Patterns and predictors of tobacco smoking cessation: A hospital-based study of pregnant women in Lebanon

OBJECTIVES: To describe patterns of cigarette and narghile (hubble-bubble or water-pipe) smoking before and during pregnancy and identify predictors of successful smoking cessation. METHODS: A survey was conducted on 4660 pregnant women who delivered single live births between September 1st, 2001 and December 31st, 2002 at five hospitals in Beirut, Lebanon. Women were classified into four groups according to patterns of tobacco use before and during pregnancy: 1) consistent non-users, 2) successful quitters, 3) unsuccessful quitters and 4) consistent users. RESULTS: High education (OR = 2.03, 95% CI: 0.99-4.15), adequate prenatal care (OR = 1.72, 95% CI: 1.02-2.91) and mild smoking at baseline (OR = 2.35, 95% CI: 1.36-4.09) were main determinants of successful cigarette smoking cessation, whereas successful quitters of narghile use were more likely to be nulliparous (OR = 1.80, 95% CI: 1.08-2.99) or to have a nonsmoking partner (OR = 7.57, 95 % CI: 2.31-24.78). CONCLUSIONS: Different populations should be targeted when designing smoking cessation interventions for cigarette and narghile users.     

Self-Reported and Serum Cotinine-Validated Smoking in Pregnant Women in Estonia

Objectives: Although widely used in epidemiological studies, self-report has been shown to underestimate the prevalence of smoking among pregnant women. Objectives of this study were to examine the discrepancy between self-reported and cotinine-validated smoking status, and the sociodemographic characteristics associated with the misclassification of real smoking status among pregnant women in Tallinn, the capital of Estonia. Methods: Serum cotinine assays were performed on a subsample (n= 1360) of the pregnant women, who had participated in a recent study of human papillomavirus type 16 (HPV-16) seroprevalence in Estonia. In the present study, serum concentrations ≥15 ng/ml were used to distinguish current smokers from nonsmokers. The serum-validated smoking level was compared with the self-reported level in the records of the Estonian Medical Birth Registry. For the group of self-reported non-smokers, the differences between the cotinine-validated smokers and the cotinine-validated nonsmokers, with respect to their sociodemographic characteristics (age, ethnicity, educational level, employment status, marital status, parity), were estimated by logistic regression. Results: Of 1239 women who reported being nonsmokers, 259 (20.9%) had serum cotinine levels ≥15 ng/ml, and can be regarded as current smokers. Among self-reported nonsmokers, nondisclosure of current smoking was significantly more frequent in non-Estonian, less educated, socially inactive, cohabiting and multiparous women. Conclusions: Self-reported data on smoking in pregnant women underestimates the real smoking prevalence in Estonia. Maternal unwillingness to declare smoking during pregnancy needs to be taken into account in the practice of maternal and child health to better target prenatal smoking cessation interventions.     

Demographic and Psychosocial Profile of Smoking Among Pregnant Women in Lebanon: Public Health Implications

Objectives: To assess the prevalence and determinants of smoking prior to and during pregnancy in Lebanon. Methods: A cross-sectional study using two structured instruments. One instrument included information on demographic characteristics, smoking patterns in the index pregnancy and previous pregnancies, use of prenatal health services, stressful life events, and social support during pregnancy. The second was the Arabic General Health Questionnaire (GHQ-12). Women who delivered in 11 randomly selected hospitals in Beirut and its suburbs within 24 hours were asked to consent to participate in the study. The total sample interviewed was 576 women. Results: The prevalence of pre-pregnancy smoking was 32% and 20% for smoking in pregnancy. Considering argileh smoking, the prevalence of tobacco use in pregnancy increased to 27% in Beirut and 25% in the suburbs. Pre-pregnancy smoking was associated with older maternal age [OR = 1.08, 95% CI (1.03, 1.14)], low and medium education [OR = 2.22, 95% CI (1.22, 4.04)], increased psychiatric distress [OR = 3.11, 95% CI (1.77, 5.46)], and a husband who smoked [OR = 5.00, 95% CI (2.98, 8.39)]. Continued smoking during pregnancy was associated with low and medium education [OR = 3.77, 95% CI (1.31, 10.8)], younger age [OR = 1.11, 95% CI (1.02–1.20)], and a heavy pre-pregnancy smoking pattern [OR = 13.9, 95% CI (1.40, 137.4)]. Conclusion: Policies and programs to eliminate or reduce smoking during pregnancy should be targeted toward young and less educated females and involving the spouse. Obstetricians should promote smoking cessation during pregnancy using evidence-based methods.     

Predictors of Smoking Cessation in Pregnancy and Maintenance Postpartum in Low-Income Women

Objective: To describe factors associated with smoking status of low-income women during pregnancy and postpartum. Methods: Data from a randomized clinical trial were used to conduct separate analyses on 327 women who smoked at baseline (time at enrollment) and for whom smoking status was available at delivery, and on 109 women who reported not smoking at delivery (quit spontaneously or after study enrollment) and for whom smoking status was available at 6-months postpartum. Salivary cotinine was used to assess the accuracy of self-reported smoking status for the sample as a whole. Data were collected between May 1997 and November 2000. Results: 18% of the 327 baseline smokers stopped smoking before delivery. Cessation was less likely in older women, those reporting Medicaid coverage (vs. commercial or no insurance), who were at a later week of pregnancy at baseline, were more addicted, had a husband/partner who smoked, and did not receive the study intervention. 37% of the 109 women who reported not smoking at delivery maintained abstinence at 6-months postpartum. Factors associated with abstinence were later week of pregnancy at baseline and quitting spontaneously with pregnancy, while women who lived with a smoker were less likely to report abstinence. Spontaneous quitters were less likely to relapse by 6 months postpartum than women who quit smoking later in pregnancy. Conclusions: Partner participation in smoking cessation programs for pregnant and postpartum women merits exploration. Lower relapse rates among spontaneous quitters indicate a need to foster an environment that encourages quitting at pregnancy.     

Quality of Measurement of Smoking Status by Self-Report and Saliva Cotinine Among Pregnant Women

Objective. The objectives of this paper were to determine the rate of misclassification of smoking and nonsmoking status by self-reports and saliva cotinine of pregnant women participating in a smoking cessation trial, determine the relationship of the number of cigarettes smoked per day and saliva cotinine, and examine whether misclassification was due to an inappropriate saliva cotinine cutoff point. Methods. End of pregnancy self-reports of smoking status and saliva cotinine were used to calculate misclassification rates. Results. The findings revealed that 61 of 441 self-reported smokers had biochemical values inconsistent with smoking status for a smoking misclassification rate of 13.8%. The results also revealed that 28 of 107 self-reported quitters had cotinine values consistent with smoking status for a nonsmoking misclassification rate of 26.2%. Receiver Operating Characteristic (ROC) curves were then plotted to determine whether misclassification resulted from an inappropriate cutoff point. The cotinine cutoff point that maximized sensitivity and specificity for all women was 24 ng/ml. Racial ROC comparisons indicated a higher cutoff point for blacks than whites. Use of any of the ROC indicated cutoff points would not change the misclassification rates. Conclusions. These findings suggest that underreporting of smoking status during pregnancy is high and that social desirability of nonsmoking status may have contributed to the lack of precision in saliva cotinine to distinguish smoking status in this study.     

A biochemical prevalence study of smoking in pregnancy for a cross-section of women in Christchurch, New Zealand

Objective: To biochemically measure and compare the prevalence of maternal smoking by trimester in a cross-section of pregnant women residing in Christchurch, New Zealand, during 1997.
Methods: Residual sera from routinely collected blood samples drawn in early and late pregnancy over a 12-month period, 1 January 1997 to 31 December 1997, was accumulated and anonymously assayed. Cotinine levels were measured by an ELISA test with a result greater than 14 ng/mL indicative of active smoking.
Results: Analysis was conducted upon 4,178 samples collected from 3,082 women. Adjusted cotinine validated smoking rates in the first, second and third trimesters were 26.8% (95% CI 24.5–29.2%), 25.0% (95% CI 22.3–27.8%) and 23.0% (95% CI 20.8–25.2%), respectively. This represents an absolute reduction in smoking rates of 4.7% (p=0.02), 6.6% (p=0.04) and 3.8% (p=0.04) for the first, second and third trimesters, respectively, among pregnant women in Christchurch since 1994.
Conclusion: Smoke reduction and cessation programs implemented locally and nationally have been effective in significantly reducing the biochemically measured prevalence of maternal smoking in pregnancy within a three-year period.
Implications: Cigarette smoking during pregnancy is an important yet preventable factor affecting rates of prenatal, perinatal and paediatric morbidity and mortality. Reliable and repeated surveys of pregnant women are necessary to accurately measure changes in the maternal smoking prevalence and determine the efficacy of smoke reduction and cessation programs.     

A biochemical prevalence study of smoking in pregnancy for a cross-section of women in Christchurch,New Zealand

OBJECTIVE: To biochemically measure and compare the prevalence of maternal smoking by trimester in a cross-section of pregnant women residing in Christchurch, New Zealand, during 1997. METHODS: Residual sera from routinely collected blood samples drawn in early and late pregnancy over a 12-month period, 1 January 1997 to 31 December 1997, was accumulated and anonymously assayed. Cotinine levels were measured by an ELISA test with a result greater than 14 ng/mL indicative of active smoking. RESULTS: Analysis was conducted upon 4,178 samples collected from 3,082 women. Adjusted cotinine validated smoking rates in the first, second and third trimesters were 26.8% (95% CI 24.5-29.2%), 25.0% (95% CI 22.3-27.8%) and 23.0% (95% CI 20.8-25.2%), respectively. This represents an absolute reduction in smoking rates of 4.7% (p = 0.02), 6.6% (p = 0.04) and 3.8% (p = 0.04) for the first, second and third trimesters, respectively, among pregnant women in Christchurch since 1994. CONCLUSION: Smoke reduction and cessation programs implemented locally and nationally have been effective in significantly reducing the biochemically measured prevalence of maternal smoking in pregnancy within a three-year period. IMPLICATIONS: Cigarette smoking during pregnancy is an important yet preventable factor affecting rates of prenatal, perinatal and paediatric morbidity and mortality. Reliable and repeated surveys of pregnant women are necessary to accurately measure changes in the maternal smoking prevalence and determine the efficacy of smoke reduction and cessation programs.     

Prenatal smoking cessation among Black and White women in Eastern North Carolina

PURPOSE: Limited information is available about Black:White disparities in prenatal smoking cessation, and the results of prior research are inconsistent. We analyzed smoking cessation and factors associated with cessation (attitudes, environment, and nicotine addiction) in a sample of pregnant Black and White women. METHODS: Women were interviewed at the first prenatal visit at two hospital-based clinics. RESULTS: Among former and current smokers, there were no significant differences in the percentage of former smokers between Black (46.8%) and White (43.3%) pregnant women, or in the percentage of "spontaneous quitters" (i.e., those who quit after learning that they were pregnant) for Blacks (36%) and Whites (28%). Both Black and White spontaneous quitters had evidence of occasional relapses to smoking. For Black and White women, smoking more than a pack a day prior to pregnancy was associated with smoking during pregnancy. DISCUSSION: Among current and former smokers, spontaneous cessation was about the same for Black and White women, and about two thirds of women who were smokers when they learned of the pregnancy continued to smoke during pregnancy. Nicotine addiction contributed to continued smoking.     

Smoking cessation intervention practices in Chinese physicians: do gender and smoking status matter?

Healthcare settings provide a major arena for administering smoking cessation interventions. However, few studies have reported differences in the frequency of practice in healthcare professionals by gender and smoking status. This might also be influenced by a difference in smoking prevalence by gender, especially in China and other developing countries. This study examined factors associated with the frequency of cessation intervention practices by smoking status among Chinese physicians in men and women. A cross-sectional survey was conducted in 2006 in physicians with direct patient contact from nine hospitals in Guangzhou with a response rate of 60.8%. Significantly more female physicians who were non-smokers (79.7%) reported "initiation and/or advice" smoking cessation interventions than male physicians who were smokers (71.2%) and non-smokers (71.6%). Factors significantly associated with "initiation and/or advice" were prior smoking cessation training (OR = 4.2, 95% CI 1.8-9.6) and lack of knowledge to help patients to quit (OR = 0.4, 95% CI 0.2-0.9) among male physicians who smoked; and organisational support (OR = 1.7, 95% CI 1.3-2.2) and successful past experience (OR = 0.4, 95% CI 0.2-1.0) among male physicians who did not smoke. Among female physicians who did not smoke, significant factors were agreeing that quitting smoking is the most cost-effective way to prevent chronic disease and cancer (OR = 3.0, 95% CI 1.4-6.1), helping patients stop smoking is part of expected role and responsibility (OR = 2.0, 95% CI 1.0-3.7), lack of knowledge to help patients to quit (OR = 0.5, 95% CI 0.2-1.0) and organisational support (OR = 1.3, 95% CI 1.0-1.6) for non-smoking female physicians. This study is the first to show that male physicians were less likely to provide smoking cessation counselling regardless of their smoking status while non-smoking female physicians were more active in advising patients on quitting. The findings highlight the need for developing tailored smoking cessation training programmes for physicians according to their smoking status and gender in China.     

Baby BEEP: A Randomized Controlled Trial of Nurses’ Individualized Social Support for Poor Rural Pregnant Smokers

Objectives We tested the effect of nurse-delivered telephone individualized social support (“Baby BEEP”) and eight mailed prenatal smoking cessation booklets singly and in combination (2 × 2 factorial design) on smoking cessation in low-income rural pregnant women (N = 695; 75% participation). Methods Participants randomized to Baby BEEP groups (n = 345) received weekly calls throughout pregnancy plus 24-7 beeper access. Saliva cotinine samples were collected monthly from all groups by other nurses at home visits up to 6 weeks post-delivery. Primary outcomes were point prevalence abstinence (cotinine < 30 ng/ml) in late pregnancy and post-delivery. Results Only 47 women were lost to follow-up. Intent-to-treat analyses showed no difference across intervention groups (17–22%, late pregnancy; 11–13.5%, postpartum), and no difference from the controls (17%, late pregnancy; 13%, postpartum). Post hoc analyses of study completers suggested a four percentage-point advantage for the intervention groups over controls in producing early and mid-pregnancy continuous abstainers. Partner smoking had no effect on late pregnancy abstinence (OR = 1.7, 95% CI = 0.95, 3.2), but post-delivery, the effect was pronounced (OR = 3.2, 95% CI = 1.8, 5.9). Conclusions High abstinence rates in the controls indicate the power of biologic monitoring and home visits to assess stress, support, depression, and intimate partner violence; these elements plus booklets were as effective as more intensive interventions. Targeting partners who smoke is needed.     

Waist circumference and weight following smoking cessation in a general population: the Inter99 study

OBJECTIVE: Central obesity is an independent risk factor of mortality. Change in waist circumference after smoking cessation has not been previously reported in a population-based prospective study of both sexes. METHODS: Population-based study, Inter99, 1999-2001 in Copenhagen, Denmark. 2408 daily smokers completed questionnaires and had their waist circumference and weight measured. Of these, 221 biochemically verified non-smokers and 1122 continuous smokers attended 1-year follow-up and had their waist circumference and weight measured. RESULTS: The mean increase in waist circumference was 3.88 cm (+/-5.4 cm) and 42% of the quitters had increased their waist circumference by > or = 5 cm. Quitters with high baseline tobacco consumption (OR 1.05, 95% CI=1.0-1.1) and quitters with self-reported reduced physical activity (OR 3.4, 95% CI=1.5-7.7) were more likely to have substantially increased waist circumference. The mean weight gain in quitters was 4.22 kg (+/-4.3 kg) and 41% had gained at least 5 kg. Female quitters gained more weight and had a higher increase in waist circumference than men. Abstinence from smoking was the most important predictor of substantial weight gain and substantial increase in waist circumference. CONCLUSIONS: Smoking cessation resulted in substantial increase in weight and central fat, which might attenuate some of the beneficial effects of smoking cessation. Quitters who reduced their physical activity and persons with high baseline tobacco consumption were more likely to have had a substantial increase in abdominal fat. Abstinence from smoking was the most important predictor of short-term weight gain and increase in waist circumference. It is a challenge for future smoking cessation interventions to achieve a combination of high quit rates and weight-control.     

Predictors of smoking cessation among African-Americans enrolled in a randomized controlled trial of bupropion

OBJECTIVES: Identification of individual characteristics that predict successful smoking cessation treatment has been limited to studies with mostly white participants. This study identifies factors that predict successful quitting among African-Americans participating in a smoking cessation trial. METHODS: Twenty-one baseline variables were analyzed as potential predictors from a double-blind placebo-controlled, randomized trial that used bupropion SR for smoking cessation among 600 African-American smokers. Chi-square tests, two sample t tests, and multiple logistic regression procedures were employed to identify predictors of 7-day abstinence among the 535 participants who completed the 7-week medication phase. RESULTS: Univariate predictors of cessation were receiving bupropion (P < 0.0001), not smoking menthol cigarettes (P = 0.0062), smoking after 30 min of waking (P < 0.0001), older age (P = 0.0085), smoking fewer cigarettes per day (P = 0.0038), and lower cotinine levels (P = 0.0002). Logistic regression identified three significant independent predictors. Participants who received bupropion treatment were more than twice as likely to quit smoking at the end of treatment compared to participants who received placebo (OR = 2.62; 95% CI = 1.77-3.88, P < 0.0001), while smoking within 30 min of waking (OR = 0.40; 95% CI = 0.25-0.62, P < 0.0001) and higher salivary cotinine levels at baseline (OR = 0.799; 95% CI = 0.629-0.922, P < 0.0001) reduced the likelihood of quitting. CONCLUSIONS: This is the first report identifying predictors of smoking cessation among African-Americans participating in a clinical trial. Results indicate that, aside from bupropion treatment, various indicators of addiction were the strongest predictors. While this is similar to findings among white smokers, thresholds of addiction may need to be adjusted for African-American smoking patterns. Additional studies focused on diverse populations are needed to improve treatment approaches and to identify population-specific factors that are important for treatment-matching approaches.     

Maternal smoking cessation and relapse prevention during health care visits

BACKGROUND: Although effects of maternal smoking during pregnancy could be alleviated if women quit early in pregnancy, most do not. Relapse rates among quitters are high. OBJECTIVE: To test the effects of a low-intensity, smoking-cessation/relapse-prevention intervention delivered by clinic staff and providers and based on stages-of-change constructs of the transtheoretical model and brief motivational interviewing techniques. METHODS: A quasi-experimental prospective cohort design employed in obstetric, in-patient, and pediatric care delivery settings of a large health maintenance organization in Portland, Oregon. Subjects were pregnant smokers registered for their first prenatal visit. Primary outcome measures were sustained (self-reported) quit rates during pregnancy and smoking abstinence between 6 and 12 months after delivery. RESULTS: Regression analyses found statistically significant improvement for intervention women in sustained pregnancy quit rates (OR=2.7, CI=1. 2-5.7) and on smoking abstinence between 6 and 12 months after delivery (OR=2.4, CI=1.1-5.3). CONCLUSIONS: While these outcomes are based on self-report only, they emerged despite variable delivery of the intervention across clinics and represent clinically meaningful improvements in rates of nonsmoking. The intervention supports women who want to quit smoking during pregnancy and improves the likelihood of their remaining nonsmokers for the long term.     

Down's syndrome and maternal smoking in early pregnancy

Several previous studies have suggested that maternal smoking is associated with a decreased incidence of trisomy 21. By using the Swedish health registries, 1,321 infants with Down's syndrome (DS) were selected among 1,117,021 infants born in 1983–1993 with known smoking exposure in early pregnancy. No association between maternal smoking and all cases of DS was found [age-adjusted odds ratio (OR) for maternal smoking: 0.98; 95% confidence interval (CI): 0.86–1.11], but heterogeneity over strata existed. A slightly decreased OR (0.91; 95% CI: 0.72–1.15) for any maternal smoking was indicated among primiparas, but among multiparas, no effect of smoking on the incidence of DS could be detected (OR: 1.01; 95% CI: 0.87–1.17). The difference between the OR for smoking ≥10 cigarettes per day among primiparas (OR: 0.59; 95% CI: 0.38–0.90) and multiparas (OR: 1.06; 95% CI: 0.86–1.31) was statistically significant. If not due to statistical fluctuation, the findings indicate that no direct effect of smoking on DS risk exists but the association observed in primiparas is due to covarying factors. Genet. Epidemiol. 14:77–84,1997. © 1997 Wiley-Liss, Inc.     

Gender differences in smoking cessation after 3 years in the Lung Health Study.

OBJECTIVES. An analysis of gender differences in smoking cessation was conducted among 3923 participants in the Special Intervention group of the Lung Health Study. This report focuses on gender differences in sustained quit rates at 12 and 36 months. METHODS. Special Intervention participants were offered a 12-session, 12-week smoking cessation program using nicotine gum and were followed for 3 years. Self-reported smoking status was validated with carbon monoxide and salivary cotinine. RESULTS. Men had higher sustained quit rates at 12 and 36 months; gender differences were found in baseline variables that also predicted sustained abstinence; and controlling for selected baseline variables reduced the association between gender and sustained abstinence. When other variables were controlled, gender predicted sustained abstinence at 36 months (odds ratio [OR] = 1.24, 95% confidence interval [CI] = 1.04, 1.48) but not 12 months (OR = 1.08, 95% CI = 0.92, 1.27), reflecting more late relapse among women. CONCLUSIONS. Demographics and smoking history were more important than gender per se in sustained smoking cessation in the Lung Health Study. Programs tailoring smoking cessation by gender need to include coping skills for problems associated with less education and social support and for improving persistence with quit attempts.     

The Association between Smoking Cessation and Depressive Symptoms: Diet Quality Plays a Mediating Role

Objective: This cross-sectional study aimed to explore the association between smoking cessation and depressive symptoms and investigate the mediating role of dietary quality. Methods: We used data from the 2007–2014 National Health and Nutrition Examination Survey. Logistic regression models were applied to evaluate the associations between smoking cessation and depressive symptoms. Stratified analysis was performed according to different HEI levels. We examined the mediating role of HEI in the relationship between depressive symptoms and cessation duration using the Karlson–Holm–Breen (KHB) method. Results: A total of 20,004 participants aged 20 years or older were included in the analyses. There were significant correlations between years for smoking cessation and depressive symptoms (OR: 0.985, 95% CI: 0.971~0.999) after adjusting for correlation covariables. A likelihood ratio test showed that there was an interaction between smoking cessation and diet quality (p = 0.047). In the mediation analysis, we estimated that the increase in HEI scores after quitting smoking could explain the 6.91% decline in depressive symptoms. Conclusion: In this cross-sectional study, smoking cessation showed a protective effect on depressive symptoms and that diet quality can influence and mediate this association.     

Prenatal Cigarette Smoking and Smokeless Tobacco Use Among Alaska Native and White Women in Alaska, 1996–2003

Objective To examine trends in prenatal cigarette smoking and smokeless tobacco use among Alaska Native (AN) and white women in Alaska. Methods Using 1996–2003 data from the population-based Pregnancy Risk Assessment Monitoring System, we determined trends in self-reported prenatal tobacco use among AN and white women and used chi-square tests and multiple variable logistic regression analysis to identify maternal factors associated with prenatal tobacco use. Results Over the study period, prevalence of any tobacco use during pregnancy declined by 27% among AN women (from 55.8 to 40.9%) (P < 0.0001) and by 17% among white women (from 18.8 to 15.6%) (P < 0.0001). In 2003, among AN women the prevalence of self-reported smokeless tobacco use was 16.9%, cigarette smoking was 25.7%, and any tobacco use was 40.9%; corresponding values for white women were 0.4, 15.0, and 15.6%, respectively. Western Alaska had the highest prevalence of tobacco use. Conclusion The prevalence of tobacco use decreased between 1996 and 2003, but remained higher among AN women than white women, especially for smokeless tobacco. Support for cessation interventions targeting pregnant women should be made a public health priority in Alaska. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.     

Meta-analysis of prenatal smoking cessation interventions

Our purpose was to assess the effect of prenatal smoking interventions on rates of smoking cessation. A total of 37 trials, conducted between 1976 and 2002 and comprising over 14000 women were identified and included in the meta-analyses. There was a significant increasing in the odds of women who quit smoking in late pregnancy in the intervention group (OR = 1.6; 95% CI 1.4-1.8). The effectiveness of the intervention was significantly higher in the studies that smoking cessation intervention included written materials for pregnant women then in the studies without those materials. The percentage of pregnant women who quit smoking was higher among American women than among women from the European Countries.