News Release 11/30/04 WI SMOKERS TRYING TO QUIT THE HARD WAY Counseling and medication can make quitting easier Madison--According to a new report on “How Wisconsin Smokers Quit,” nearly one-half of Wisconsin smokers tried to quit smoking last year. Close to 8 out of 10 tried to quit “cold turkey” (without medication or counseling) and 90 percent relapsed within three months. Although new methods for quitting double or triple their chances for success, most Wisconsin smokers are still trying to quit the hard way. The report, the first in a series based on the 2003 Wisconsin Tobacco Survey of over 8000 Wisconsin residents, concluded that smokers are making multiple, unsuccessful quit attempts and not using methods that are shown to increase quitting success. More than 50 percent of current Wisconsin smokers have made three or more tries at quitting smoking. “We now have a number of medications and counseling strategies that can greatly increase quit rates—nicotine replacement therapies, Zyban, telephone counseling,” said Dr. Michael Fiore, director of the UW Center for Tobacco Research and Intervention, one of the organizations releasing the report. “But many people are either unaware or cannot afford these treatments. As we approach New Year’s resolutions to quit, smokers should see their doctors or call the Wisconsin Tobacco Quit Line at 1-877-270-STOP to get help in quitting smoking.” “That 75 percent of smokers want to quit and most have made an attempt is very encouraging,” said Mark Zehner, the report’s lead author. The report found that more young adults are trying to quit compared to smokers over 65. “There may be signs of discouragement in smokers over 65 who were the least likely to have made a quit attempt.” African Americans were more likely to have made a quit attempt in the previous year (63 percent) than Whites (46 percent) and they were more likely to try to quit “cold turkey” (92 percent vs. 78 percent for Whites). “This paper indicates that we need to increase awareness of treatments that are approved and that work. We also need to encourage public and private health insurers to make treatments available,” said Fiore. “Through more research focusing on African Americans and the elderly, we can better assist them to quit smoking.” Other papers in the series will address barriers to quitting, women and smoking, and clinician behavior and smoking status. The papers are based on the 2003 Wisconsin Tobacco Survey conducted with 8111 Wisconsin residents by the University of Wisconsin Survey Center for the UW Center for Tobacco Research and Intervention and UW Comprehensive Cancer Center. The Wisconsin Department of Health and Family Services funded the survey and The Robert Wood Johnson Foundation funded the publication of the report. Copies of “How Wisconsin Smokers Quit” are available online at www.ctri.wisc.edu and www.tobwis.org. The Center for Tobacco Research and Intervention, University of Wisconsin Medical School, has provided cessation and prevention services in Wisconsin since 1992 and is a nationally-recognized research center. News Release 08/02/04 States Fail to Cover Smoking Cessation Treatment for Employees Despite recommendations from federal public health experts that smoking cessation treatment should be provided to all smokers, state employers are failing to provide their employees with recommended smoking cessation treatment coverage, according to a study published in this month’s American Journal of Public Health. According to a study of insurance coverage provided to the nation’s five million state employees, only 29 of 45 states surveyed required that any smoking cessation treatment be included in their insurance coverage for state employees. And a mere 17 of the 45 states provided the complete range of smoking cessation coverage recommended by the U. S. Public Health Service to any of their employees. “What this research shows is that most state employers are missing an opportunity to reduce smoking rates among their employees by not providing coverage of the full range of smoking cessation treatment such as medication and counseling,” said Marguerite Burns, M.A., the study’s lead author. Researchers from the University of Wisconsin Transdisciplinary Tobacco Use Research Center found that only seven states required smoking cessation treatment coverage that was fully consistent with recommendations in the U.S. Public Health Service Clinical Practice Guideline for all state employees. This means they required coverage for counseling and one or more of the FDA-approved medications for smoking cessation treatment. An additional ten states required this coverage for at least some of their state employees. A surprising 16 states did not require coverage of treatment for any state employees. These results echo those of previous studies in other populations. The provision of insurance coverage for smoking cessation treatment remains spotty. In many cases, only some employees are covered and/or they are covered for only some treatments. Although research findings concerning the effects of insurance coverage are not conclusive, insurance coverage for smoking cessation treatment holds promise as a means of reducing smoking rates in insured populations. “In many markets, states and other public employers serve as leaders influencing insurance coverage,” said Burns. “Unfortunately, many are not rising to the occasion as models for healthcare purchasers in terms of covering smoking cessation treatment.” Forty-five of 50 states participated in the study, which was conducted between September 2002 and February 2003. The seventeen states that provide the recommended coverage to their employees were: Alabama, Arkansas, California, Indiana, Maine, Missouri, North Carolina, New Jersey, New Mexico, Oklahoma, South Dakota, Tennessee, Virginia, Vermont, Washington, Wisconsin and West Virginia. This study was supported by a grant from the Robert Wood Johnson Foundation through its Partners with Tobacco Use Research Centers program. The Robert Wood Johnson Foundation was established as a national philanthropy in 1972 and today it is the largest US foundation devoted to improving the health and health care of all Americans. News Release 05/11/04 Smokers Welcome Help in Quitting According to a study just published in Preventive Medicine, 68 percent of smokers who were offered free cessation treatment at their regular clinics took advantage of the invitation. These results contradict previous research that suggested that smokers are not eager for intervention by their physicians. When offered a choice of treatment, 75 percent of the participants in the study selected counseling in conjunction with nicotine patch medication. This study, conducted in primary care clinics in Madison and Milwaukee, Wis., by researchers at the University of Wisconsin Center for Tobacco Research and Intervention (CTRI) and the University of Wisconsin Medical School-Milwaukee was designed to assess the acceptance, use and effectiveness of free smoking cessation treatments integrated into routine primary care. With 70 percent of smokers visiting their primary care physicians at least once a year, health care clinics are well-suited sites for tobacco cessation treatment. “Lack of interest among patients has been cited as a reason for not offering cessation help to smokers,” said Michael Fiore, MD, MPH, lead researcher and CTRI director. “This study demonstrated convincingly that smokers are interested in getting help to quit. In fact, over two-thirds said, ‘Yes’ to offers of cessation treatment even when that was not the reason for their doctor visit. And, when offered a choice of treatment, they preferred the most intensive treatment available.” The study was designed to reduce barriers to treatment use by offering free, convenient treatment. Medical assistants at diverse clinics invited smokers to participate in a treatment program involving free nicotine replacement therapy and possible counseling. Recruitment was integrated into the regular clinic routine. Participants simply had to say “Yes” when asked if they were interested in receiving cessation treatment to begin enrollment. Participants who enrolled in treatment were assigned to one of two conditions—a “random” condition or a “free choice” condition. In the “random” condition, they were randomly assigned to one of the following treatments—the nicotine patch, the patch plus the Committed Quitters (CQ) program (self-help materials and telephone counseling provided by the patch manufacturer) or the patch plus CQ plus individual counseling. In the “free choice” condition, smokers themselves selected among these three treatment options. “We conclude from this study that smokers are willing to engage in cessation treatment,” said Dr. Fiore. “Lack of easy access to free, convenient care, rather than lack of interest, may be keeping the millions of smokers who want to quit from doing so. This study provides a model for a tobacco cessation treatment referral program for primary care clinics which could be used anywhere in the country.” Of the 4,174 smokers who were invited, 68 percent accepted the invitation for treatment. Those smokers who tend to have more trouble quitting--women and African American smokers--were especially likely to accept treatment. Of those who accepted, passed the screening, and were assigned to the “free choice” condition, 75 percent elected to receive treatment that included counseling. More than 40 percent selected face-to-face counseling. Participants followed through with treatment at higher than expected levels, as well. Nearly 85 percent of participants picked up free nicotine patches that were available at their clinic pharmacies. Both African American smokers and other minorities were less likely to pick up their patches than were white smokers, despite the greater initial interest in treatment among African American smokers. On average, participants reported using patches for 5.7 of the 8 weeks recommended. Sixty-nine percent of eligible participants enrolled in the CQ telephone and mailing support program. For the face-to-face counseling program, 67 percent attended at least one session and 41 percent attended all four. Six months after the quit date, 13 percent of all participants were abstinent, which is consistent with results from past nicotine patch clinical trials. This is markedly higher than the 2 percent to 5 percent long-term quit rate among smokers who try to quit on their own. The study did not find that abstinence rates were significantly related to counseling intensity. Abstinence rates were significantly lower among African Americans than white smokers. Additional research is necessary to find a better way to deliver treatments to African American smokers who accepted treatment in this study at high levels, but remained abstinent at low levels. The findings in this study support the Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence recommendation that every smoker who visits a health care setting should be offered evidence-based treatment. This research was supported by a grant from the National Cancer Institute and a Transdisciplinary Tobacco Use Research Center (TTURC) grant from the National Cancer Institute (NCI) and the National Institute on Drug Abuse (NIDA). The University of Wisconsin TTURC is one of seven TTURCs funded by NCI and NIDA to investigate new ways of combating tobacco use and nicotine addiction, using an innovative, integrated approach. The Robert Wood Johnson Foundation also funds the TTURCs through the Partners with Tobacco Use Research Centers program. The Partners program supplements research funded by NCI and NIDA and supports tobacco-related policy research and communications activities. News Release 11/04/03 Pregnant Women Who Smoke Heavily Increase the Risk That Their Children Will Also Smoke Heavily Later In Life Boston, MA— In the first long-term study to assess the effect of maternal smoking during pregnancy and risk for nicotine dependence among offspring, researchers from the Harvard School of Public Health and Brown Medical School in Providence, Rhode Island, have found that offspring of mothers who smoked a pack or more of cigarettes per day during pregnancy had a higher risk for developing nicotine dependence compared to children whose mothers didn’t smoke during pregnancy. The association was independent of the mothers’ postnatal smoking and the child’s age. The results of the study appear in the November issue of the American Journal of Psychiatry (http://ajp.psychiatryonline.org/). Participants in the study were the grown children of mothers enrolled in the Providence, Rhode Island site of the National Collaborative Perinatal Project (NCPP), a multi-site study that involved the observation and examination of more than 50,000 pregnancies through the first seven years of life. Participants for the NCPP were enrolled between 1959 and 1966 and were visited regularly by NCPP investigators. Beginning with the first prenatal meeting and in each subsequent meeting until delivery, the mothers in the study were asked if they smoked, and if so, the number of cigarettes per day. From these data the researchers were able to establish the maximum number of cigarettes smoked at any point during the pregnancy. More than 60 percent of the women smoked during their pregnancies; approximately 35 percent smoked more than a pack per day (20 cigarettes) and nearly 25 percent smoked less than a pack per day. Offspring whose mothers reported smoking a pack or more of cigarettes per day during their pregnancy were significantly more likely to meet DSM criteria for lifetime nicotine dependence than offspring of mothers who never smoked during their pregnancy. Among offspring who tried cigarettes, the odds of progressing to nicotine dependence was almost twice as great for those whose mothers smoked heavily during pregnancy. In contrast, the use of marijuana was not increased among children whose mothers smoked cigarettes during pregnancy. Marijuana use among the adult offspring was of particular interest to the researchers because of its similar route of administration (inhalation) and because research has shown an association between cigarette smoking and marijuana use. Stephen Buka, lead author of the study and an associate professor in the Department of Society, Human Development and Health at the Harvard School of Public Health said, “More than half a million infants each year are exposed to cigarette smoke before birth. In the short term, this increases the risk of low birthweight and birth defects, and in the longterm, this adds to the likelihood that children will become heavy smokers, dependent on nicotine. Eliminating smoking during pregnancy and afterwards remains a critical challenge for clinicians and for public health practionners.” Ray Niaura, PhD, Professor, Centers for Behavioral and Preventive Medicine, Brown Medical School/The Miriam Hospital explains the importance of these findings for clinicians, "According to the PHS Guidelines for Smoking Cessation, health care providers must take advantage of every opportunity to ask, advise and assist patients in efforts to quit smoking. Healthy baby prenatal visits, labor and delivery, and post-natal care visits are golden opportunities for providers to offer assistance to quit smoking and prevent relapse, thereby reducing risk of children progressing to nicotine dependence, and preventing exposure to toxic environmental tobacco smoke." This research was conducted within the Transdisciplinary Tobacco Use Research Center: New England Family Study, which investigates multiple factors associated with nicotine dependence across the lifespan and across generations. Seven Transdisciplinary Tobacco Use Research Centers (TTURC) are funded by the National Cancer Institute and the National Institute on Drug Abuse to investigate new ways of combating tobacco use and nicotine addiction, using an innovative, integrated approach. News Release 10/30/03 Study Finds Classroom Study Groups More Effective When Organized By Social Networks ALHAMBRA, CA, October 30, 2003 When it comes to organizing students into classroom study groups, the most commonly used method may not be the most educationally effective way for pupils to learn their lessons, according to a study by researchers at the Transdisciplinary Tobacco Use Research Center at the Keck School of Medicine at the University of Southern California. The study compared three ways of organizing study groups and assigning student leaders to them to deliver a smoking prevention program. The most effective groups, according to the study in the November issue of the American Journal of Public Health, were those organized by a method using social networking data: Each student was assigned to work with a peer group leader he or she had personally nominated. The method most commonly used in U.S. classrooms -- in which students are randomly assigned to student leaders elected by the entire classroom -- was shown to be less effective for teaching health promotion. Also less effective was a third method in which the teacher both selected the leaders and assigned the students. This is one of the first studies to demonstrate the use of social network data to design a health promotion intervention, and it points to the possibility of using the network model in a variety of settings. "Most school-based tobacco prevention programs are based on a social influences model," says Thomas W. Valente, Ph.D., associate professor of preventive medicine and the study’s lead author, "but they haven’t been structured to take full advantage of the possible positive aspects of peer influence. Previous studies have suggested that peer leaders are important components to health promotion programs; this is the first study to evaluate how these leaders should be assigned to groups." The study was designed to test the effectiveness of the network method for identifying peer opinion leaders and constructing study groups by comparing it with two other methods: random and teacher selection. Some 1,961 sixth-graders in 16 Los Angeles-area schools took part in the smoking prevention study. In the network condition, the leaders were defined as those who had received the most nominations. By using a mathematical algorithm, they were matched to students who had nominated them, thus recognizing that opinion leaders are not leaders for everyone but rather are leaders for those who nominate them as leaders, according to the study. If a student’s nominee was not chosen as a leader, he or she was assigned to a group leader nominated by his or her nominee. Peer leaders were taught how to organize and work with their groups. The aim of the programs was to change psychosocial factors involved in tobacco use such as attitudes toward smoking, self-efficacy (the belief that you can accomplish what you set out to do), refusal skills, coping skills and intention to smoke. Students in the network groups liked the prevention program more, had improved attitudes, showed improved self-efficacy and had decreased intention to smoke when compared to students organized in the two other types of groups. "Many adults fear that peers can have a strong influence on deviant behavior," Valente said, "but our study adds to evidence that peer influence can be harnessed in a way that benefits health promotion programs." The article cautioned that although the results reported here were positive, the outcomes measured were attitudinal mediators and not behaviors, and it remains to be seen if behaviors will be affected. This research was funded by the National Cancer Institute and the National Institute of Drug Abuse through the Transdisciplinary Tobacco Use Research Center of the University of Southern California (http://ipr.usc.edu/tturc). News Release 10/10/03 Novelty-Seeking Teens More Receptive to Tobacco Advertising (Philadelphia, PA) Adolescents who demonstrate impulsive and risk-taking behavior and an increased need for stimulation, a personality trait known as “novelty-seeking,” are more receptive to tobacco advertising and are at high risk for smoking initiation, a study by researchers from the University of Pennsylvania School of Medicine and Georgetown University indicates. This study appears in the October issue of Health Communication. “While previous research has shown that receptivity to tobacco advertising is associated with higher levels of smoking among adolescents, few studies have examined how variability in personality traits among adolescents may make certain teens more receptive to tobacco advertising. To better understand the influence of tobacco advertising on youth, this study sought to identify subgroups of adolescents who have been most receptive to tobacco advertising and promotional activities,” said lead author Janet Audrain, PhD, member of the Abramson Cancer Center of the University of Pennsylvania, and assistant professor in the Department of Psychiatry at Penn’s School of Medicine. Audrain led a research team that interviewed 1,071 ninth-grade adolescents at five public high schools. These students completed a questionnaire that assessed smoking habits, exposure to other smokers, receptivity to tobacco advertising, and novelty-seeking personality trait. The researchers determined the level of receptivity to tobacco advertising by whether adolescents could name an often-advertised cigarette brand, had a favorite tobacco advertisement, and if they possessed or were willing to use a tobacco industry promotional item. Novelty-seeking was measured by the adolescents’ responses to questions regarding impulsive and sensation-seeking behaviors. Forty-four percent of the adolescents had moderate to high levels of receptivity. The researchers found that adolescents in this group were more likely to have tried smoking and to be higher in the novelty-seeking trait. Novelty-seeking adolescents, both smokers and non-smokers, were twice as likely to be receptive to tobacco advertising. This finding leads researchers to believe that novelty-seeking may be a key factor in receptivity to tobacco advertising regardless of smoking status and may put teens with this trait at a higher risk for smoking initiation. “The heightened receptivity to tobacco advertising among youth high in novelty-seeking may be attributable to their greater need for stimulation and rewarding experiences,” said Audrain. “Tobacco industry promotional campaigns, which often highlight stimulating activities and adventurous behavior, appear to be designed to appeal to this feature of novelty-seeking youth.” This study indicates that in order to counter the influence of tobacco-industry advertising, anti-tobacco advertising campaigns may need to target youth high in novelty seeking. Anti-tobacco advertising directed at novelty-seeking adolescents should be dramatic as well as physically and emotionally intense as these adolescents may have stronger reactions to messages containing high levels of stimulation. This research, which appears in Health Communication in an article titled “Which adolescents are most receptive to tobacco industry marketing? Implications for counter-advertising campaigns,” is part of a four-year investigation Audrain and her colleagues are conducting to explore the social, psychological and genetic factors that influence adolescents’ decisions about smoking. This research was funded by the National Cancer Institute and the National Institute on Drug Abuse and was conducted by the University of Pennsylvania/Georgetown University Transdisciplinary Tobacco Use Research Center. News Release 08/01/03 Depression Not Always a Barrier to Successfully Quitting Smoking Providence, RI (August 2003) - Having experienced a depressive episode at some point in one’s lifetime does not necessarily predict failure in smoking cessation treatment, based on new research results released in the August issue of the Journal of Consulting and Clinical Psychology. The study evaluated the widely held belief that smokers with any lifetime experience of depression are significantly less likely to quit than those without such a history. The study found no significant association between history of depression and smoking treatment outcome. The meta-analysis, which used statistical procedures to combine the results from previous studies examining the relationship between history of depression and ability to quit smoking in treatment, was completed by a team of researchers, led by Brian Hitsman, PhD, Centers for Behavioral and Preventive Medicine, Brown Medical School and The Miriam Hospital. Their review of smoking treatment studies published between 1966-2000, revealed fifteen studies that assessed both history of depression and smoking abstinence. The combined sample included a total of 2,984 smokers. Of the fifteen studies, only two of thirteen showed a significant association between a history of depression and short-term quitting success (three months or less), and only one of twelve showed a significant association between a history of depression and long-term quitting success (six months or more). Smokers with a history of depression were just as likely to quit smoking than those without such a history. Smokers have higher rates of depression than non-smokers. While 17% of the US population have a lifetime history of major depression, up to 60% of individuals in smoking treatment programs have a history of depression. Moreover, despite a national smoking rate of approximately 23%, up to 75% of people in treatment for major depression are daily smokers. Study results offer hope to smokers who in the past may have been discouraged from trying to quit smoking because of their depression, or who may have been unsuccessful due to mismatched treatments. “We hope these results encourage clinicians to take a fresh look at how they treat smokers who have experienced depression at some point in their lives,” explains Hitsman, “Clinicians should base their treatment recommendations on the same smoker characteristics, such as level of motivation to quit or degree of nicotine dependence, that are used to determine treatment for smokers in the general population. “While these results confirm that single episode depression does not influence smoking cessation success, it is unclear whether other forms of depression, such as recurrent major depression, interfere with quitting,” summarizes Hitsman. “We suspect that specific subgroups of smokers, including those who have had multiple episodes of depression, may require specialized, intensive smoking cessation treatment." This study was supported by the National Institute on Drug Abuse, with additional support from the National Heart, Lung and Blood Institute, and the National Cancer Institute, Transdisciplinary Tobacco Use Research Center. News Release 11/01/02 Genetic Variant May Impact Smoking Cessation (Philadelphia, PA) Smokers with a specific genetic variant may be more vulnerable to cigarette cravings and relapse when trying to quit smoking, a study by researchers from the Tobacco Use Research Center of the University of Pennsylvania School of Medicine indicates. This study also shows that the anti-depressant drug bupropion - better known by its brand name, Zyban - may lessen these effects, especially among females. The study, titled “Pharmacogenetic Investigation of Smoking Cessation Treatment,” appears in the November issue of Pharmacogenetics. While previous research has shown that bupropion is an effective smoking cessation aid, smokers experience variability in response to this drug and only 30-45 percent remain abstinent. By identifying the genetic factors that influence response to bupropion, researchers hope to aid in the development of more effective treatment strategies that are tailored to individual smokers. Lead author Caryn Lerman, Ph.D., Associate Director for Cancer Control and Population Science at the Abramson Cancer Center of the University of Pennsylvania and Professor in Penn’s School of Medicine and the Annenberg Public Policy Center, led a research team that examined 426 smokers enrolled in a randomized clinical trial of bupropion for smoking cessation. Participants all provided blood samples and received bupropion or placebo plus seven sessions of behavioral group counseling. Smoking status, abstinence symptoms and side effects were recorded weekly, and smoking status was verified at the end of treatment and again at a six-month follow-up appointment. The researchers found that participants with a decreased activity variant of the CYP2B6 gene reported greater increases in cravings for cigarettes following the quit date and were about one and a half times more likely to relapse during the treatment phase. “This study provides an important first step toward utilizing genotype to identify smokers who are more vulnerable to relapse and who may benefit most from more intensive smoking cessation treatment,” said Lerman. In previous research, the CYP2B6 enzyme (the product of this gene) has been found to affect both nicotine metabolism and bupropion metabolism. Lerman and her colleagues speculate that the effect of the genetic variant on cessation may be due to inherited differences in nicotine metabolism. “Brain concentrations of human CYP2B6 may alter local metabolism of nicotine. Such effects could contribute to neuroadaptations that alter the subjective effects of abstinence from smoking, thereby promoting relapse,” said Lerman. The present data do not suggest that the CYP2B6 genetic effect on smoking cessation is attributable to individual differences in bupropion metabolism; however, further research in this area is needed. The study also provides preliminary evidence that bupropion may help smokers, especially females, overcome the effects of genetic predisposition on relapse rates. Among women with the CYP2B6 polymorphism, 54 percent of those who were treated with bupropion were abstinent at the end of treatment, compared with 19 percent of those who received placebo. The researchers believe that this difference might be due to bupropion’s effect on abstinence-induced negative moods that are more common among women. This research was funded by the National Cancer Institute and the National Institute on Drug Abuse and was conducted by the University of Pennsylvania/Georgetown University Transdisciplinary Tobacco Use Research Center.