and Child Cohort Study 
Nicotine & Tobacco Research  2012;15(2):428-434.
This study investigated changes in smoking behavior across pregnancies in a sample of 10,890 primiparous women participating in the prospective population-based Norwegian Mother and Child Cohort Study (MoBa) in order to identify risk factors that may inhibit smoking cessation and promote smoking during a woman’s second pregnancy.
Registry information regarding smoking, age, marital status, parity, and year of birth was applied, in addition to questionnaire assessments of own and partner’s smoking behavior, educational attainment, and symptoms of anxiety and depression at weeks 17 and 30 of gestation from both pregnancies.
The vast majority did not smoke in either of the pregnancies, and more women quit smoking than relapsed to smoking in their second pregnancy. Among smokers in the first pregnancy, 30.9% quit smoking by their second pregnancy. Women living with a nonsmoking partner or a partner who quit between pregnancies were more likely to quit smoking, as were women smoking occasionally in their first pregnancy. Symptoms of psychological distress and increasing number of years between pregnancies were negatively associated with smoking cessation. Among women not smoking in their first pregnancy, 2.3% did smoke during their second. Living with a smoking partner, low educational attainment, symptoms of psychological distress, and increasing number of years between pregnancies were all associated with smoking during the second pregnancy.
These findings, linking smoking behavior to changes taking place between pregnancies, offer new and additional insight into modifiable risk factors that may help facilitate more targeted smoking cessation interventions for women at the highest risk.
PMCID: PMC3611994  PMID: 22855885
22.  Pharmacogenetic Smoking Cessation Intervention in a Health Care Setting: A Pilot Feasibility Study 
Nicotine & Tobacco Research  2012;15(2):518-526.
There is increasing evidence that response to pharmacological treatment for nicotine dependence may be moderated by genetic polymorphisms. However, the feasibility, acceptability, and impact of genetically tailoring treatment in real-world clinical settings are unknown.
We conducted a multiphased, mixed-methods feasibility study with current smokers to develop and evaluate a patient-centered, theoretically grounded personalized medicine treatment protocol. The initial research phase included formative work to develop intervention materials. The second phase included a randomized pilot trial to evaluate the intervention. Trial participants (n = 36) were genotyped for ANKK1 rs1800497 and were randomized to receive genetic feedback (GF) plus standard behavioral counseling (BC) for smoking cessation or BC without GF. All participants received genetically tailored pharmacotherapy (nicotine patch or bupropion).
The intervention was feasible to implement and was acceptable to participants based on satisfaction ratings and objective measures of participation. There was no evidence that the GF resulted in adverse psychological outcomes (e.g., depression, fatalism, reduced perceived control over quitting, differential motivation for quitting) based on quantitative or qualitative outcomes.
Study results suggest that it is feasible to offer treatment within a health care setting that includes genetically tailored pharmacotherapy and doing so had no apparent adverse psychological impacts. Further evaluation of pharmacogenetically tailored smoking cessation interventions appears warranted.
PMCID: PMC3611995  PMID: 22949583
23.  Effects of Brief Mindfulness Instructions on Reactions to Body Image Stimuli Among Female Smokers: An Experimental Study 
Nicotine & Tobacco Research  2012;15(2):376-384.
Recent research has shown that body image stimuli increase negative affect and smoking urges among female smokers. Mindfulness (paying attention to present-moment experience with an attitude of nonjudgmental acceptance) may be a useful technique to minimize the influence of body dissatisfaction on negative affect, smoking urges, and smoking behavior.
This study investigated whether mindfulness influences how female college smokers respond to a body image challenge. The study used a 2×2 factorial design with body image challenge (trying on a bathing suit vs. looking at a purse) crossed with instructions (mindfulness vs. silence). Female smokers (n = 64; M age = 20.03 [±1.77], 87.5% Caucasian) were randomly assigned to one of four conditions: Purse + Silence (n = 16), Body Image + Silence (n = 15), Purse + Mindfulness (n = 15), and Body Image + Mindfulness (n = 18).
PMCID: PMC3611996  PMID: 22987786
24.  Perceived Treatment Assignment and Smoking Cessation in a Clinical Trial of Bupropion Versus Placebo 
Nicotine & Tobacco Research  2012;15(2):567-571.
Psychoactive effects of smoking cessation medi cations such as bupropion may allow participants in smoking cessation clinical trials to correctly guess their treatment assignment at rates greater than chance. Previous research has found an association between perceived treatment assignment and smoking cessation rates among moderate to heavy smokers (≥10 cigarettes per day [cpd]) in two bupropion clinical trials.
The aim of this study was to determine the impact of perceived treatment assignment on end-of-treatment cotinine-verified smoking abstinence at Week 7 and Week 26 among African American light smokers (≤10 cpd) enrolled in a double-blind, placebo-controlled study of bupropion. Participants (n = 390) included in this study reported their perceived treatment assignment on the end-of-treatment (Week 7) survey.
Participants were predominantly female (63.1%), 48.1 years of age (SD = 11.2), and smoked an average of 8 cpd (SD = 2.5). Participants given bupropion were more likely to correctly guess their treatment assignment (69%; 140/203) than those assigned to placebo (51.3%; 96/187) (p < .0001). After adjusting for treatment condition, participants who perceived assignment to bupropion versus placebo were not more likely to be abstinent than those who perceived assignment to placebo at Week 7 or at Week 26. The interaction between treatment and perceived treatment assignment was also nonsignificant.
Consistent with two previous studies testing bupropion, participants assigned to bupropion were more likely to correctly guess their treatment assignment than those assigned to placebo. However, in contrast to previous studies with heavier smokers, perceived treatment assignment did not significantly impact cotinine-verified abstinence in light smokers.
PMCID: PMC3611997  PMID: 22949570
25.  Nornicotine Nitrosation in Saliva and Its Relation to Endogenous Synthesis of N′-Nitrosonornicotine in Humans 
Nicotine & Tobacco Research  2012;15(2):591-595.
We recently reported that certain amounts of the carcinogen N′-nitrosonornicotine (NNN) can be formed endogenously from nicotine and/or nornicotine in some users of oral nicotine replacement therapy products. Although the acidic environment of the stomach creates the most favorable conditions for nitrosation, this reaction could also occur in the oral cavity in the presence of bacteria that catalyze nitrosation at neutral pH.
To test the hypothesis that endogenous formation of NNN could occur in the oral cavity, we investigated nitrosation of nicotine and nornicotine in human saliva. To specifically identify NNN as derived from precursors added to saliva, we incubated saliva samples with [pyridine-D4]nicotine and [pyridine-D4]nornicotine, with and without the addition of nitrite, and subsequently analyzed [pyridine-D4]NNN by liquid chromatography–tandem mass spectrometry.
Consistent with kinetic studies on nicotine and nornicotine nitrosation, incubation of saliva with [pyridine-D4]nornicotine alone produced detectable amounts of [pyridine-D4]NNN, whereas only traces of [pyridine-D4]NNN were found in samples incubated with [pyridine-D4]nicotine and sodium nitrite. Incubation of saliva samples from 10 nonsmoking volunteers with [pyridine-D4]nornicotine resulted in the formation of [pyridine-D4]NNN in 8 samples, with yields ranging from 0.003% to 0.051% of the added alkaloid.
Our results demonstrate that NNN can be formed from nornicotine in human saliva without deliberate addition of any other substance. Therefore, nornicotine, as present in tobacco or in nicotine replacement products, is a carcinogen precursor.
PMCID: PMC3611998  PMID: 22923602

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