Mechanisms underlying mindfulness-based addiction treatment versus cognitive behavioral therapy and usual care for smoking cessation.

OBJECTIVE: To examine cognitive and affective mechanisms underlying mindfulness-based addiction treatment (MBAT) versus cognitive-behavioral therapy (CBT) and usual care (UC) for smoking cessation. METHOD: Participants in the parent study from which data were drawn (N = 412; 54.9% female; 48.2% African American, 41.5% non-Latino White, 5.4% Latino, 4.9% other; 57.6% annual income <$30,000) were randomized to MBAT (n = 154), CBT (n = 155), or UC (n = 103). From quit date through 26 weeks postquit, participants completed measures of emotions, craving, dependence, withdrawal, self-efficacy, and attentional bias. Biochemically confirmed 7-day smoking abstinence was assessed at 4 and 26 weeks postquit. Although the parent study did not find a significant treatment effect on abstinence, mixed-effects regression models were conducted to examine treatment effects on hypothesized mechanisms, and indirect effects of treatments on abstinence were tested. RESULTS: Participants receiving MBAT perceived greater volitional control over smoking and evidenced lower volatility of anger than participants in both other treatments. However, there were no other significant differences between MBAT and CBT. Compared with those receiving UC, MBAT participants reported lower anxiety, concentration difficulties, craving, and dependence, as well as higher self-efficacy for managing negative affect without smoking. Indirect effects of MBAT versus UC on abstinence occurred through each of these mechanisms. CONCLUSIONS: Whereas several differences emerged between MBAT and UC, MBAT and CBT had similar effects on several of the psychosocial mechanisms implicated in tobacco dependence. Results help to shed light on similarities and differences between mindfulness-based and other active smoking cessation treatments. (PsycINFO Database Record

User Perceptions and Reactions to an Online Cancer Risk Assessment Tool: a Process Evaluation of Cancer Risk Check.

Online cancer risk assessment tools, which provide personalized cancer information and recommendations based on personal data input by users, are a promising cancer education approach; however, few tools have been evaluated. A randomized controlled study was conducted to compare user impressions of one tool, Cancer Risk Check (CRC), to non-personalized educational information delivered online as series of self-advancing slides (the control). CRC users (N = 1452) rated the tool to be as interesting as the control (p > .05), but users were more likely to report that the information was difficult to understand and not applicable to them (p < .05). Information seeking and sharing also were lower among CRC users; thus, although impressions of CRC were favorable, it was not shown to be superior to existing approaches. We hypothesized CRC was less effective because it contained few visual and graphical elements; therefore, CRC was compared to a text-based control (online PDF file) post hoc. CRC users rated the information to be more interesting, less difficult to understand, and better able to hold their attention (p < .05). Post hoc results suggest the visual presentation of risk is critical to tool success.

Attentional bias to negative affect moderates negative affect's relationship with smoking abstinence.

OBJECTIVE: To examine whether initial orienting (IO) and inability to disengage (ITD) attention from negative affective stimuli moderate the association of negative affect with smoking abstinence during a quit attempt. METHOD: Data were from a longitudinal cohort study of smoking cessation (N = 424). A negative affect modified Stroop task was administered 1 week before and on quit day to measure IO and ITD. Ecological Momentary Assessments were used to create negative affect intercepts and linear slopes for the week before quitting and on quit day. Quit day and long-term abstinence measures were collected. RESULTS: Continuation ratio logit model analyses found significant interactions for prequit negative affect slope with prequit ITD, odds ratio (OR) = 0.738 (0.57, 0.96), p = .02, and for quit day negative affect intercept with quit day ITD, OR = 0.62 (0.41, 950), p = .03, predicting abstinence. The Prequit Negative Affect Intercept × Prequit IO interaction predicting quit day abstinence was significant, OR = 1.42 (1.06, 1.90), p = .02, as was the Quit Day Negative Affect Slope × Quit Day IO interaction predicting long-term abstinence, OR = 1.45 (1.02, 2.08), p = .04. CONCLUSION: The hypothesis that the association of negative affect with smoking abstinence would be moderated by ITD was generally supported. Among individuals with high ITD, negative affect was inversely related to abstinence, but unrelated to abstinence among individuals with lower levels of ITD. Unexpectedly, among individuals with low IO, negative affect was inversely related to abstinence, but unrelated to abstinence among individuals with higher levels of ITD. (PsycINFO Database Record

Efficacy of mindfulness-based addiction treatment (MBAT) for smoking cessation and lapse recovery: A randomized clinical trial.

OBJECTIVE: To compare the efficacy of Mindfulness-Based Addiction Treatment (MBAT) to a Cognitive Behavioral Treatment (CBT) that matched MBAT on treatment contact time, and a Usual Care (UC) condition that comprised brief individual counseling. METHOD: Participants (N = 412) were 48.2% African American, 41.5% non-Latino White, 5.4% Latino, and 4.9% other, and 57.6% reported a total annual household income < $30,000. The majority of participants were female (54.9%). Mean cigarettes per day was 19.9 (SD = 10.1). Following the baseline visit, participants were randomized to UC (n = 103), CBT (n = 155), or MBAT (n = 154). All participants were given self-help materials and nicotine patch therapy. CBT and MBAT groups received 8 2-hr in-person group counseling sessions. UC participants received 4 brief individual counseling sessions. Biochemically verified smoking abstinence was assessed 4 and 26 weeks after the quit date. RESULTS: Logistic random effects model analyses over time indicated no overall significant treatment effects (completers only: F(2, 236) = 0.29, p = .749; intent-to-treat: F(2, 401) = 0.9, p = .407). Among participants classified as smoking at the last treatment session, analyses examining the recovery of abstinence revealed a significant overall treatment effect, F(2, 103) = 4.41, p = .015 (MBAT vs. CBT: OR = 4.94, 95% CI: 1.47 to 16.59, p = .010, Effect Size = .88; MBAT vs. UC: OR = 4.18, 95% CI: 1.04 to 16.75, p = .043, Effect Size = .79). CONCLUSION: Although there were no overall significant effects of treatment on abstinence, MBAT may be more effective than CBT or UC in promoting recovery from lapses. (PsycINFO Database Record

Dispositional Mindfulness Predicts Enhanced Smoking Cessation and Smoking Lapse Recovery.

BACKGROUND: Although mindfulness has been hypothesized to promote health behaviors, no research has examined how dispositional mindfulness might influence the process of smoking cessation. PURPOSE: The current study investigated dispositional mindfulness, smoking abstinence, and recovery from a lapse among African American smokers. METHODS: Participants were 399 African Americans seeking smoking cessation treatment (treatments did not include any components related to mindfulness). Dispositional mindfulness and other psychosocial measures were obtained pre-quit; smoking abstinence was assessed 3, 31 days, and 26 weeks post-quit. RESULTS: Individuals higher in dispositional mindfulness were more likely to quit smoking both initially and over time. Moreover, among individuals who had lapsed at day 3, those higher in mindfulness were more likely to recover abstinence by the later time points. The mindfulness-early abstinence association was mediated by lower negative affect, lower expectancies to regulate affect via smoking, and higher perceived social support. CONCLUSIONS: Results suggest that mindfulness might enhance smoking cessation among African American smokers by operating on mechanisms posited by prominent models of addiction.

Testing a Moderated Mediation Model of Mindfulness, Psychosocial Stress, and Alcohol Use among African American Smokers.

Mindfulness-based strategies have received empirical support for improving coping with stress and reducing alcohol use. The present study presents a moderated mediation model to explain how mindfulness might promote healthier drinking patterns. This model posits that mindfulness reduces perceived stress, leading to less alcohol use, and also weakens the linkage between stress and alcohol use. African American smokers (N = 399, 51% female, Mage = 42) completed measures of dispositional mindfulness, perceived stress, quantity of alcohol use, frequency of binge drinking, and alcohol use disorder symptoms. Participants with higher levels of dispositional mindfulness reported less psychosocial stress and lower alcohol use on all measures. Furthermore, mindfulness moderated the relationship between perceived stress and quantity of alcohol consumption. Specifically, higher perceived stress was associated with increased alcohol use among participants low, but not high, in mindfulness. Mindfulness may be one strategy to reduce perceived stress and associated alcohol use among African American smokers.

Coping Mediates the Association of Mindfulness with Psychological Stress, Affect, and Depression Among Smokers Preparing to Quit.

It is not surprising that smoking abstinence rates are low given that smoking cessation is associated with increases in negative affect and stress that can persist for months. Mindfulness is one factor that has been broadly linked with enhanced emotional regulation. This study examined baseline associations of self-reported trait mindfulness with psychological stress, negative affect, positive affect, and depression among 158 smokers enrolled in a smoking cessation treatment trial. Several coping dimensions were evaluated as potential mediators of these associations. Results indicated that mindfulness was negatively associated with psychological stress, negative affect and depression, and positively associated with positive affect. Furthermore, the use of relaxation as a coping strategy independently mediated the association of mindfulness with psychological stress, positive affect, and depression. The robust and consistent pattern that emerged suggests that greater mindfulness may facilitate cessation and attenuate vulnerability to relapse among smokers preparing for cessation. Furthermore, relaxation appears to be a key mechanism underlying these associations. The ClinicalTrials.gov identifier is NCT00297479.

Social support mediates the association of health literacy and depression among racially/ethnically diverse smokers with low socioeconomic status.

Nearly half of U.S. adults have health literacy (HL) difficulties, and lack the ability to effectively obtain, process, and understand health information. Poor HL is associated with depression, yet mechanisms of this relation are unclear. This study examined whether social support mediated the relation between HL and depressive symptoms in 200 low-socioeconomic status (SES), racially/ethnically diverse smokers enrolled in cessation treatment. Mediation analyses were conducted using bootstrapping and controlling for SES and nicotine dependence. In simple mediation models, social support [Interpersonal Support Evaluation List (ISEL) total, subscales (Appraisal, Belonging, Tangible)] mediated the effect of HL on depression, such that lower HL was associated with lower perceived support, which predicted higher depressive symptoms (ps < .05). A multiple mediation model, with ISEL subscales entered simultaneously as mediators, was significant (p < .05) but only the Belonging subscale demonstrating independent significance (p < .05). Thus, social support may be a critical factor underlying the HL-depression relationship in low-SES, racially/ethnically diverse smokers.

Lower health literacy predicts smoking relapse among racially/ethnically diverse smokers with low socioeconomic status.

BACKGROUND: Nearly half of U.S. adults have difficulties with health literacy (HL), which is defined as the ability to adequately obtain, process, and understand basic health information. Lower HL is associated with negative health behaviors and poor health outcomes. Racial/ethnic minorities and those with low socioeconomic status (SES) are disproportionately affected by poor HL. They also have higher smoking prevalence and more difficulty quitting smoking. Thus, lower HL may be uniquely associated with poorer cessation outcomes in this population. METHODS: This study investigated the association between HL and smoking cessation outcomes among 200, low-SES, racially/ethnically diverse smokers enrolled in smoking cessation treatment. Logistic regression analyses adjusted for demographics (i.e., age, gender, race/ethnicity, relationship status), SES-related characteristics (i.e., education, income), and nicotine dependence were conducted to investigate associations between HL and smoking relapse at the end of treatment (3 weeks post quit day). RESULTS: Results indicated that smokers with lower HL (score of < 64.5 on the Rapid Estimate of Adult Literacy in Medicine [REALM]) were significantly more likely than those with higher HL (score of ≥ 64.5 on the REALM) to relapse by the end of treatment, even after controlling for established predictors of cessation including demographics, SES, and nicotine dependence (OR = 3.26; 95% CI = 1.14, 9.26). CONCLUSIONS: Findings suggest that lower HL may serve as an independent risk factor for smoking relapse among low-SES, racially/ethnically diverse smokers enrolled in treatment. Future research is needed to investigate longitudinal relations between HL and cessation outcomes and potential mechanisms of this relationship.

Mindfulness predicts lower affective volatility among African Americans during smoking cessation.

Recent research suggests that mindfulness benefits emotion regulation and smoking cessation. However, the mechanisms by which mindfulness affects emotional and behavioral functioning are unclear. One potential mechanism, lower affective volatility, has not been empirically tested during smoking cessation. This study examined longitudinal associations among mindfulness and emotional responding over the course of smoking cessation treatment among predominantly low-socioeconomic status (SES) African American smokers, who are at high risk for relapse to smoking and tobacco-related health disparities. Participants (N = 399, 51% female, mean age = 42, 48% with annual income <$10,000) completed a baseline measure of trait mindfulness. Negative affect, positive affect, and depressive symptoms were assessed at five time points during smoking cessation treatment (up to 31 days postquit). Volatility indices were calculated to quantify within-person instability of emotional symptoms over time. Over and above demographic characteristics, nicotine dependence, and abstinence status, greater baseline trait mindfulness predicted lower volatility of negative affect and depressive symptoms surrounding the quit attempt and up to 1 month postquit, ps < 0.05. Although volatility did not mediate the association between greater mindfulness and smoking cessation, these results are the first to show that mindfulness is linked to lower affective volatility (or greater stability) of negative emotions during the course of smoking cessation. The present study suggests that mindfulness is linked to greater emotional stability and augments the study of mindfulness in diverse populations. Future studies should examine the effects of mindfulness-based interventions on volatility and whether lower volatility explains effects of mindfulness-based treatments on smoking cessation.

The Ask-Advise-Connect approach for smokers in a safety net healthcare system: a group-randomized trial.

BACKGROUND: Because smoking has a profound impact on socioeconomic disparities in illness and death, it is crucial that vulnerable populations of smokers be targeted with treatment. The U.S. Public Health Service recommends that all patients be asked about their smoking at every visit and that smokers be given brief advice to quit and referred to treatment. PURPOSE: Initiatives to facilitate these practices include the 5A's (ask, advise, assess, assist, arrange) and Ask-Advise-Refer (AAR). Unfortunately, primary care referrals are low, and most smokers referred fail to enroll. This study evaluated the efficacy of the Ask-Advise-Connect (AAC) approach to linking smokers with treatment in a large, safety net public healthcare system. DESIGN: The study design was a pair-matched group-randomized trial with two treatment arms. SETTING/PARTICIPANTS: Ten safety net clinics in Houston TX. INTERVENTION: Clinics were randomized to AAC (n=5; intervention) or AAR (n=5; control). Licensed vocational nurses (LVNs) were trained to assess and record the smoking status of all patients at all visits in the electronic health record. Smokers were given brief advice to quit. In AAC, the names and phone numbers of smokers who agreed to be connected were sent electronically to the Texas quitline daily, and patients were proactively called by the quitline within 48 hours. In AAR, smokers were offered a quitline referral card and encouraged to call on their own. Data were collected between June 2010 and March 2012 and analyzed in 2012. MAIN OUTCOME MEASURES: The primary outcome was impact, defined here as the proportion of identified smokers that enrolled in treatment. RESULTS: The impact (proportion of identified smokers who enrolled in treatment) of AAC (14.7%) was significantly greater than the impact of AAR (0.5%), t(4)=14.61, p=0.0001, OR=32.10 (95% CI=16.60, 62.06). CONCLUSIONS: The AAC approach to aiding smoking cessation has tremendous potential to reduce tobacco-related health disparities.

Neighborhood vigilance, health locus of control, and smoking abstinence.

OBJECTIVES: To examine whether health locus of control mediated relations of self-reported neighborhood vigilance and biochemically verified, continuous short-term smoking abstinence among 200 smokers enrolled in a cohort study. METHODS: A nonparametric bootstrapping procedure was used to assess mediation. RESULTS: Health locus of control-chance mediated relations between neighborhood vigilance and smoking abstinence in analyses adjusted for sociodemographics and tobacco dependence (p < .05). Greater vigilance was associated with greater attributions that health was affected by chance, which was associated with a lower likelihood of smoking abstinence. CONCLUSIONS: Results suggest that neighborhood perceptions influence residents' attributions for health outcomes, which can affect smoking abstinence.

Lifestyle and cancer prevention in women: knowledge, perceptions, and compliance with recommended guidelines.

BACKGROUND: Most women in the United States do not meet minimum recommendations for physical activity or fruit/vegetable consumption. Thus, many are overweight/obese and are at increased risk for cancer morbidity and mortality. This study investigated women's perceptions about the importance of physical activity and a healthy diet in preventing cancer, perceptions of engaging in these behaviors, and whether or not the behaviors met cancer prevention recommendations. METHOD: A cross-sectional, national, random-digit-dialed telephone survey was conducted with 800 women, ages 18 and older. The response rate was 24.5%. Measures assessed demographics, perceived health status, beliefs about the role of physical activity and diet in cancer prevention, perceived engagement in these behaviors, and actual behaviors. RESULTS: Only 9.9% of women who reported eating a healthy diet met minimum fruit and vegetable recommendations; 39.7% of women who reported regular physical activity met the minimum recommendation. Analyses adjusted for demographics indicated that low education was associated with reporting regular physical activity to prevent cancer, yet failing to meet the minimum recommendation (odds ratio [OR]=0.90, 95% confidence interval [CI]: 0.82-0.98, p=0.01). Racial/ethnic minority status was marginally significantly associated with reporting eating a healthy diet to prevent cancer, yet failing to consume sufficient fruits and vegetables (OR=2.94, 95% CI: 0.99-8.71, p=0.05). CONCLUSIONS: Most women who reported eating a healthy diet and being physically active to prevent cancer failed to meet the minimum cancer prevention recommendations. Furthermore, low socioeconomic status and racial/ethnic minority women may be particularly vulnerable to discrepancies between beliefs and behavior.

Associations between health literacy and established predictors of smoking cessation.

OBJECTIVES: We examined associations between health literacy and predictors of smoking cessation among 402 low-socioeconomic status (SES), racially/ethnically diverse smokers. METHODS: Data were collected as part of a larger study evaluating smoking health risk messages. We conducted multiple linear regression analyses to examine relations between health literacy and predictors of smoking cessation (i.e., nicotine dependence, smoking outcome expectancies, smoking risk perceptions and knowledge, self-efficacy, intentions to quit or reduce smoking). RESULTS: Lower health literacy was associated with higher nicotine dependence, more positive and less negative smoking outcome expectancies, less knowledge about smoking health risks, and lower risk perceptions. Associations remained significant (P < .05) after controlling for demographics and SES-related factors. CONCLUSIONS: These results provide the first evidence that low health literacy may serve as a critical and independent risk factor for poor cessation outcomes among low-socioeconomic status, racially/ethnically diverse smokers. Research is needed to investigate potential mechanisms underlying this relationship.

Ask-Advise-Connect: a new approach to smoking treatment delivery in health care settings.

IMPORTANCE: Several national health care-based smoking cessation initiatives have been recommended to facilitate the delivery of evidence-based treatments, such as quitline (telephone-based tobacco cessation services) assistance. The most notable examples are the 5 As (Ask, Advise, Assess, Assist, Arrange) and Ask. Advise. Refer. (AAR) programs. Unfortunately, rates of primary care referrals to quitlines are low, and most referred smokers fail to call for assistance. OBJECTIVE: To evaluate a new approach--Ask-Advise-Connect (AAC)--designed to address barriers to linking smokers with treatment. DESIGN: A pair-matched, 2-treatment-arm, group-randomized design in 10 family practice clinics in a single metropolitan area. Five clinics were randomized to the AAC (intervention) and 5 to the AAR (control) conditions. In both conditions, clinic staff were trained to assess and record the smoking status of all patients at all visits in the electronic health record, and smokers were given brief advice to quit. In the AAC clinics, the names and telephone numbers of smokers who agreed to be connected were sent electronically to the quitline daily, and patients were called proactively by the quitline within 48 hours. In the AAR clinics, smokers were offered a quitline referral card and encouraged to call on their own. All data were collected from February 8 through December 27, 2011. SETTING: Ten clinics in Houston, Texas. PARTICIPANTS: Smoking status assessments were completed for 42,277 patients; 2052 unique smokers were identified at AAC clinics, and 1611 smokers were identified at AAR clinics. INTERVENTIONS: Linking smokers with quitline-delivered treatment. MAIN OUTCOME MEASURE: Impact was based on the RE-AIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) conceptual framework and defined as the proportion of all identified smokers who enrolled in treatment. RESULTS: In the AAC clinics, 7.8% of all identified smokers enrolled in treatment vs 0.6% in the AAR clinics (t4 = 9.19 [P < .001]; odds ratio, 11.60 [95% CI, 5.53-24.32]), a 13-fold increase in the proportion of smokers enrolling in treatment. CONCLUSIONS AND RELEVANCE: The system changes implemented in the AAC approach could be adopted broadly by other health care systems and have tremendous potential to reduce tobacco-related morbidity and mortality.

Pathways linking socioeconomic status and postpartum smoking relapse.

BACKGROUND: Low socioeconomic status (SES) exacerbates the high rate of smoking relapse in women following childbirth. PURPOSE: This study examined multiple models of potential mechanisms linking SES and postpartum smoking relapse among women who quit smoking due to pregnancy. METHODS: Participants were 251 women enrolled in a randomized clinical trial of a new postpartum smoking relapse prevention intervention. Four models of the prepartum mechanisms linking SES and postpartum smoking relapse were evaluated using a latent variable modeling approach. RESULTS: Each of the hypothesized models were a good fit for the data. As hypothesized, SES indirectly influenced postpartum smoking relapse through increased prepartum negative affect/stress, reduced sense of agency, and increased craving for cigarettes. However, the model that included craving as the sole final pathway between SES and relapse demonstrated superior fit when compared with all other models. CONCLUSIONS: Findings have implications for future interventions that aim to reduce postpartum relapse.

Motivation and Problem Solving (MAPS): Motivationally Based Skills Training for Treating Substance Use.

Over 10 years ago, Baer and colleagues proposed the integration of skills training and motivational strategies for the treatment of substance abuse. Since that time, several studies evaluating the efficacy of such hybrid approaches have been published, but few have been efficacious. Motivation and Problem Solving (MAPS) is a comprehensive, dynamic, and holistic intervention that incorporates empirically supported cognitive behavioral and social cognitive theory-based treatment strategies within an overarching motivational framework, and has been demonstrated to be effective in a randomized clinical trial focused on the prevention of postpartum smoking relapse. MAPS was designed to be applicable to not only relapse prevention but also the cessation of substance use, and is relevant for individuals regardless of their motivation to change. MAPS views motivation as dynamically fluctuating from moment to moment throughout the behavior change process, and comprehensively addresses multiple issues important to the individual and relevant to change through the creation of a wellness program. As a result, we believe that MAPS enhances the likelihood that individuals will successfully achieve and maintain abstinence from substance use, and that its comprehensive focus on addressing diverse and salient issues enhances both engagement in treatment and its applicability in modifying other health risk behaviors. The current paper introduces MAPS, distinguishes it from other hybrid and stage-based substance use treatments, and provides detailed information and clinical text regarding how MAPS is specifically and uniquely implemented to address key mechanisms relevant to quitting smoking and maintaining abstinence.

A randomized controlled trial to assess the efficacy of an interactive mobile messaging intervention for underserved smokers: Project ACTION.

BACKGROUND: Despite a significant decrease in smoking prevalence over the past ten years, cigarette smoking still represents the leading cause of preventable morbidity and mortality in the United States. Moreover, smoking prevalence is significantly higher among those with low levels of education and those living at, or below, the poverty level. These groups tend to be confronted with significant barriers to utilizing more traditional smoking cessation intervention approaches. The purpose of the study, Project ACTION (Adult smoking Cessation Treatment through Innovative Outreach to Neighborhoods), is to utilize a mobile clinic model, a network of community sites (i.e., community centers and churches) and an interactive mobile messaging system to reach and deliver smoking cessation treatment to underserved, low-income communities. METHODS/DESIGN: We are using a group-randomized design, with the community site as the sampling unit, to compare the efficacy of three smoking cessation interventions: 1) Standard Care--brief advice to quit smoking, nicotine replacement therapy (NRT), and self-help materials; 2) Enhanced Care--standard care components plus a cell phone-delivered text/graphical messaging component; and 3) Intensive Care--enhanced care components plus a series of 11 cell phone-delivered proactive counseling sessions. An economic evaluation will also be performed to evaluate the relative cost effectiveness of the three treatment approaches. We will recruit 756 participants (252 participants in each of the 3 intervention groups). At the time of randomization, participants complete a baseline assessment, consisting of smoking history, socio-demographic, and psychosocial variables. Monthly cell phone assessments are conducted for 6 months-post enrollment, and a final 12-month follow-up is conducted at the original neighborhood site of enrollment. We will perform mixed-model logistic regression to compare the efficacy of the three smoking cessation intervention treatment groups. DISCUSSION: It is hypothesized that the intensive care approach will most successfully address the needs of the target population and result in the highest smoking cessation rates. In addition to increasing cessation rates, the intervention offers several features (including neighborhood outreach and use of mHealth technology) that are likely to reduce treatment barriers while enhancing participant engagement and retention to treatment. TRIAL REGISTRATION: This randomized controlled trial is registered with clinicaltrials.gov registration number NCT00948129.

Individual- and area-level unemployment influence smoking cessation among African Americans participating in a randomized clinical trial.

African Americans suffer disproportionately from the adverse health consequences of smoking, and also report substantially lower socioeconomic status than Whites and other racial/ethnic groups in the U.S. Although socioeconomic disadvantage is known to have a negative influence on smoking cessation rates and overall health, little is known about the influence of socioeconomic status on smoking cessation specifically among African Americans. Thus, the purpose of the current study was to characterize the impact of several individual- and area-level indicators of socioeconomic status on smoking cessation among African Americans. Data were collected as part of a smoking cessation intervention study for African American smokers (N = 379) recruited from the Houston, Texas, metropolitan area, who participated in the study between 2005 and 2007. The separate and combined influences of individual-level (insurance status, unemployment, education, and income) and area-level (neighborhood unemployment, education, income, and poverty) indicators of socioeconomic status on continuous smoking abstinence were examined across time intervals using continuation ratio logit modeling. Individual-level analyses indicated that unemployment was significantly associated with reduced odds of smoking abstinence, while higher income was associated with greater odds of abstinence. However, only unemployment remained a significant predictor of abstinence when unemployment and income were included in the model together. Area-level analyses indicated that greater neighborhood unemployment and poverty were associated with reduced odds of smoking abstinence, while greater neighborhood education was associated with higher odds of abstinence. However, only neighborhood unemployment remained significantly associated with abstinence status when individual-level income and unemployment were included in the model. Overall, findings suggest that individual- and area-level unemployment have a negative impact on smoking cessation among African Americans. Addressing unemployment through public policy and within smoking cessation interventions, and providing smoking cessation treatment for the unemployed may have a beneficial impact on tobacco-related health disparities.

Mediators of the association of major depressive syndrome and anxiety syndrome with postpartum smoking relapse.

OBJECTIVE: Based on conceptual models of addiction and affect regulation, this study examined the mechanisms linking current major depressive syndrome (MDS) and anxiety syndrome (AS) to postpartum smoking relapse. METHOD: Data were collected in a randomized clinical trial from 251 women who quit smoking during pregnancy. Simple and multiple mediation models of the relations of MDS and AS with postpartum relapse were examined using linear regression, continuation ratio logit models, and a bootstrapping procedure to test the indirect effects. RESULTS: Both MDS and AS significantly predicted postpartum smoking relapse. After adjusting for MDS, AS significantly predicted relapse. However, after adjusting for AS, MDS no longer predicted relapse. Situationally based self-efficacy, expectancies of controlling negative affect by means other than smoking, and various dimensions of primary and secondary tobacco dependence individually mediated the effect of both MDS and AS on relapse. In multiple mediation models, self-efficacy in negative/affective situations significantly mediated the effect of MDS and AS on relapse. CONCLUSIONS: The findings underscore the negative impact of depression and anxiety on postpartum smoking relapse and suggest that the effects of MDS on postpartum relapse may be largely explained by comorbid AS. The current investigation provided mixed support for affect regulation models of addiction. Cognitive and tobacco dependence-related aspects of negative and positive reinforcement significantly mediated the relationship of depression and anxiety with relapse, whereas affect and stress did not. The findings emphasize the unique role of low agency with respect to abstaining from smoking in negative affective situations as a key predictor of postpartum smoking relapse.