Exercise training and smoking cessation as the cornerstones of managing claudication.

Based on research, the classic recommendation to prevent progression of lower extremity peripheral arterial disease (PAD) is "start exercising and stop smoking." Unfortunately, a paramount problem for clinicians is motivating targeted individuals to begin and adhere to an exercise regimen and quit smoking. The purpose of this review is to provide the most current information regarding exercise training and smoking cessation. It is hoped that this article will help health care professionals present accurate information to their patients with PAD, address the difficulties in lifestyle change, and intervene effectively.

Cotinine levels in Southeast Asian smokers.

Understanding the contribution of race to factors associated with cigarette smoking and nicotine metabolism is essential for the characterization of patterns of tobacco use, nicotine dependence and incidence of tobacco-related diseases. This paper reports an investigation of cotinine levels among Southeast Asian smokers in two separate studies. Study 1 included 327 male and female smokers who participated in community-based interviews where smoking history information was obtained and a saliva continine sample was collected. Results indicated that subjects smoked an average of 11.2 cigarettes/day, with men reporting significantly higher consumption rates as compared to women (p < 0.0001). Subjects' mean cotinine level was 65 ng/ml with an average cotinine/cigarette ratio of 8.2. In Study 2, plasma and saliva cotinine in six Southeast Asian adult smokers were measured during 2 days of smoking followed by 6 days of abstinence. On day 1, mean plasma and saliva continine levels were 268 and 235 ng/ml, respectively. After 6 days of abstinence, mean levels had dropped to 12 ng/ml for plasma and 8 ng/ml in saliva. On average, it required at least 4.7 days for saliva continine levels to reach < 14 ng/ml. Mean cotinine concentrations during smoking differed in these two separate studies. Implications of these findings are discussed and future research recommendations are presented.

Implementing the Agency for Health Care Policy and Research's Smoking Cessation Guideline in a lung cancer surgery clinic.

PURPOSE/OBJECTIVES: To determine the effectiveness of a nurse-managed smoking cessation intervention based on the Agency for Health Care Policy and Research's (AHCPR's) Smoking Cessation Guideline in a lung cancer surgery clinic. DESIGN: Quasi-experimental. SETTING: Urban, Midwest, academic, and tertiary care. SAMPLE: 25 adult male and female smokers with a confirmed diagnosis of lung cancer that had been surgically managed. Subjects were assigned to an intervention group (n = 14) or a usual-care group (n = 11). METHODS: Participants in the intervention group received a nurse-delivered, AHCPR-based smoking cessation intervention that included face-to-face and phone follow-up contact beginning with the first preoperative clinic consultation. Usual-care participants received routine care provided at the institution. MAIN RESEARCH VARIABLES: Self-reported smoking status with expired air carbon monoxide confirmation six months postsurgery. FINDINGS: Seventy-one percent of the intervention group was biochemically confirmed to be abstinent by expired air carbon monoxide, as compared to 55% in the usual-care group. CONCLUSIONS: Smokers diagnosed with lung cancer desired to quit smoking and may benefit from an intensive smoking cessation intervention at time of diagnosis. IMPLICATIONS FOR NURSING PRACTICE: Further research should include continuing evaluation of an intensive smoking cessation intervention with this population, and all clinicians should be trained to implement AHCPR's Smoking Cessation Guideline in practice.

Tobacco use characteristics among rural Ohio Appalachians.

Appalachians remain at high risk for cancer, heart and lung disease, in part because of their high prevalence of tobacco use; yet, information about their tobacco consumption patterns is limited. The purpose of this study was to describe tobacco consumption variables among rural adult Appalachian tobacco users. Subjects, aged 18 and older (N = 249), participated in a face-to-face interview about tobacco consumption variables and knowledge regarding the health effects of tobacco at fairs in two rural Ohio Appalachian counties. The majority of participants were categorized as precontemplators, although 21 percent were classified in preparation stage of change. Mean age of initiation was 16.6 years and number of cigarettes smoked per day (cpd) was significantly higher for men, as compared to women. One-third of males reported the use of smokeless tobacco. The majority had not tried to quit for more than a year and the average number of previous quit attempts was low. One-half of the sample had been advised in the past to quit by their physician. Few had used nicotine replacement with past quit attempts but greater than half would consider this approach with future attempts. Knowledge about the health effects of smoking indicated that most were aware of the relationship between smoking and cancer but less than one-half recognized its association with heart disease. Those with less education were less informed about the health effects to self and non-smokers. While a sizeable portion expressed interest in quitting, knowledge about the health effects of smoking is lacking, especially with regard to heart disease and among those with less education.

Descriptive outcomes of the American Lung Association of Ohio hypnotherapy smoking cessation program.

Hypnosis smoking cessation treatment is one type of program available to smokers. This paper describes a large randomly selected sample from such a program, which has not been previously reported. During 1997, 2,810 smokers participated in single-session, group hypnotherapy smoking cessation programs sponsored by the American Lung Association of Ohio. A randomly selected sample of 452 participants completed telephone interviews 5 to 15 months after attending a treatment session. Twenty-two percent of participants (n = 101) reported not smoking during the month prior to the interview. Use of other smoking cessation strategies since the treatment session were assessed. Interestingly, only 20% of participants who used pharmaceutical products to assist with smoking cessation took them for the recommended treatment duration. Hypnotherapy smoking cessation treatment offers an alternative cessation method, which may meet the unique needs of certain individuals.

Smoking behavior, dysphoric states and the menstrual cycle: results from single smoking sessions and the natural environment.

A 2-way factorial repeated measures design examined the effects of menstrual cycle phase and smoking on: 1) smoking behavior, 2) mood state, 3) nicotine withdrawal symptomatology, and 4) menstrual symptomatology. Female smokers, aged 20-39, were followed for two consecutive menstrual cycles with two data collection sessions per cycle, which were conducted in the University's General Clinical Research Center (GCRC). Participants were randomly assigned to order of smoking condition, which included: 1) smoking ad libitum, and 2) 24-hour abstinence prior to data collection. Data were collected in the mid-to-late follicular (MLF) phase (between days 6 through to 11) and the four days prior to menses in late luteal (LL) phase. Participants completed the Profile of Mood States and Menstrual Symptom Severity List and recorded daily cigarette smoking rate in the natural environment during MLF and LL phases. Nicotine boost and carbon monoxide (CO) boost were measured and the Shiffman-Jarvick Tobacco Withdrawal Questionnaire was administered during GCRC data collection sessions. Results indicated that subjects smoked more cigarettes per day during the LL phase and CO boost was greater during MLF. No difference was noted in nicotine boost by condition or phase. No difference in mood state was noted by either condition or phase. Withdrawal symptomatology and craving for cigarettes were increased after 24 hours of abstinence. No difference was noted in menstrual symptoms by condition or phase. Further investigations are still needed to characterize the importance of cycle phase in the design of smoking cessation interventions for women of reproductive age.

The impact of a brief intervention on maternal smoking behavior.

OBJECTIVE: To determine if mothers receiving a smoking cessation intervention emphasizing health risks of environmental tobacco smoke (ETS) for their children have a higher quit rate than 1) mothers receiving routine smoking cessation advice or 2) a control group. DESIGN: Randomized, controlled trial. SETTING: Primary care center in a large urban children's hospital. INTERVENTION: Four hundred seventy-nine mothers were randomly assigned to a smoking cessation intervention either aimed at their child's health or their own health, or to a control group receiving safety information. OUTCOME MEASURES: Smoking status, stage of change, cigarettes/day, location smoking occurred, and knowledge of ETS effects. RESULTS: Complete data (baseline and both follow-ups) were available for 166 subjects. There was no impact of group assignment on the quit rate, cigarettes/day, or stage of change. The Child Health Group intervention had a sustained effect on location where smoking reportedly occurred (usually outside) and on improved knowledge of ETS effects. CONCLUSIONS: Further research is needed to devise more effective methods of using the pediatric health care setting to influence adult smoking behaviors.

Smoke constituent exposure and stage of change in black and white women cigarette smokers.

Differences in smoke constituent exposure by ethnicity and menthol preference and differences in decisional balance and habit strength by stage of change, ethnicity, and menthol preference were examined in this 2-factor study design. Ninety-five women, half of whom were Black and half of who smoked menthol cigarettes, participated in a cigarette smoking bout in the Clinical Research Center. Measures of smoking topography, plasma cotinine and nicotine, and expired carbon monoxide were obtained in addition to self-report of the pros and cons of smoking, time to first cigarette, and smoking history. Black women smoked significantly fewer cigarettes per day, but had higher cotinine levels compared to White women. Menthol smokers (n = 49) had significantly larger puff volumes, higher cotinine levels, and shorter time to first cigarette compared to nonmenthol smokers (n = 46). Precontemplators (n = 44) were significantly lower on beliefs about the negative aspects of smoking compared to contemplators and those in preparation stage. Black women, all stages combined, had higher negative beliefs about smoking than did White women. Implications for assessment of smoking patterns and intervention are discussed.

Nicotine metabolism variability and nicotine addiction.

Individual variation in nicotine metabolism may play a role in a person's level of smoking, as well as in the transition from initiation to maintenance of a smoking behavior pattern. Since there is a paucity of research on nicotine metabolism in youth that smoke, a brief review of salient aspects of nicotine metabolism in adults provides a basis from which to extrapolate. We do know that factors influencing the rate of nicotine metabolism include differences in nicotine intake and absorption, inhalation patterns, genetic polymorphisms of pertinent enzymes, as well as daily activities such as meal consumption. Variability is illustrated with differences in cotinine levels identified in African-American and Caucasian women and in menthol and nonmenthol smokers. There are a number of areas where more information to improve understanding the initiation and maintenance of smoking behavior is needed. Characterization of nicotine metabolism and smoking topography in youth from multiple ethnic groups who are engaged in smoking initiation is currently lacking. Important measures of smoke constituent exposure such as carbon monoxide, nicotine and cotinine, as well as puff volume and duration and respiratory movements should be addressed. While there are numerous factors that impact initiation and maintenance of smoking behavior, nicotine metabolism may represent one important aspect.

Smoking cessation interventions in nursing practice.

Smoking cessation treatment by nurses in clinical practice significantly increases the number of smokers who are able to successfully quit the behavior. Nurse-managed cessation interventions have been shown to be effective with smokers, yet many nurses lack the knowledge to identify smokers easily, to identify those treatments that are most efficacious, and to deliver appropriate interventions. This article highlights recent developments in smoking cessation treatment that can be integrated into nursing practice. Attention is given to cessation techniques in special populations, including youth.

Smoking behaviors of women whose children attend an urban pediatric primary care clinic.

OBJECTIVE: To characterize smoking behaviors of caregivers whose children attend a large urban pediatric primary care center. DESIGN: Descriptive survey. Women (n = 479) classified as smokers completed a questionnaire including demographics, smoking habits, measures of addiction, social reinforcers for smoking, attitudes and knowledge, other health and safety habits, and the pediatrician's role in smoking cessation counseling. RESULTS: Of 1421 women surveyed, 36.6% (517) were classified as daily smokers. Four hundred and seventy-nine (93%) were enrolled in the study. Thirty-eight (7%) refused or were ineligible. Smokers differed significantly from non-smokers, with smokers more likely to have lower incomes (p<.03), lower educational attainment (p<.001), and were more likely to be white than non-smokers (p<.001). The average smoker smoked 14 cigarettes per day for 10 years. Half of the subjects had not considered quitting smoking in the near future. The majority of subjects (66%) lived with at least one other smoker, and reported that more than half of their friends smoked. Most (79%) participants agreed that pediatricians should give smoking cessation advice to parents of their patients. However, only 19% recalled being counseled to quit, and 55% recalled their child's doctor discussing the danger of environmental tobacco smoke. CONCLUSION: The pediatric visit is an excellent opportunity for identifying women who smoke. Efforts to assist women with smoking cessation in similar settings will need to take into account their poverty and the high degree of social support for their continued smoking.

Nicotine dependence and smoking topography among black and white women.

Nicotine dependence is a complex phenomenon involving behavioral, biological, and pharmacological components that influence smoking cessation rates. The purpose of this study was to characterize the multidimensional aspects of nicotine dependence and cigarette smoking topography behaviors among Black and White women smokers. Thirty-seven women participated in a 2-hr protocol in the General Clinical Research Center. Plasma cotinine to cigarette ratio was significantly associated with three topography variables: total puff duration, total cigarette time, and carbon monoxide (CO) boost. Black women scored higher on plasma cotinine levels, cotinine per cigarette ratio, and CO increase pre- to postcigarette than White women. Implications for clinical practice include assessing nicotine dependence beyond self-reported cigarettes per day to develop more appropriate smoking cessation interventions.

Menthol and nonmenthol cigarettes and smoke exposure in black and white women.

Purposes of this investigation were to compare smoke constituent exposure (CO and nicotine boosts) and smoking topography parameters between black and white women, and between women regularly using menthol or nonmenthol cigarettes. A two-factor factorial design with a sample of 37 women stratified by race and menthol or nonmenthol cigarette use was implemented. There were significant main and interaction effects of race and menthol/nonmenthol use on CO boost. Black women had a mean CO boost of 10.1 ppm vs. 7.2 ppm for white women, while women using nonmenthol cigarettes had a higher CO boost (mean = 10.6 ppm) compared to those regularly using menthol cigarettes mean = 6.5 ppm). White menthol smokers had the lowest CO boost of all subgroups. There was a trend for black women to have higher nicotine boost than white women (21.4 ng/ml vs. 15.9 ng/ml). Black women had nonsignificantly higher puff volumes compared to white women (mean = 48.4 vs. 43.5 ml), while nonmenthol smokers had nonsignificantly higher puff volumes than menthol smokers (mean = 48.5 vs. 42.7 ml). Lower CO boost with mentholated cigarettes suggests factors beyond mentholation may affect elevated smoke constituent exposure among black women.

Patterns of cigarette consumption and cotinine levels among African American women smokers.

Cigarette smoking intensifies a number of serious health problems, including lung cancer, hypertension, low birth weight, and infant mortality, that disproportionately affect black Americans. Cotinine, a major nicotine metabolite, is one indicator of smoke exposure. It has been reported that black women have higher mean cotinine levels than white women. This divergence may be attributed to biologic factors or to inaccuracy in reporting cigarette use. The purpose of this study was to characterize nicotine dependence and the relationship between self-reported cigarette use and cotinine levels among black women smokers. The sample consisted of 142 black women cigarette smokers recruited individually at urban health centers and worksites. A cotinine/cigarette ratio was determined for light, moderate, and heavy smokers. Underreporting of cigarette consumption, previously defined as cotinine value > 25 ng/ml/cigarette, ranged from 86% among light smokers to 70% among moderate smokers and 21% among heavy smokers. There were significant differences in cotinine/cigarette and nicotine dependence scores across levels of smoking. Average cotinine/cigarette values were higher in black women compared with previous reports for Mexican American women smokers. No comparable values are available for white women. Additional study is needed to begin to explain variations in levels of cotinine, as well as perceived nicotine dependence among black women.

Health-promoting behaviors of African American women.

Limited information exists concerning health behaviors of African American women. The purposes of this study were to describe health-promoting lifestyle behaviors among a sample of 187 African American women and to compare findings to other published reports on the Health-Promoting Lifestyle Profile (HPLP) instrument. Subscales with the highest means in this study were interpersonal support and self-actualization. However, when compared to reports of HPLP scores for other groups, total HPLP and subscale scores of women in this study were generally lower. Readability and applicability of the HPLP instrument may affect its validity and reliability in a diverse sample.

Factors associated with nicotine dependence among African American women cigarette smokers.

Cigarette smoking contributes to disproportionate morbidity and mortality among African Americans. Purposes of the study were to describe smoking behavior and test a model of nicotine dependence among African American women. Participants (n = 187) smoked a low rate of high nicotine mentholated cigarettes and had a mean salivary cotinine of 402 ng/mL. The proposed model predicted 48% of variance in nicotine dependence with smoking to cope, number of cigarettes/day, positive outcome expectancies about smoking, and interest in quitting, as significant contributors. Suggested interventions include developing alternative coping skills, cognitive restructuring, and techniques focused on the precontemplation stage of smoking cessation.

Processes of change across five stages of smoking cessation.

A cross-sectional design with 190 smokers and exsmokers selected by random digit dialing was used to determine differences in processes individuals use to modify behavior across five stages of smoking cessation. Five stages of cessation are: precontemplation, contemplation, recent quitting, long-term quitting, and relapse. Ten processes of change (POC) or ways individuals modify behavior were assessed. Examples of POCs are: consciousness raising, self-liberation, reinforcement management, and stimulus control. Biochemical validation of smoking abstinence was performed on a random subset of exsmoker subjects. Individuals in five stages of smoking cessation used processes of change differently as reflected by a significant MANOVA, F (40,590) = 5.02, p = .0001. It is important to assess an individual's stage of smoking cessation when planning interventions related to POCs.

Work stress after smoking cessation.

1. Since smoking relapse occurs most frequently during the first 3 to 6 months after cessation, worksite maintenance sessions during this critical time may promote long term abstinence. 2. Uncertainty or ambiguity about what is expected of the worker on the job is a consistent predictor of relapse during the first year postcessation. 3. A worker's perception of workload is related to smoking status. Workers who perceived a heavier load at 3, 6, and 12 months postcessation were likely to have resumed smoking.