Category: Smoking

A study led by researchers in the Oregon Health & Science University Smoking Cessation Center may change the way clinicians make treatment decisions for their patients who smoke.

Their findings published online in the journal Addiction suggest that current treatment theories that maintain any smoking after the planned target quit day predicts treatment failure need to be expanded to take into account a more dynamic quitting process. The team's analysis points to two types of successful quitters: those who quit immediately and remain abstinent through the end of treatment and those who are "delayed" in attaining abstinence but achieve success by the end of treatment.

"In 'real-world' clinic settings, health care providers must decide whether or not to continue a specific treatment based on their clinical judgment and the published reports in the scientific literature. They can lose confidence that a specific cessation treatment is effective when the patient is unable to quit on the recommended target quit day or if the patient is unable to maintain total abstinence within the early weeks of treatment," said David Gonzales, Ph.D., the study's lead author and a senior clinical investigator in Pulmonary and Critical Care Medicine at the OHSU Smoking Cessation Center, OHSU School of Medicine.

"Patients also can become discouraged that a treatment is not working and worry about continuing to pay for treatments they believe do not work. As a result, cessation treatment for some patients may be discontinued before the prescribed treatment period is completed and the patient and/or the treatment considered a failure."

In this study, however, the data show a substantial proportion of smokers who became 'successful quitters' by the end of 12 weeks of treatment smoked in one or more weeks during the first eight weeks and were delayed in achieving a period of continuous abstinence. This was true of successful quitters treated with varenicline, bupropion and with counseling alone [placebo], Gonzales explained, and appears to be a previously unreported and natural pattern of quitting for motivated smokers who seek treatment to quit.

"Had treatment been interrupted or discontinued for these 'delayed quitters,' opportunities for achieving continuous abstinence could have been lost for up to 45 percent of quitters who were ultimately successful," Gonzales said.

Gonzales and colleagues analyzed data from two identically designed, published studies (Gonzales et al. JAMA 2006 and Jorenby et al. JAMA 2006) conducted between June 2003 and April 2005. Participants included 2,052 generally healthy adult smokers who randomly received either a smoking cessation drug — varenicline or bupropion — or a placebo for 12 weeks of treatment plus 40 weeks of follow-up. All participants received brief smoking cessation counseling at clinic visits and investigators were blinded to the treatment assignments.

Successful quitters were defined as smokers who achieved continuous abstinence, not even one puff, for the last four weeks of treatment (weeks nine through 12). Among successful quitters, two groups were identified: "immediate quitters," smokers who quit and remained abstinent from their target quit date through the end of week 12; and "delayed quitters," smokers who had periods of smoking prior to attaining continuous abstinence for at least the last four weeks of treatment.

The overall end-of-treatment quit rates for the two studies were previously shown to be higher for varenicline, but in this analysis, the researchers found cumulative continuous abstinence increased similarly for all treatments during weeks three through eight. They also found quitting patterns among delayed quitters were similar regardless of whether they took varenicline, bupropion or received counseling only (placebo).

While delayed quitters did not fare quite as well as immediate quitters following the end of active treatment, they still accounted for approximately one-third of those who remained continuously abstinent at 12 months regardless of treatment group.

"Based on these findings, we believe that treatment failure, or success for that matter, should not be assessed until the recommended period of treatment is completed. An analogy with antibiotic treatment, while not totally appropriate, is, nevertheless, a useful framework for illustrating some of the dynamics of the quitting process," explained Gonzales. "We know that some patients quit taking antibiotics when there is relief of symptoms [success] and others quit taking medication if symptoms don't seem to be resolving [failure]. In both cases discontinuing treatment prematurely risks treatment failure. Stopping smoking cessation treatment seems to have similar risks."

The take-home message for clinicians and patients, according to Gonzales, is that 'real-world' quit rates may be significantly increased by just continuing cessation treatments without interruption for patients who remain motivated to quit despite lack of success during the first eight weeks of treatment.

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Journal Reference:

1. David Gonzales, Douglas E. Jorenby, Thomas H. Brandon, Carmen Arteaga and Theodore C. Lee. Immediate versus delayed quitting and rates of relapse among smokers treated successfully with varenicline, bupropion SR or placebo. Addiction, 2010; DOI: 10.1111/j.1360-0443.2010.03058.x

While some teenagers may puff on cigarettes to 'self-medicate' against the blues, scientists at the University of Toronto and the University of Montreal have found that smoking may actually increase depressive symptoms in some adolescents. Published in the journal Addictive Behaviors, the findings are part of the long-term Nicotine Dependence in Teens (NDIT) study based at the University of Montreal Hospital Research Centre.

"This observational study is one of the few to examine the perceived emotional benefits of smoking among adolescents," says lead author Michael Chaiton, a research associate at the Ontario Tobacco Research Unit of the University of Toronto. "Although cigarettes may appear to have self-medicating effects or to improve mood, in the long term we found teens who started to smoke reported higher depressive symptoms."

As part of the study, some 662 high school teenagers completed up to 20 questionnaires from grades 7 to 11 about their use of cigarettes to affect mood. Secondary schools were selected to provide a mix of French and English participants, urban and rural schools, and schools located in high, moderate and low socioeconomic neighbourhoods.

Participants were divided into three groups: never smokers; smokers who did not use cigarettes to self-medicate, improve mood or physical state; smokers who used cigarettes to self-medicate. Depressive symptoms were measured using a scale that asked how often participants felt too tired to do things; had trouble going to sleep or staying asleep; felt unhappy, sad, or depressed; felt hopeless about the future; felt nervous or tense; and worried too much about things.

"Smokers who used cigarettes as mood enhancers had higher risks of elevated depressive symptoms than teens who had never smoked," says coauthor Jennifer O'Loughlin, a professor at the University of Montreal Department of Social and Preventive Medicine and scientist at the of the University of Montreal Hospital Research Centre. "Our study found that adolescent smokers who reported emotional benefits from smoking are at higher risk of developing depressive symptoms."

The association between depression and smoking exists principally among teens that use cigarettes to feel better. "It's important to emphasize that depressive symptom scores were higher among teenagers who reported emotional benefits from smoking after they began to smoke," says Dr. Chaiton.

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Journal Reference:

1. Michael Chaiton, Joanna Cohen, Jennifer O'Loughlin, Juergen Rehm. Use of cigarettes to improve affect and depressive symptoms in a longitudinal study of adolescents. Addictive Behaviors, 2010; DOI: 10.1016/j.addbeh.2010.07.002

Blocking thoughts of cigarettes helps reduce smokers' intake at first, but means they smoke more than usual when they stop suppressing, according to new research.

The study was carried out by researchers at St George's, University of London and the University of Hertfordshire.

Co-author Dr James Erskine, a psychologist at St George's, says the study shows that many smokers attempting to give up — as well as people trying to quit other vices — may be thwarted by the very technique they use to stop.

Dr Erskine said: "These findings have obvious implications for individuals seeking to give up certain behaviours, for example, smoking, overeating, drinking, sex and other excessive behaviours.

"If trying to avoid thoughts of something in an attempt to give it up actually unwittingly triggers a subsequent increase, it's a poor method of achieving self control. This work may stop people using quitting techniques that are ultimately harmful."

Dr Erskine and his team set out to test whether smokers experienced behavioural rebound — the phenomenon where trying not to think about something leads to an increase in the behaviour. Their previous research into eating behaviour and thought suppression showed that people trying not to think about chocolate subsequently ate much more than people who were deliberately thinking about it. However, previous studies only examined behavioural rebound over a period of five minutes, rather than days and weeks.

Eighty five smokers, who smoked at least ten cigarettes a day, took part in the latest study, which has been published in the journal Psychological Science. They were split into three groups and asked to monitor their cigarette intake over three weeks. All three groups were asked to behave as usual in the first and third weeks. But in the second week one group of 30 people was told to suppress their thoughts of smoking, and one group of 29 people was told to actively express thoughts about smoking. A control group of 26 was told not to change anything.

The first week's results showed that each group smoked a different average number of cigarettes, so the researchers applied a formula to the following weeks' results to ensure they were comparing like for like.

The results showed that neither the expression group nor the control group differed significantly in the number of cigarettes smoked from week to week. However, in the second week the suppression group smoked, on average, nearly five less cigarettes each than the expression group and almost four less than the control group. And in the third week — when they stopped suppressing their thoughts — the suppression group smoked nearly three more than the expression group and the control group. From the raw results, the suppressions group's increase from week two to three was six cigarettes per person, roughly three more each than smoked in the first week.

Dr Erskine said: "This shows a clear behavioural rebound. The fact that the suppression group smoked less in the second week shows that this method may be effective in reducing unwanted behaviour in the short term. But this actually isn't helpful, as smokers might then think that thought suppression is a useful strategy in quitting smoking.

"In this case, we asked the suppression group to stop suppressing in week three, but the rebound effect should be the same whether it is deliberate, or whether other real life factors cause someone to stop suppressing thoughts of smoking. In real life, it can be hard to continue suppressing your thoughts.

"Although the differences in the number of cigarettes smoked from week to week may seem small, we know that habitual smokers are remarkably consistent in how many they smoke. So, even a small difference can be considered significant.

"Knowing what techniques not to use should lead to better understanding of what methods of quitting do work."

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Journal Reference:

1. James A.K. Erskine, George J. Georgiou, Lia Kvavilashvili. I Suppress, Therefore I Smoke: Effects of Thought Suppression on Smoking Behavior. Psychological Science, 2010; DOI: 10.1177/0956797610378687

Point-of-sale tobacco advertising works impressively well on teens — so well that federal regulators should consider barring such marketing efforts from convenience stores, gas stations and small groceries, a Stanford University School of Medicine researcher said.

A study to be published in the August issue of Pediatrics led by Lisa Henriksen, PhD, senior research scientist at the Stanford Prevention Research Center, reports that teens' exposure to cigarette advertising at retail outlets substantially increases the odds they will start smoking. According to the findings, students who visited these stores on a regular basis were at least twice as likely to try smoking as those who visited infrequently.

"The tobacco industry argues the purpose of advertising is to encourage smokers to switch brands, but this shows that advertising encourages teenagers to pick up a deadly habit," said Henriksen, who has studied tobacco marketing for more than a decade.

The study's publication comes just as the new federal Tobacco Regulation Law goes into effect, empowering the U.S. Food and Drug Administration to regulate the manufacturing, marketing and sale of tobacco products. As of June 22, tobacco companies are banned from using terms such as "light," "low" and "mild" on advertising and packaging and sponsoring cultural and sporting events, but regulators may impose additional constraints if warranted.

Point-of-sale is the major form of marketing used for tobacco — representing 90 percent of the industry's $12.5 billion marketing budget in 2006 — and the study suggests that further limits on such activity could affect long-term smoking habits. The teen years are when the vast majority of smokers start, and if teens make it through to adulthood without smoking, their likelihood of ever becoming addicted is very small, Henriksen said.

In recent years, the decline in teenage smoking has leveled off. According to the Centers for Disease Control and Prevention, high-school students who reported current cigarette use declined sharply from a peak of 36.4 percent in 1997, to 21.9 percent in 2003, after which the percentage dropped just a little to 19.5 in 2009. "The huge decreases are really starting to slow," said Henriksen. "The train won't continue downhill without further action. Regulating retail marketing would be ideal for smoking prevention."

Henriksen based the study on repeat surveys of 11- to 14-year-olds at three middle schools in Tracy, Calif., and assessments of cigarette advertisements at stores near the schools. The survey included questions about students' smoking experience as well as how often they visited the types of stores with lots of cigarette ads — convenience stores, gas stations and small groceries — and then checked back later, first at one year and then at 30 months.

Of the 2,110 students surveyed in 2003 when the study began, 1,681 reported never smoking. A survey of these non-smoking students a year later revealed 18 percent of these students had smoked over the year, at least one puff, and that smoking initiation was much more prevalent among the students who had reported frequent visits to stores with the most cigarette ads.

Among those who had reported visiting these types of stores at least twice a week, 29 percent had taken at least one puff in the previous year. Among those who rarely visited — less than twice a month — only 9 percent had smoked at all.

A survey 30 months after the study began found that by then 27 percent had tried smoking: 34 percent of those who visited stores at least twice a week, and only 21 percent of those who rarely visited.

To measure exposure to ads, the researchers multiplied the frequency of visits by the number of advertising "impressions" in stores near the schools — cigarette-branded ads, product displays and functional objects, like clocks, trash cans and register mats. On average, students experienced 325 cigarette-brand impressions per week, ranging from an average of 114 among infrequent shoppers to 633 among those who shopped frequently.

"I was surprised by the sheer number of cigarette brand impressions in signs and displays in convenience stores near schools," said Henriksen. "The exposure is unavoidable. It's impossible to miss."

Factors other than advertising influence smoking. To determine the effect of point-of-sale advertising alone, the researchers measured many other factors so they could hold these constant in the analysis. These other factors included risk-taking behavior, unsupervised time after school, exposure to smoking in movies or on TV, and smoking by household members and friends. The researchers also factored in grades and demographics including gender, race and ethnicity.

When the project's statistician adjusted for all the variables, she found that the relationship between store visits and smoking initiation was strong. A year after the survey, those who had initially reported moderate visits (a frequency between once every two weeks and twice a week) were 64 percent more likely to have taken at least one puff than infrequent shoppers. Those frequent shoppers, who had reported more than two visits a week, were more than twice as likely. Even 30 months after the initial survey, by which time more students had begun smoking, the apparent influence of the store visits remained: Those who had initially reported moderate store visits were 19 percent more likely than infrequent visitors to have tried smoking; those who had reported frequent visits were 42 percent more likely to have had a puff.

How can simply spending time in the presence of advertisements make such an impact? "Young people are very susceptible to advertising messages," said Stanford adolescent medicine specialist Seth Ammerman, MD, who treats patients at Lucile Packard Children's Hospital and researches smoking cessation. Ammerman was not involved in the study.

"One particularly nefarious aspect of advertising at convenience stores is it really normalizes the product. What do you buy there? Cigarettes, but also soup, laundry detergent, soda, cat food — normal, common things. So advertising there really gives the impression that smoking is normal," said Ammerman, a clinical professor of adolescent medicine at Stanford. "Tobacco companies understand this. They're not stupid."

Henriksen's co-authors are statistical analyst Nina Schleicher, PhD, and two former Stanford Prevention Research Center members: senior author Stephen Fortmann, MD, now senior investigator at Kaiser Permanente Center for Health Research in Portland, Ore.; and Ellen Feighery, now associate director for international research at Campaign for Tobacco-Free Kids, Washington, DC.

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Journal Reference:

1. Lisa Henriksen, Nina C. Schleicher, Ellen C. Feighery, and Stephen P. Fortmann. A Longitudinal Study of Exposure to Retail Cigarette Advertising and Smoking Initiation. Pediatrics, 2010; DOI: 10.1542/peds.2009-3021

Nicotine patches and gum are common — and often ineffective — ways of fighting cigarette cravings, as most smokers have discovered. Now a new study from Tel Aviv University shows why they're ineffective, and may provide the basis for more successful psychologically-based smoking cessation programs.

In the new study published in the Journal of Abnormal Psychology, Dr. Reuven Dar of Tel Aviv University's Department of Psychology found that the intensity of cravings for cigarettes had more to do with the psychosocial element of smoking than with the physiological effects of nicotine as an addictive chemical.

"These findings might not be popular with advocates of the nicotine addiction theory, because they undermine the physiological role of nicotine and emphasize mind over matter when it comes to smoking," Dr. Dar says. He hopes this research will help clinicians and health authorities develop more successful smoking cessation programs than those utilizing expensive nicotine patches or gum.

Up in the air

Dr. Dar and his colleagues' conclusions are based on two landmark studies. In the most recent study, he and his colleagues monitored the smoking behavior and craving levels of in-flight attendants, both women and men, who worked at the Israeli airline El Al. Each participant was monitored during two flights — a long flight of 10 to 13 hours in duration, from Tel Aviv to New York, for example; and a two-hop shorter trip from Israel to Europe and back, each leg lasting three to five hours. Using a questionnaire, he sampled craving levels of the attendants throughout the duration of their flights.

Dr. Dar and his colleagues found that the duration of the flight had no significant impact on craving levels, which were similar for short and long flights. Moreover, craving levels at the end of each short flight were much higher those at the end of the long flight, demonstrating that cravings increased in anticipation of the flight landing, whatever the flight's total duration. He concluded that the craving effect is produced by psychological cues rather than by the physiological effects of nicotine deprivation.

No smoking on the Sabbath

In an earlier 2005 study, Dr. Dar examined smokers who were religious Jews, forbidden by their religion to smoke on the Sabbath. He asked them about their smoking cravings on three separate days: the Sabbath, a regular weekday, and a weekday on which they'd been asked to abstain. Participants were interviewed at the end of each day about their craving levels during that day.

What Dr. Dar found is that cravings were very low on the morning of the Sabbath, when the smoker knew he would not be able to smoke for at least 10 hours. Craving levels gradually increased at the end of the Sabbath, when participants anticipated the first post-Sabbath cigarette. Craving levels on the weekday on which these people smoked as much as they wanted were just as high as on the day they abstained, showing that craving has little to do with nicotine deprivation.

Dr. Dar's studies conclude that nicotine is not addictive as physiological addictions are usually defined. While nicotine does have a physiological role in increasing cognitive abilities such as attention and memory, it's not an addictive substance like heroin, which creates true systemic and biologically-based withdrawal symptoms in the body of the user, he says.

Dr. Dar believes that people who smoke do so for short-term benefits like oral gratification, sensory pleasure and social camaraderie. Once the habit is established, people continue to smoke in response to cues and in situations that become associated with smoking. Dr. Dar believes that understanding smoking as a habit, not an addiction, will facilitate treatment. Smoking cessation techniques should emphasize the psychological and behavioral aspects of the habit and not the biological aspects, he suggests.

 A team of health researchers from The University of Nottingham are spearheading a new project to reduce tobacco use in an area which has one of the highest rates of smoking in the country.

Funded by NHS Nottingham City, the initiative is harnessing the power of local community champions to challenge the general acceptance of smoking in Nottingham's Aspley ward and to encourage more people to quit.

Nottingham has the 3rd highest rate of smoking in England and more than half the people who live in Aspley smoke — 53 per cent, compared to the national average of 21 per cent. Smoking is a key reason why people living in Aspley die, on average, 10 years younger than people in wealthier parts of the city.

The researchers, led by Professor Ann McNeill, of the UK Centre for Tobacco Control Studies at the University, set out to discover why so many people in Aspley smoke and what effect social challenges, including high unemployment and low incomes were having on the community's smoking rates.

By getting a fuller understanding of the issues contributing to the problem, they are hoping to develop more of a community-led approach to tobacco control in the ward and to foster a positive environment in which young people do not start to smoke and people who do want to give up are offered all the support they need.

The study is focusing on three estates within the ward — Aspley, Bells Lane and Broxtowe. During the initial phase of the project, researchers conducted 100 street interviews and held a series of focus groups with smokers, ex-smokers and non-smokers of all ages to explore attitudes towards smoking

Among the consistent themes they uncovered were:

• Smoking was very much the social norm. It was strongly associated with unemployment, boredom and stress and was often seen as a shared activity, creating a sense of belonging and identity with the rest of the community.
• There was a general lack of health awareness in relation to healthy eating, alcohol and smoking, but considerable sympathy on the part of residents for the plight of people who were seen as both disadvantaged and addicted to tobacco.
• There was an acceptance of the dangers of passive smoking, especially to children, but government warnings on the dangers of smoking were viewed by some with suspicion and hostility.
• Children in smoking families had little to counteract the strong pressure to smoke and it was generally believed that there needed to be more education about the dangers of smoking and that this should start in primary school.
• Cigarettes are still regarded by many smokers, as a 'little luxury' that disadvantaged people could enjoy and this view is often shared by non smokers. Whilst stopping smoking is an aspiration among most smokers, it was often 'put on hold' until the time or mental state was perceived to be right.
• There was a need for stop smoking services such as New Leaf to be seen to have a more flexible approach and be more accessible to these communities.
• Resentment existed over the presence of illicit supplies of cheap tobacco from local 'fag houses' and even, in one case, an ice cream van, but there was a general acceptance that this would be difficult to tackle during the tough economic climate.
• There was a need to challenge some of the negative messages circulating by 'word of mouth' by disseminating positive messages regarding healthy lifestyles and smoking.

Professor McNeill said: "Another theme which we identified was the strong sense of community within each of the separate estates that could be used to promote our anti-smoking initiatives. We felt that we would have more success by presenting our project positively and allowing problems to be addressed at a local level. People in the Aspley ward want to be able to feel a sense of pride in the communities in which they live." Professor McNeill said: "Another theme which we identified was the strong sense of community within each of the separate estates that could be used to promote our anti-smoking initiatives. We felt that we would have more success by presenting our project positively and allowing problems to be addressed at a local level. People in the Aspley ward want to be able to feel a sense of pride in the communities in which they live."

Marilyn Antoniak, a research fellow working on the project, commented: "We aim to galvanise the local communities to adopt a tobacco control agenda in an effort to denormalise smoking in the area. Together with local community members, we will be profiling positive messages to smokers to encourage them to make use of the support available locally to help them to reduce and stop smoking."

The study also sought the views of local stop smoking service providers and the network of community health professionals, such as health trainers and Change Makers, based within each estate.

Local retailers were asked for their views regarding stocking nicotine replacement therapies (NRT) and problems with underage youngsters attempting to buy cigarettes illegally or by harassing other customers to buy them on their behalf.

The two-year project is an example of innovative 'action research', where researchers address issues and solve social problems in tandem with the local community.

As a result, the team will be enlisting the help of local community 'champions' in order to raise awareness of the issue; in some cases these will be ex-smokers or smokers who are trying to give up. By offering cessation training to the existing network of community organisations such as local action groups it is hoped that they will become involved in the wider smoking cessation programme.

Drop-in information and advice sessions will be held at community centres on each of the estates and a mobile trailer providing information and support on stopping smoking will also be located in the area.

The project will be targeting the local schools offering them educational materials on the dangers of smoking and feeding into the existing DARE programme to get the message across. In this way it is hoped that informed youngsters will step up the pressure on parents who smoke.

Many of the shopkeepers in the area have also agreed to do their bit by displaying New Leaf smoking cessation leaflets and posters within their shops.

Dr Jeanelle de Gruchy, Deputy Director of Public Health at NHS Nottingham City, said: "This kind of research is crucial to understanding why smoking is so high in certain communities and why they aren't following the national trend of reducing smoking levels. Once we know that, we can more effectively target our resources to support community actions to provide an environment which prevents young people starting to smoke and supports people wanting to quit. NHS Nottingham City is committed to reducing health inequalities — and reducing the rate of people smoking in Aspley would be a significant step towards this."

Exposure to secondhand smoke appears to be associated with psychological distress and the risk of future psychiatric hospitalization among healthy adults, according to a report posted online that will appear in the August print issue of Archives of General Psychiatry.

"A growing body of literature has demonstrated the harmful physical health effects of secondhand smoke exposure," the authors write as background information in the article. "Given the highly prevalent exposure to secondhand smoke — in the United States, an estimated 60 percent of American non-smokers had biological evidence of exposure to secondhand smoke — even a low level of risk may have a major public health impact."

Mark Hamer, Ph.D., of University College London, and colleagues studied 5,560 non-smoking adults (average age 49.8) and 2,595 smokers (average age 44.8) who did not have a history of mental illness and participated in the Scottish Health Survey in 1998 or 2003. Participants were assessed with a questionnaire about psychological distress, and admissions to psychiatric hospitals were tracked over six years of follow-up. Exposure to secondhand smoke among non-smokers was assessed using saliva levels of cotinine — the main product formed when nicotine is broken down by the body — "a reliable and valid circulating biochemical marker of nicotine exposure," the authors write.

A total of 14.5 percent of the participants reported psychological distress. Non-smokers with a high exposure to secondhand smoke (cotinine levels between 0.70 and 15 micrograms per liter) had higher odds of psychological distress when compared with those who had no detectable cotinine.

Over the six-year follow-up, 41 individuals were newly admitted to psychiatric hospitals. Smokers and non-smokers with high exposure to secondhand smoke were both more likely than non-smokers with low levels of secondhand smoke exposure to be hospitalized for depression, schizophrenia, delirium or other psychiatric conditions.

Animal data have suggested that tobacco may induce a negative mood, and some human studies have also identified a potential association between smoking and depression. "Taken together, therefore, our data are consistent with other emerging evidence to suggest a causal role of nicotine exposure in mental health," the authors write.

"To our knowledge, this is the first study to demonstrate a prospective association between objectively assessed secondhand smoke exposure and mental health in a representative sample of a general population," they conclude.

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Journal Reference:

1. Mark Hamer; Emmanuel Stamatakis; G. David Batty. Objectively Assessed Secondhand Smoke Exposure and Mental Health in Adults: Cross-sectional and Prospective Evidence From the Scottish Health Survey. Arch Gen Psychiatry, 2010; 0 (2010): 2010. 76 

A novel study by German researchers reported that alcohol consumption and cigarette smoking were associated with increased migraines and tension-type headaches (TTH) in high school students. Coffee drinking and physical inactivity were associated specifically with migraines. Results of this study, the first to investigate modifiable risk factors for different types of headaches in a youth population, appear online early in Headache, a journal published by Wiley-Blackwell on behalf of the American Headache Society.

Prior studies have indicated that headache is one of the most frequently reported health complaints in adolescents with 5%-15% of this age group suffering from migraine and 15%-25% with TTH. Modifiable risk factors, such as alcohol use, cigarette smoking and coffee drinking which have been associated with headache in adults, have not been fully explored in a youth population.

Astrid Milde-Busch, Ph.D. and colleagues at the Ludwig-Maximilians-University in Munich, Germany invited 1,260 students in grades 10 and 11 (aged 14-20) from eleven area public schools to participate in the study. The students were asked to fill out a questionnaire on headache and associated lifestyle factors. Students were asked: 'Did you have headache during the last seven days/three months/six months?' and were classified as headache sufferers if the response was positive. Furthermore, migraine and TTH were differentiated by questions regarding headache characteristics and symptoms. The questionnaire also inquired about diet and lifestyle (e.g. 'Do you daily have breakfast before you go to school?'; 'How much beer, wine and cocktails do you normally drink?'; 'How much coffee do you normally drink?'; 'Do you smoke?').

Research results show 83.1% of students reported headache at least once during the previous six months with 10.2% reporting migraine; 48.7% citing TTH; and 19.8% having combined migraine plus TTH. For diet, 28.4% of students never had breakfast; 16.5% did not eat a daily break meal (snack); and only 24.0% had a daily warm lunch. Researchers found that 22.3% of students consumed less than 1 liter (4.23 8 ounce cups) of non-alcoholic drinks per day. Alcohol consumption, however, was widespread among students in the study with 38.5%, 18.6%, and 25.3% drinking beer, wine, and cocktails at least once per week, respectively. Results also showed that 73.3% of participants reported never smoking and 43.4% students noted that they did not drink coffee.

The authors found that a high consumption of alcoholic drinks and coffee, smoking, and lack of physical activity were significantly associated with migraine plus TTH episodes. There was a significant association of coffee drinking and physical inactivity with migraine. "Our study confirms, adolescents with any type of headache might benefit from regular physical activity and low consumption of alcoholic drinks," commented Dr. Milde-Busch. "In teens suffering from migraine a low coffee consumption should also be suggested." Skipping meals or insufficient fluid intake was not associated with any type of headache.

According to the Centers for Disease Control and Prevention (CDC), 75% of high school students in the U.S. have had one or more alcoholic drinks during their lifetime (2007). A 2004 report by the World Health Organization (WHO) notes that alcohol consumption by those under 20 varies by country and "a trend of increased drinking to intoxication." Cigarette smoking is another modifiable risk factor in which youths engage and a 2002 WHO report estimated about 1 in every 5 teens worldwide (aged 13-15) smoke. "A great number of teens are engaging in activities such as drinking and smoking which can trigger headaches," concluded Dr. Milde-Busch. "Intervention studies that assess psycho-education programs to educate youths about headache-triggering behaviors are recommended."

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Journal Reference:

1. Astrid Milde-Busch, Astrid Blaschek, Ingo Borggräfe, Florian Heinen, Andreas Straube, and Rüdiger von Kries. Associations of Diet and Lifestyle with Headache in High-School Students. Headache, June 07, 2010 DOI: 10.1111/j.1526-4610.2010.01706.x

While researchers have done a good job documenting health problems associated with the high prevalence of smoking among Americans who have HIV/AIDS, it's now time to focus on how to get these smokers to kick the habit, Saint Louis University School of Public Health research finds.

Of the 1.1 million Americans living with HIV/AIDS, between 40 and 60 percent are smokers — which is two to three times the rate of smokers in the general population.

Jenine K. Harris, Ph.D., study author and associate professor of community health at Saint Louis University School of Public Health, examined the kinds of research conducted on smoking and HIV/AIDS from 1980 to 2008. Her research was published online ahead of print on May 13 in the American Journal of Public Health.

She found the vast majority of the research — 237 of the 272 published articles — looked at the relationship between smoking and HIV/AIDS. However, fewer than 2 percent of the articles examined the effectiveness of interventions aimed at preventing or reducing smoking among those living with HIV/AIDS.

"The accumulation of nearly two decades of discovery research leaves little doubt that smoking is a widespread problem and a major modifiable risk factor for disease and death in people living with HIV/AIDS," Harris said.

Researchers don't know the best strategy to help those with HIV/AIDS quit or not start smoking. Typically, specialized smoking cessation programs that target certain populations can be effective.

However, few studies have examined targeted smoking cessation programs for those who have HIV/AIDS. One study found that a standard smoking cessation program would not help 86 percent of smokers who have HIV/AIDS.

Harris says it's time for researchers to connect the dots between the health problems associated with HIV and smoking and effective ways to help those with HIV quit smoking.

"The delay between discovery of smoking related health outcomes in people living with HIV/AIDS and the delivery of interventions to reduce smoking among this population has serious consequences," Harris said.

To speed the process of finding solutions, she suggested researchers and clinicians in the HIV/AIDS field collaborate with experts in tobacco cessation who understand how targeted population-based programs work. In addition, she suggested that researchers who are examining the link between smoking and HIV/AIDS and those who are looking at effective programs work closer together. The ultimate goal is to look at the evidence of what works to come up with effective programs that curb smoking among those who have HIV/AIDS.

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Journal Reference:

1. D. A. Luke, J. K. Harris, S. Shelton, P. Allen, B. J. Carothers, N. B. Mueller. Systems Analysis of Collaboration in 5 National Tobacco Control Networks. American Journal of Public Health, 2010; DOI: 10.2105/AJPH.2009.184358

 A new study from the David Geffen School of Medicine at UCLA suggests that increasing cigarette taxes could be an effective way to reduce smoking among individuals with alcohol, drug or mental disorders.

The study, published online in the American Journal of Public Health, found that a 10 percent increase in cigarette pricing resulted in an 18.2 percent decline in smoking among people in these groups.

The findings demonstrate that increasing cigarette taxes could be a way to curb smoking, which is still the leading preventable cause of death in the United States, according to the study's lead author, Dr. Michael Ong, an assistant professor of medicine in the division of general internal medicine and health services research at the Geffen School of Medicine.

"Whatever we can do to reduce smoking is critical to the health of the U.S.," said Ong, who is also a researcher at UCLA's Jonsson Cancer Center. "Cigarette taxes are used as a key policy instrument to get people to quit smoking, so understanding whether people will really quit is important. Individuals with alcohol, drug or mental disorders comprise 40 percent of remaining smokers, and there is little literature on how to help these people quit smoking."

Prior research on the effect of cigarette pricing on smoking, which had been conducted using information from 1991, suggested that individuals with mental illness were less likely than other individuals to quit due to price increases. Unlike that research, however, the current study expanded the research to include people with alcohol and drug disorders.

The researchers based their work on data from 7,530 individuals from the 2000-01 Healthcare for Communities Household Survey. Of those, 2,106 people, or 23 percent, had alcohol, drug or mental disorders during the previous year. Of that group, 43.8 percent were smokers — a much higher proportion than among rest of the population.

Though the researchers found that people with alcohol dependence did not cut down on cigarettes when prices rose, people with binge-drinking problems, substance-use disorders and mental disorders were significantly more likely to quit smoking if prices rose, as would occur with a cigarette tax increase.

While the study does suggest that increasing cigarette prices through taxation could reduce smoking among individuals with alcohol, drug or mental disorders, the authors note that further study is needed to determine if recent cigarette price increases have reduced smoking among individuals with such disorders, and whether the identified association is causal.

In addition to Ong, study authors were Qiong Zhou of UCLA and Hai-Yen Sung of UC San Francisco.

The Robert Wood Johnson Foundation's Substance Abuse Policy Research Program, the Jonsson Cancer Center Foundation at UCLA, and the UCLA-RAND NIMH Partnered Research Center for Quality Care funded this study.

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Journal Reference:

1. M. K. Ong, Q. Zhou, H. Y. Sung. Sensitivity to Cigarette Prices Among Individuals With Alcohol, Drug, or Mental Disorders. American Journal of Public Health, 2010; DOI: 10.2105/AJPH.2009.159962