Smokers’ Perspectives on Texting for Tobacco Dependence Treatment: A Qualitative Analysis

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Background:</div>Numerous evidence-based pharmacologic and behavioral approaches exist for the treatment of tobacco dependence. Short-message service texting is a newer modality which shows promise, but smokers’ perspectives on texting have not been widely explored.<div class=”boxTitle”>Objective:</div>To use a qualitative research approach to elicit from a sub-sample of participants in a pilot clinical trial their perspectives concerning the feasibility, acceptability, and personal relevance of a publicly available texting program for smoking cessation.<div class=”boxTitle”>Methods:</div>Adult smokers enrolled in the intervention arm in a randomized trial of tobacco treatment were interviewed by telephone. Consenting subjects engaged in a 15–30min semi-structured interview with a trained research assistant, discussing their experience with and attitudes about the texting program and how it affected their tobacco use. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Descriptive statistics were calculated for the 16 Likert-formatted items.<div class=”boxTitle”>Results:</div>Of 30 subjects in the intervention arm, 25 (83%) agreed to participate in the qualitative interviews. In general subjects found the program helpful. Common themes were that the texts served as a form of social support, provided useful strategies to reduce tobacco use, validated subjects’ attempts to quit, and offered welcome distractions from cravings. Subjects were satisfied with the frequency, timing, and number of texts, although some improvements were suggested.<div class=”boxTitle”>Conclusions:</div>Texting was perceived as feasible, acceptable, and helpful in smokers’ attempts to abstain from tobacco.<div class=”boxTitle”>Implications</div>The major themes identified included the program being a valued source of external support that provided useful strategies to reduce tobacco use. Subjects were satisfied with the frequency, timing, and number of texts. Texting was perceived as feasible, acceptable, and helpful in smokers’ attempts to abstain from tobacco. Suggestions to improve the program primarily concerned increasing customizable options and using simple, declarative sentences.</span>

Caffeine Concentrations in Coffee, Tea, Chocolate, and Energy Drink Flavored E-liquids

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>Most electronic cigarettes (e-cigarettes) contain a solution of propylene glycol/glycerin and nicotine, as well as flavors. E-cigarettes and their associated e-liquids are available in numerous flavor varieties. A subset of the flavor varieties include coffee, tea, chocolate, and energy drink, which, in beverage form, are commonly recognized sources of caffeine. Recently, some manufacturers have begun marketing e-liquid products as energy enhancers that contain caffeine as an additive.<div class=”boxTitle”>Methods:</div>A Gas Chromatography-Mass Spectrometry (GC-MS) method for the quantitation of caffeine in e-liquids was developed, optimized and validated. The method was then applied to assess caffeine concentrations in 44 flavored e-liquids from cartridges, disposables, and refill solutions. Products chosen were flavors traditionally associated with caffeine (ie, coffee, tea, chocolate, and energy drink), marketed as energy boosters, or labeled as caffeine-containing by the manufacturer.<div class=”boxTitle”>Results:</div>Caffeine was detected in 42% of coffee-flavored products, 66% of tea-flavored products, and 50% of chocolate-flavored e-liquids (limit of detection [LOD] – 0.04 µg/g). Detectable caffeine concentrations ranged from 3.3 µg/g to 703 µg/g. Energy drink-flavored products did not contain detectable concentrations of caffeine. Eleven of 12 products marketed as energy enhancers contained caffeine, though in widely varying concentrations (31.7 µg/g to 9290 µg/g).<div class=”boxTitle”>Conclusions:</div>E-liquid flavors commonly associated with caffeine content like coffee, tea, chocolate, and energy drink often contained caffeine, but at concentrations significantly lower than their dietary counterparts. Estimated daily exposures from all e-cigarette products containing caffeine were much less than ingestion of traditional caffeinated beverages like coffee.<div class=”boxTitle”>Implications:</div>This study presents an optimized and validated method for the measurement of caffeine in e-liquids. The method is applicable to all e-liquid matrices and could potentially be used to ensure regulatory compliance for those geographic regions that forbid caffeine in e-cigarette products. The application of the method shows that caffeine concentrations and estimated total caffeine exposure from e-cigarette products is significantly lower than oral intake from beverages. However, because very little is known about the effects of caffeine inhalation, e-cigarette users should proceed with caution when using caffeine containing e-cigarette products. Further research is necessary to determine associated effects from inhaling caffeine.</span>

A Randomized Trial of Adjunct mHealth Abstinence Reinforcement With Transdermal Nicotine and Counseling for Smoking Cessation

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>Abstinence reinforcement is efficacious for improving smoking treatment outcomes, but practical constraints related to the need for multiple in-person carbon monoxide (CO) breath tests daily to verify smoking abstinence have limited its use. This study tested an mHealth procedure to remotely monitor and reinforce smoking abstinence in individuals’ natural environment.<div class=”boxTitle”>Methods:</div>Eligible treatment-seeking smokers (<span style=”font-style:italic;”>N</span> = 90) were randomized to (1) usual care and ecological monitoring with abstinence reinforcement (mHealth reinforcement) or (2) without reinforcement (mHealth monitoring). Usual care was 8 weeks of transdermal nicotine and twice-weekly telephone counseling. Following training, an interactive voice response system prompted participants to conduct CO tests 1–3 daily at pseudorandom times (7 <span style=”text-transform:lowercase;font-variant:small-caps;”>am</span> to 10 <span style=”text-transform:lowercase;font-variant:small-caps;”>pm</span>) for 4 weeks. When prompted, participants used a study cell phone and CO monitor to complete a CO self-test, video record the process, and submit videos using multimedia messaging. mHealth reinforcement participants could earn prizes for smoking-negative on-time CO tests. The interactive voice response generated preliminary earnings immediately. Earnings were finalized by comparing video records against participants’ self-reports. <div class=”boxTitle”>Results:</div>mHealth reinforcement was associated with a greater proportion of smoking-negative CO tests, longest duration of prolonged abstinence, and point-prevalence abstinence during the monitoring/reinforcement phase compared to mHealth monitoring (<span style=”font-style:italic;”>p</span> < .01, <span style=”font-style:italic;”>d</span> = 0.8–1.3). Follow-up (weeks 4–24) analyses indicated main effects of reinforcement on point-prevalence abstinence and proportion of days smoked (<span style=”font-style:italic;”>p</span> ≤ .05); values were comparable by week 24.<div class=”boxTitle”>Conclusions:</div>mHealth reinforcement has short-term efficacy. Research on methods to enhance and sustain benefits is needed.<div class=”boxTitle”>Implications:</div>This study suggests that mHealth abstinence reinforcement is efficacious and may present temporal and spatial opportunities to research, engage, and support smokers trying to quit that do not exist with conventional (not technology-based) reinforcement interventions.</span>

Genotype × Environment Interaction in Smoking Behaviors: A Systematic Review

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>There has been rapid growth in research exploring gene–environment interaction (G×E) contributing to smoking behaviors. Yet, no systematic review exists to date.<div class=”boxTitle”>Methods:</div>This article aims to review evidence on the contribution of G×E to the risk of smoking. Through a search of electronic databases (ie, Google Scholar, PubMed, ScienceDirect, and Elsevier) up until May 2014, 16 studies of G×E focused on smoking behaviors were identified. These studies were compared in terms of: research design and sample studied, measure of smoking behavior and environments used, genes explored, and G×E in relation to these factors.<div class=”boxTitle”>Results:</div>Thirteen of 16 studies (81.2%) found at least one significant G×E association. Wide variation in analytic methods was found across studies, especially with respect to the phenotypes of interest, environmental measures used, and tests conducted to estimate G×E. Heterogeneity across studies made it difficult to compare findings and evaluate the strength of evidence for G×E.<div class=”boxTitle”>Conclusions:</div>G×E research on smoking contains studies that are methodologically different, making it difficult to assess the current state of the evidence. To decrease heterogeneity, we offer recommendations related to: (1) choice of measurement for environmental variables, (2) testing and reporting of main and interaction effects, (3) treatment of covariates, (4) reporting gene–environment correlation, and (5) conducting sensitivity analyses and checking for scaling artifacts. Continued study is needed to identify mechanisms by which genes and environmental factors combine to influence smoking behaviors.<div class=”boxTitle”>Implications:</div>No comprehensive review of G×E studies of smoking behavior has previously been published. The present article seeks to fill this gap by providing a comprehensive review of: how G×E has been defined, how twin and molecular genetic methodologies have been used to test for G×E, and which genes and environmental factors are associated with smoking behaviors. Variations in methodological approaches make it difficult to interpret and summarize findings, so recommendations for future research are provided as a means to more easily compare and replicate findings across studies.</span>

Daily Smoking and Subjective Health Complaints in Adolescence

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>Using data from the Health Behaviour in School-aged Children survey, this study used a repeated cross-sectional design to examine associations between daily smoking, gender, and self-reported health complaints in five cohorts of adolescents over a 16-year period.<div class=”boxTitle”>Methods:</div>Data were from nationally representative cohorts of 15-year-old youth in Norway in 1993/1994, 1997/1998, 2001/2002, 2005/2006, and 2009/2010 (<span style=”font-style:italic;”>n</span><sub>total</sub> = 7761). Dependent variables were psychological, somatic, and total health complaints. A mixed GLM model examined main and interaction effects of smoking (daily, intermittent, nonsmoking), year, and gender in predicting complaints. Time periods were segmented to compare trends across smoking groups in specific periods.<div class=”boxTitle”>Results:</div>Prevalence of daily smoking declined from 15.5% (1993/1994) to 6.0% (2009/2010). All health complaint scores were significantly higher for smokers and for girls (vs. boys). Smoking status by year interactions were significant for all complaint variables during the period of sharpest decline of daily smoking prevalence (2001/2002–2005/2006), with daily smokers experiencing increases in health complaints while intermittent and nonsmokers did not. Smoking status by gender interactions were significant for all health complaint variables, indicating that the main effect for gender (females higher) was even stronger among smokers compared with nonsmokers. Using year as unit of analysis, the size of mean differences between daily smokers and intermittent/nonsmokers in total complaints was significantly negatively correlated with daily smoking prevalence (−.963, <span style=”font-style:italic;”>n</span> = 5, <span style=”font-style:italic;”>p</span> < .01).<div class=”boxTitle”>Conclusions:</div>As prevalence of daily smoking declined, daily smokers reported higher levels of complaints, suggesting increasing health problems within this group. Girls who smoke daily had particularly elevated levels of complaints.<div class=”boxTitle”>Implications:</div>This study indicates that the relationship between daily smoking and concurrent health symptomatology in adolescents is changing over time, with higher levels of health complaints reported as overall smoking prevalence declines. To our knowledge, this finding has not previously been reported. If youth are smoking to cope with distress, pain, or other health concerns, tobacco control objectives will be increasingly difficult to achieve with adolescents. Levels of health complaints are particularly high among girls who are daily smokers. The findings suggest that restrictive measures and persuasive communications may not be sufficient tobacco prevention strategies for adolescent populations. Young smokers may need counseling and support.</span>

Daily Smoking and Subjective Health Complaints in Adolescence

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>Using data from the Health Behaviour in School-aged Children survey, this study used a repeated cross-sectional design to examine associations between daily smoking, gender, and self-reported health complaints in five cohorts of adolescents over a 16-year period.<div class=”boxTitle”>Methods:</div>Data were from nationally representative cohorts of 15-year-old youth in Norway in 1993/1994, 1997/1998, 2001/2002, 2005/2006, and 2009/2010 (<span style=”font-style:italic;”>n</span><sub>total</sub> = 7761). Dependent variables were psychological, somatic, and total health complaints. A mixed GLM model examined main and interaction effects of smoking (daily, intermittent, nonsmoking), year, and gender in predicting complaints. Time periods were segmented to compare trends across smoking groups in specific periods.<div class=”boxTitle”>Results:</div>Prevalence of daily smoking declined from 15.5% (1993/1994) to 6.0% (2009/2010). All health complaint scores were significantly higher for smokers and for girls (vs. boys). Smoking status by year interactions were significant for all complaint variables during the period of sharpest decline of daily smoking prevalence (2001/2002–2005/2006), with daily smokers experiencing increases in health complaints while intermittent and nonsmokers did not. Smoking status by gender interactions were significant for all health complaint variables, indicating that the main effect for gender (females higher) was even stronger among smokers compared with nonsmokers. Using year as unit of analysis, the size of mean differences between daily smokers and intermittent/nonsmokers in total complaints was significantly negatively correlated with daily smoking prevalence (−.963, <span style=”font-style:italic;”>n</span> = 5, <span style=”font-style:italic;”>p</span> < .01).<div class=”boxTitle”>Conclusions:</div>As prevalence of daily smoking declined, daily smokers reported higher levels of complaints, suggesting increasing health problems within this group. Girls who smoke daily had particularly elevated levels of complaints.<div class=”boxTitle”>Implications:</div>This study indicates that the relationship between daily smoking and concurrent health symptomatology in adolescents is changing over time, with higher levels of health complaints reported as overall smoking prevalence declines. To our knowledge, this finding has not previously been reported. If youth are smoking to cope with distress, pain, or other health concerns, tobacco control objectives will be increasingly difficult to achieve with adolescents. Levels of health complaints are particularly high among girls who are daily smokers. The findings suggest that restrictive measures and persuasive communications may not be sufficient tobacco prevention strategies for adolescent populations. Young smokers may need counseling and support.</span>

The Association of Cigarette Smoking With Depression and Anxiety: A Systematic Review

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Background:</div>Many studies report a positive association between smoking and mental illness. However, the literature remains mixed regarding the direction of this association. We therefore conducted a systematic review evaluating the association of smoking and depression and/or anxiety in longitudinal studies.<div class=”boxTitle”>Methods:</div>Studies were identified by searching PubMed, Scopus, and Web of Science and were included if they: (1) used human participants, (2) were longitudinal, (3) reported primary data, (4) had smoking as an exposure and depression and/or anxiety as an outcome, or (5) had depression and/or anxiety as the exposure and smoking as an outcome.<div class=”boxTitle”>Results:</div>Outcomes from 148 studies were categorized into: smoking onset, smoking status, smoking heaviness, tobacco dependence, and smoking trajectory. The results for each category varied substantially, with evidence for positive associations in both directions (smoking to later mental health and mental health to later smoking) as well as null findings. Overall, nearly half the studies reported that baseline depression/anxiety was associated with some type of later smoking behavior, while over a third found evidence that a smoking exposure was associated with later depression/anxiety. However, there were few studies directly supporting a bidirectional model of smoking and anxiety, and very few studies reporting null results.<div class=”boxTitle”>Conclusions:</div>The literature on the prospective association between smoking and depression and anxiety is inconsistent in terms of the direction of association most strongly supported. This suggests the need for future studies that employ different methodologies, such as Mendelian randomization (MR), which will allow us to draw stronger causal inferences.<div class=”boxTitle”>Implications:</div>We systematically reviewed longitudinal studies on the association of different aspects of smoking behavior with depression and anxiety. The results varied considerably, with evidence for smoking both associated with subsequent depression and anxiety, and vice versa. Few studies supported a bidirectional relationship, or reported null results, and no clear patterns by gender, ethnicity, clinical status, length to follow-up, or diagnostic test. Suggesting that despite advantages of longitudinal studies, they cannot alone provide strong evidence of causality. Therefore, future studies investigating this association should employ different methods allowing for stronger causal inferences to be made, such as MR.</span>

The Association of Cigarette Smoking With Depression and Anxiety: A Systematic Review

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Background:</div>Many studies report a positive association between smoking and mental illness. However, the literature remains mixed regarding the direction of this association. We therefore conducted a systematic review evaluating the association of smoking and depression and/or anxiety in longitudinal studies.<div class=”boxTitle”>Methods:</div>Studies were identified by searching PubMed, Scopus, and Web of Science and were included if they: (1) used human participants, (2) were longitudinal, (3) reported primary data, (4) had smoking as an exposure and depression and/or anxiety as an outcome, or (5) had depression and/or anxiety as the exposure and smoking as an outcome.<div class=”boxTitle”>Results:</div>Outcomes from 148 studies were categorized into: smoking onset, smoking status, smoking heaviness, tobacco dependence, and smoking trajectory. The results for each category varied substantially, with evidence for positive associations in both directions (smoking to later mental health and mental health to later smoking) as well as null findings. Overall, nearly half the studies reported that baseline depression/anxiety was associated with some type of later smoking behavior, while over a third found evidence that a smoking exposure was associated with later depression/anxiety. However, there were few studies directly supporting a bidirectional model of smoking and anxiety, and very few studies reporting null results.<div class=”boxTitle”>Conclusions:</div>The literature on the prospective association between smoking and depression and anxiety is inconsistent in terms of the direction of association most strongly supported. This suggests the need for future studies that employ different methodologies, such as Mendelian randomization (MR), which will allow us to draw stronger causal inferences.<div class=”boxTitle”>Implications:</div>We systematically reviewed longitudinal studies on the association of different aspects of smoking behavior with depression and anxiety. The results varied considerably, with evidence for smoking both associated with subsequent depression and anxiety, and vice versa. Few studies supported a bidirectional relationship, or reported null results, and no clear patterns by gender, ethnicity, clinical status, length to follow-up, or diagnostic test. Suggesting that despite advantages of longitudinal studies, they cannot alone provide strong evidence of causality. Therefore, future studies investigating this association should employ different methods allowing for stronger causal inferences to be made, such as MR.</span>

Prenatal Tobacco Exposure Shortens Telomere Length in Children

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>Preliminary evidence suggests a possible association between prenatal tobacco exposure and telomere length in children. This study was conducted to investigate whether maternal smoking during pregnancy was associated with telomere shortening in their children and whether prenatal and childhood exposure to environmental tobacco had any impact on this association.<div class=”boxTitle”>Methods:</div>This is a population-representative study on the association between prenatal tobacco exposure and telomere length in children. Ninety-eight Hong Kong Chinese children aged under 15 years with prenatal tobacco exposure and 98 age- and gender-matched controls were recruited from a population health study with stratified random sampling.<div class=”boxTitle”>Results:</div>Telomere length in children with prenatal tobacco exposure was significantly shorter than in those with no exposure (mean T/S ratio = 24.9 [SD = 8.58] in exposed vs. 28.97 [14.15] in control groups; <span style=”font-style:italic;”>P</span> = 0.02). A negative dose–response relationship was observed between the T/S ratio and tobacco exposure duration: the longer the duration of maternal smoking in pregnancy, the shorter the child’s telomere length. The association between the child’s telomere length and prenatal tobacco exposure remained significant after considering the influence of family socioeconomic status and exposure to environmental tobacco smoke during pregnancy and childhood.<div class=”boxTitle”>Conclusions:</div>Prenatal tobacco exposure was associated with telomere shortening in children. As this may impose significant health impacts through fetal genetic programming, more efforts should be made to reduce fetal tobacco exposure by educating pregnant women to not smoke and motivating smokers to quit in early pregnancy.<div class=”boxTitle”>Implications:</div>As reflected by telomere shortening, prenatal tobacco exposure in children can cause premature aging and increased health risks, which we suggest is entirely preventable. Not smoking during pregnancy or quitting smoking is critical to improving the health outcome of our future generations as prenatal tobacco exposure may affect children’s biological programming.</span>

Prenatal Tobacco Exposure Shortens Telomere Length in Children

<span class=”paragraphSection”><div class=”boxTitle”>Abstract</div><div class=”boxTitle”>Introduction:</div>Preliminary evidence suggests a possible association between prenatal tobacco exposure and telomere length in children. This study was conducted to investigate whether maternal smoking during pregnancy was associated with telomere shortening in their children and whether prenatal and childhood exposure to environmental tobacco had any impact on this association.<div class=”boxTitle”>Methods:</div>This is a population-representative study on the association between prenatal tobacco exposure and telomere length in children. Ninety-eight Hong Kong Chinese children aged under 15 years with prenatal tobacco exposure and 98 age- and gender-matched controls were recruited from a population health study with stratified random sampling.<div class=”boxTitle”>Results:</div>Telomere length in children with prenatal tobacco exposure was significantly shorter than in those with no exposure (mean T/S ratio = 24.9 [SD = 8.58] in exposed vs. 28.97 [14.15] in control groups; <span style=”font-style:italic;”>P</span> = 0.02). A negative dose–response relationship was observed between the T/S ratio and tobacco exposure duration: the longer the duration of maternal smoking in pregnancy, the shorter the child’s telomere length. The association between the child’s telomere length and prenatal tobacco exposure remained significant after considering the influence of family socioeconomic status and exposure to environmental tobacco smoke during pregnancy and childhood.<div class=”boxTitle”>Conclusions:</div>Prenatal tobacco exposure was associated with telomere shortening in children. As this may impose significant health impacts through fetal genetic programming, more efforts should be made to reduce fetal tobacco exposure by educating pregnant women to not smoke and motivating smokers to quit in early pregnancy.<div class=”boxTitle”>Implications:</div>As reflected by telomere shortening, prenatal tobacco exposure in children can cause premature aging and increased health risks, which we suggest is entirely preventable. Not smoking during pregnancy or quitting smoking is critical to improving the health outcome of our future generations as prenatal tobacco exposure may affect children’s biological programming.</span>