The Indexical Hypothesis suggests a new method for enhancing children's reading comprehension. Young readers may not consistently "index," or map, words to the objects the words represent. Consequently, these readers fail to derive much meaning from the text. The instructional method involves manipulating toy objects referred to in the text (e.g., a barn, a tractor, a horse, in a text about a farm) to simulate the actions described in the text. Correctly manipulating the objects forces indexing and facilitates the derivation of meaning. Both actual manipulation and imagined manipulation resulted in markedly better (compared with rereading) memory for and comprehension of the text material, thereby lending strong support to the Indexical Hypothesis.

The construct of tobacco dependence is important from both scientific and public health perspectives, but it is poorly understood. The current research integrates person-centered analyses (e.g., latent profile analysis) and variable-centered analyses (e.g., exploratory factor analysis) to understand better the latent structure of dependence and to guide distillation of the phenotype. Using data from four samples of smokers (including treatment and non-treatment samples), latent profiles were derived using the Wisconsin Inventory of Smoking Dependence Motives (WISDM) subscale scores. Across all four samples, results revealed a unique latent profile that had relative elevations on four dependence motive subscales (Automaticity, Craving, Loss of Control, and Tolerance). Variable-centered analyses supported the uniqueness of these four subscales both as measures of a common factor distinct from that underlying the other nine subscales, and as the strongest predictors of relapse, withdrawal and other dependence criteria. Conversely, the remaining nine motives carried little unique predictive validity regarding dependence. Applications of a factor mixture model further support the presence of a unique class of smokers in relation to a common factor underlying the four subscales. The results illustrate how person-centered analyses may be useful as a supplement to variable-centered analyses for uncovering variables that are necessary and/or sufficient predictors of disorder criteria, as they may uncover small segments of a population in which the variables are uniquely distributed. The results also suggest that severe dependence is associated with a pattern of smoking that is heavy, pervasive, automatic and relatively unresponsive to instrumental contingencies.

Trial (NLST) found a reduction in lung cancer mortality among participants screened with low-dose computed tomography vs chest radiography. In February 2015, Medicare announced its decision to cover annual lung screening for patients with a significant smoking history. These guidelines promote smoking cessation treatment as an adjunct to screening, but the frequency and effectiveness of clinician-delivered smoking cessation interventions delivered after lung screening are unknown.OBJECTIVE To determine the association between the reported clinician-delivered 5As (ask, advise, assess, assist [talk about quitting or recommend stop-smoking medications or recommend counseling], and arrange follow-up) after lung screening and smoking behavior changes. DESIGN, SETTING, AND PARTICIPANTSA matched case-control study (cases were quitters and controls were continued smokers) of 3336 NLST participants who were smokers at enrollment examined participants' rates and patterns of 5A delivery after a lung screen and reported smoking cessation behaviors. MAIN OUTCOMES AND MEASURESPrevalence of the clinician-delivered 5As and associated smoking cessation after lung screening.RESULTS Delivery of the 5As 1 year after screening were as follows: ask, 77.2%; advise, 75.6%; assess, 63.4%; assist, 56.4%; and arrange follow-up, 10.4%. Receipt of ask, advise, and assess was not significantly associated with quitting in multivariate models that adjusted for sociodemographic characteristics, medical history, screening results, nicotine dependence, and motivation to quit. Assist was associated with a 40% increase in the odds of quitting (odds ratio, 1.40; 95% CI, 1.21-1.63), and arrange was associated with a 46% increase in the odds of quitting (odds ratio, 1.46; 95% CI, 1.19-1.79). CONCLUSIONS AND RELEVANCEAssist and arrange follow-up delivered by primary care providers to smokers who were participating in the NLST were associated with increased quitting; less intensive interventions (ask, advise, and assess) were not. However, rates of assist and arrange follow-up were relatively low. Our findings confirm the need for and benefit of clinicians taking more active intervention steps in helping patients who undergo screening to quit smoking.

Internet interventions for smoking cessation are ubiquitous. Yet, to date, there are few randomized clinical trials that gauge their efficacy. This study is a randomized clinical trial (N= 284, n= 140 in the treatment group, n= 144 in the control group) of an Internet smoking cessation intervention. Smokers were randomly assigned to receive either bupropion plus counseling alone, or bupropion and counseling in addition to 12 weeks of access to the Comprehensive Health Enhancement Support System for Smoking Cessation and Relapse Prevention (CHESS SCRP; a Web site which provided information on smoking cessation as well as support). We found that access to CHESS SCRP was not significantly related to abstinence at the end of the treatment period (OR= 1.13, 95% CI 0.66-2.62) or at 6 months postquit (OR= 1.48, 95% CI 0.66-2.62). However, the number of times participants used CHESS SCRP per week was related to abstinence at both end of treatment (OR= 1.79, 95% CI 1.25-2.56) and at the 6-month follow-up (OR= 1.59, 95% CI 1.06-2.38). Participants with access to CHESS SCRP logged in an average of 33.64 times (SD=30.76) over the 90-day period of access. Rates of CHESS SCRP use did not differ by ethnicity, level of education or gender (all p>.05). In sum, results suggest that participants used CHESS SCRP frequently, CHESS SCRP use was related to success, but the effects in general did not yield intergroup effects.

IMPORTANCE Health care systems need effective models to manage chronic diseases like tobacco dependence across transitions in care. Hospitalizations provide opportunities for smokers to quit, but research suggests that hospital-delivered interventions are effective only if treatment continues after discharge. OBJECTIVE To determine whether an intervention to sustain tobacco treatment after hospital discharge increases smoking cessation rates over standard care. DESIGN A randomized controlled trial conducted from August 2010-November 2012 compared Sustained Care, a post-discharge tobacco cessation intervention, vs. Standard Care among hospitalized adult smokers who received a tobacco dependence intervention in the hospital and wanted to quit smoking after discharge. SETTING Massachusetts General Hospital, Boston, MA. PARTICIPANTS 397 hospitalized daily smokers (mean age 53 years, 48% male, 81% nonhispanic white). 92% of eligible patients and 44% of screened patients enrolled. INTERVENTION Sustained Care participants received automated interactive voice response telephone calls and their choice of free FDA-approved cessation medication for 90 days. The automated calls promoted cessation, provided medication management, and triaged smokers for additional counseling. Standard Care patients received recommendations for post-discharge pharmacotherapy and counseling. MAIN OUTCOMES Biochemically-validated past 7-day tobacco abstinence 6 months after discharge (primary outcome); self-reported tobacco abstinence and smoking cessation treatment use at 1, 3, and 6 months. RESULTS Smokers assigned to Sustained Care (n=198) used more counseling and more pharmacotherapy at each follow-up than those assigned to Standard Care (n=199). Biochemically-validated 7-day tobacco abstinence at 6 months was higher with Sustained Care than Standard Care (26% vs. 15%; RR 1.71, 95% CI 1.14–2.56, p=0.009; NNT=9.4, 95% CI 6.4–35.5). Using multiple imputation for missing outcomes, the RR was 1.55 (95%CI 1.03–2.21, p=0.038). Sustained Care also produced higher self-reported continuous abstinence rates for 6 months after discharge (27% vs. 16%; RR 1.70, 95% CI 1.15–2.51, p=0.007). CONCLUSION Among hospitalized adult smokers who planned to quit smoking, a post-discharge intervention providing automated telephone calls and free medication resulted in higher rates of smoking cessation at 6 months compared with a standard recommendation to use counseling and medication after discharge. These findings, if replicated, suggest an approach to help achieve sustained smoking cessation after a hospital stay.

Background Randomized efficacy clinical trials conducted in research settings may not accurately reflect the benefits of tobacco dependence treatments when used in real-world clinical settings. Effectiveness trials (e.g., in primary care settings) are needed to estimate the benefits of cessation treatments in real-world use. Methods 1346 primary care patients attending routine appointments were recruited by medical assistants in 12 primary care clinics. Patients were randomly assigned to five active pharmacotherapies: three monotherapies (Nicotine Patch, Nicotine Lozenge, and Bupropion SR) and two combination therapies (Patch+Lozenge and Bupropion+Lozenge). Patients were referred to a telephone quitline for cessation counseling. Primary outcomes included seven-day point-prevalence abstinence at one week, eight weeks, and six months post-quit, and number of days to relapse. Results Among 7128 eligible smokers (≥ 10 cigarettes per day) attending routine primary care appointments, 19% (N=1346) enrolled in the study. Six month abstinence rates were: Bupropion=16.8%; Lozenge=19.9%; Patch=17.7%; Patch+Lozenge=26.9%; and Bupropion+Lozenge=29.9%. Bupropion SR+Lozenge was superior to all of the monotherapies (odds ratios [ORs]: 0.46 to 0.56); Patch+Lozenge was superior to Patch and Bupropion monotherapies (ORs: 0.56 and 0.54, respectively). Conclusions One in five smokers attending a routine primary care appointment was willing to make a serious quit attempt that included evidence-based counseling and medication. In this comparative effectiveness study of five tobacco dependence treatments, combination pharmacotherapy significantly increased abstinence compared to monotherapies. Provision of free cessation medications plus quitline counseling arranged in the primary care setting holds promise for assisting large numbers of smokers to quit.

Background Contextual variables often predict long-term abstinence, but little is known about how these variables exert their effects. These variables could influence abstinence by affecting the ability to quit at all, or by altering risk of lapsing, or progressing from a lapse to relapse. Purpose To examine the effect of common predictors of smoking-cessation failure on smoking-cessation processes. Methods The current study (N = 1504, 58% female, 84% Caucasian; recruited from January 2005 to June 2007; data analyzed in 2009) uses the approach advocated by Shiffman et al., (2006), which measures cessation outcomes on three different cessation milestones (achieving initial abstinence, lapse risk, and the lapse-relapse transition) to examine relationships of smoker characteristics (dependence, contextual and demographic factors) with smoking-cessation process. Results High nicotine dependence strongly predicted all milestones: not achieving initial abstinence, and a higher risk of both lapse and transitioning from lapse to complete relapse. Numerous contextual and demographic variables were associated with higher initial cessation rates and/or decreased lapse risk at 6 months post-quit (e.g., ethnicity, gender, marital status, education, smoking in the workplace, number of smokers in the social network, and number of supportive others). However, aside from nicotine dependence, only gender significantly predicted the risk of transition from lapse to relapse. Conclusions These findings demonstrate that: (1) higher nicotine dependence predicted worse outcomes across every cessation milestone; (2) demographic and contextual variables are generally associated with initial abstinence rates and lapse risk and not the lapse-relapse transition. These results identify groups who are at risk for failure at specific stages of the smoking-cessation process, and this may have implications for treatment.

Background Continued smoking after cancer diagnosis may adversely affect treatment effectiveness, subsequent cancer risk, and survival. The prevalence of continued smoking following cancer diagnosis is understudied. Methods In the multi-regional Cancer Care Outcomes Research and Surveillance cohort (lung cancer [N=2456], colorectal cancer [N=3063]), we examined smoking rates at diagnosis and 5 months following diagnosis and factors associated with continued smoking. Results 90.2% of lung and 54.8% of colorectal cancer patients reported ever smoking. At diagnosis, 38.7% of lung cancer and 13.7% of colorectal cancer patients were smoking; 14.2% of lung cancer and 9.0% of colorectal cancer patients were smoking 5 months post-diagnosis. Factors associated with continued smoking among non-metastatic lung cancer patients were: Medicare, other public/unspecified insurance, not having chemotherapy, not having surgery, prior cardiovascular disease, lower body mass index, lower emotional support, and higher ever daily smoking rates (all p<.05). Factors independently associated with continued smoking among non-metastatic colorectal cancer patients were male sex, high school education, being uninsured, not having surgery, and higher ever daily smoking rates (all p<.05). Conclusion Following diagnosis, a substantial minority of lung and colorectal cancer patients continue smoking. Lung cancer patients had higher rates of smoking at diagnosis and following diagnosis; colorectal cancer patients were less likely to quit smoking following diagnosis. Factors associated with continued smoking differed between the two groups. Future smoking cessation efforts should examine differences by cancer type, particularly when comparing cancers for which smoking is a well established risk factor versus cancers for which it is not.