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Study Title and Description

Smoking relapse after 2 years of abstinence: findings from the VA Normative Aging Study.



Key Questions Addressed
1 For [population], is caffeine intake above [exposure dose], compared to intakes [exposure dose] or less, associated with adverse effects on behavior*?
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Primary Publication Information
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TitleData
Title Smoking relapse after 2 years of abstinence: findings from the VA Normative Aging Study.
Author EA Krall,AJ Garvey,RI Garcia,
Country
Year 2002
Numbers

Secondary Publication Information
There are currently no secondary publications defined for this study.


Extraction Form: Behavior - Design Details - INCLUDED Studies
Arms
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Design Details
Question... Follow Up Answer Follow-up Answer
Refid 11906685
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What outcome is being evaluated in this paper? Behavior
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What is the objective of the study (as reported by the authors)? The purposes of this analysis were (a) to estimate the rate of relapse after 2 or more years of abstinence, and (b) to identify social, demographic, and smoking behavior characteristics that are related to the risk of late smoking relapse in a cohort of men followed for more than three decades.
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Provide a general description of the methods as reported by the authors. Information should be extracted based on relevance to the SR (i.e., caffeine related methods) Subjects The subjects in this analysis were men who participated in the VA Normative Aging Study (NAS), a closed-panel prospective study of aging that was begun in the 1960s and is still ongoing (Bell, Rose, & Damon, 1966). Subjects gave informed consent on forms approved by the Subcommittee on Human Studies of the VA Boston Healthcare System. At the study baseline, the NAS enrolled 2280 men between the ages of 21 and 84 years who were free of chronic disease and lived in the greater Boston metropolitan area. Participants return to the study site approximately every 3 years, at which time they receive comprehensive clinical examinations and complete questionnaires. While the majority of the participants are veterans, they are not patients of the VA healthcare system and receive medical care from private health care providers. The mean age of participants at baseline was 41 ± 8 years and in 1999 was 73 ± 7 years (range = 54–97 years). This analysis includes only those 483 men who were cigarette smokers at the NAS baseline but quit at a subsequent examination. Measurements Smoking history was obtained by an interviewer administered questionnaire at the baseline examination. Data were collected about age at which the subject started smoking, current and maximum number of cigarettes per day, and use of cigars and pipes. At each subsequent examination, information on current status and dose of cigarettes, cigars and pipes was updated. Relapse was defined as a report of current cigarette use at one or more examinations following a report of having been a former smoker. In 1972 and 1976, study participants received mailed surveys that included additional questions on situations in which they smoked and reasons for quitting, if applicable. Subjects were asked to report the number of cigarettes smoked while having cocktails before dinner, during or after dinner when eating out or at home, and at mealtimes throughout the day. They were also asked if there were occasions when they smoked more than usual such as when drinking alcoholic beverages, when hungry, or at family functions. Additional information collected at each examination included body weight and height, marital status, and alcohol and caffeine consumption. Body weight was measured on a beam balance and current height measured with a stadiometer. Body mass index (BMI) was computed as the ratio of weight to the square of height (kg/ m2 ). Marital status was categorized as currently married or not. Information on alcohol and caffeine consumption was obtained from items on the Cornell Medical Index (Broadman, Erdmann, Lorge, & Wolff, 1949). The respective questions were, Do you usually take two or more alcoholic drinks a day? and Do you drink more than six cups of coffee or tea a day?More detailed alcohol data were obtained from questionnaires mailed at four separate times between 1983 and 1991. Subjects reported the number of drinks of alcohol (from beer, wine, and distilled spirits) typically consumed each day in the year preceding each mailed questionnaire. One drink was assumed to be equivalent to 12 ounces of beer, 4 ounces of wine, or 1.5 ounces of distilled spirits. These detailed data were available for 350 men who smoked at the NAS baseline and were still active participants on these dates. At the baseline examination, subjects reported their educational level and maximum adult weight prior to baseline. Education was dichotomized into completed college or not. Maximum body mass index was computed using baseline height and maximum adult weight. Statistical analysis T tests and x2 statistics were used to compare characteristics of men who relapsed to those who remained abstinent during follow-up. Characteristics of men that predicted the risk of smoking relapse were identified by stepwise proportional hazards regression analysis (SAS, Cary, NC, USA). Proportional hazards analysis estimates the likelihood of an event (smoking relapse) when the final status of the event is known for some subjects but unknown (censored) for others because they were either lost to followup or there is a possibility that the event could yet occur after the last time point used in the analysis. Subjects who did not relapse before their last available examination contributed information for as long as they were observed. In the models, the dependent variable was the number of years abstinent before relapse or the last available examination. Years abstinent were computed as the length of time from the quit date to either the first examination they reported smoking again, or the last available examination if never relapsed. The date of relapse was not reported. When a subject relapsed, it was not detected until the following examination so the period of abstinence was assumed to end at the midpoint between examinations. Because the average time between examinations was almost 4 years, it was not feasible to accurately measure smoking relapse within a period of less than 2 years. Independent variables considered for inclusion in the model were the age smoking began; duration smoked prior to quitting;
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How many outcome-specific endpoints are evaluated? 1
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What is the (or one of the) endpoint(s) evaluated? (Each endpoint listed separately) risk-taking behavior
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List additional health endpoints (separately).
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List additional health endpoints (separately)
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Notes smoking relapse
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Clinical
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Physiological
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Other
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What is the study design? Cohort
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Randomized or Non-Randomized?
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What were the diagnostics or methods used to measure the outcome? Objective
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Optional: Name of Method or short description Self-report of smoking relapse
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Caffeine (general)
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Coffee Coffee
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Chocolate
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Energy drinks
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Gum
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Medicine/Supplement
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Soda
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Tea
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Measured
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Self-report Self-report
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Children
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Adolescents
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Adults Adults
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Pregnant Women
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What was the reference, comparison, or control group(s)? (e.g. high vs low consumption, number of cups, etc.) high (> 6 cups/day) vs low consumption (≤ 6 cups/day)
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What were the listed confounders or modifying factors as stated by the authors? (e.g. multi-variable components of models.  Copy from methods) the age smoking began; duration smoked prior to quitting; maximum number of cigarettes smoked per day; baseline education; maximum BMI; change in weight after quitting smoking; presence of another smoker in the household; and most recent status of pipe/cigar use, marital status, and alcohol and coffee consumption from the Cornell Medical Index
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Provide a general description of results (as reported by the authors). In multivariate analysis in the total group of 483 men, factors that were significantly related to the risk of relapse were coffee consumption level (>six cups/day) and cigar or pipe smoking. However, in the subset of 350 men who completed the expanded alcohol questionnaires, alcohol intake of five drinks or more per day was a significant predictor of smoking relapse, along with coffee consumption (Risk Ratio = 2.33, 95% CI = 1.28-4.25) and cigar and pipe smoking (Table 2).
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Did the authors perform a dose-response analysis (or trend/related analysis)? No
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What were the authors's observations re: trend analysis?
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What were the author's conclusions? This study also identified some characteristics of men who relapse two or more years after quitting cigarettes. These characteristics were: (1) use of cigars and pipes, and (2) high levels of coffee and alcohol intake. We also observed an increased risk among men with high levels of coffee consumption, a habit that is strongly associated with cigarette use as well (Talcott, Poston, & Haddock, 1998). Predictors for late smoking relapse in this group of men were use of cigars and pipes, consumption of more than six cups of coffee per day, and consumption of five or more alcoholic drinks per day.
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What were the sources of funding? This study was supported by the Massachusetts Veterans Epidemiology Research and Information Center of the US Department of Veterans Affairs, and the National Institute on Drug Abuse (R01 DA 10073). Dr. Garcia is supported by a Career Development Award from the Health Services Research and Development Service, US Department of Veterans Affairs.
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What conflicts of interest were reported? N/A
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Does the exposure (dose) need to be standardized to the SR? Yes
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Provide calculations/conversions for the exposure based on the decision tree in the guide (for all endpoints/exposure levels of interest). 1 cup of coffee = 95 mg caffeine > 6 cups of coffee = > 570 mg caffeine
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List all the endpoint(s) followed by the dose (mg) which will be used in comparison to Nawrot.  Characterize value as LOAEL/NOAEL, etc. if possible.  Risk taking behavior (risk of smoking relapse) - LOAEL = > 570 mg/day
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Notes regarding selection/listing of endpoints and exposures/doses to be compared to Nawrot. poor exposure characterization, results may have counted tea along with coffee
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What is the importance of the study with respect to the adverseness of the outcome? Low
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