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All analyses were conducted using Stata version After undertaking the planned analyses we generated a Bayes factor from the difference in saliva cotinine, using an online calculator We were unable to identify any studies that investigated nicotine intake of concurrent smokers and NRT users in pregnancy, so an expected difference of In the SNIPP trial, women were assigned to the nicotine patch arm and women were assigned to the placebo patch arm.

In the nicotine patch arm, Overall, 12 women had missing cotinine data at this point and were excluded from the study, leaving a sample of for analysis in the nicotine group and in the placebo group.

When comparing SNIPP trial participants excluded from this study with those included, it was found that more women in this study had a partner who smoked. There were also significantly lower levels of craving, lower numbers of cigarettes smoked in the previous week and women's partners were reported to have smoked fewer cigarettes in both nicotine and placebo patch groups. This means that women assigned nicotine patches smoked less at week 2 compared to women assigned placebo patches.

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Interactions between the remaining indicators of smoking intensity and nicotine patch assignment were not significant. Upon further exploration it was discovered that there was an interaction between nicotine patch assignment and women with higher baseline cotinine concentrations Fig. The interaction tests found no significant interaction for nicotine patch assignment; however, graphical exploration found that there was a significant interaction for nicotine patch assignment and participants who reported smoking between and cigarettes a week at baseline Supporting information, Fig.

Our findings show that women prescribed nicotine patches but who also admitted smoking had similar cotinine concentrations to those generated when they only smoked. These women also reported smoking less and had lower expired air CO readings than when they smoked prior to their quit attempt.

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In comparison, smokers issued with placebo patches had lower cotinine concentrations than when smoking; they also showed reductions in numbers of cigarettes smoked and expired CO concentrations. Our results also indicate that women who smoke and use nicotine patches smoke less later in pregnancy. A limitation to our study is that, while we know that women included in this study were prescribed nicotine patches, we have very limited information about how much these were used. In SNIPP, women were defined as smokers if they had reported any smoking in the week prior to a study visit, and this was validated by an expired CO reading.

To our knowledge, there has been no previous study that has investigated smoking behaviour and CO exposure from concurrent use of nicotine patches and smoking in pregnancy. Hence, we believe this makes an original contribution to the field. Women's nicotine metabolic rates NMR increase as pregnancy progresses, and these would be expected to affect their plasma nicotine concentrations and so, potentially, also their cravings and intensity of smoking 13 , However, any effect would seem to be marginal as, even in the placebo group, women reported smoking fewer cigarettes.

It seems likely, therefore, that the differences reported reflect differences in smoking behaviour and not changes in women's physiology during pregnancy. Our study informs about cotinine concentrations in pregnant women who use nicotine patches but are not abstinent from smoking, and show that cotinine concentrations in such women were no higher than when they were smoking. Additionally, women included in this study had simultaneous and statistically significant reductions in their cigarette use, validated by a reduction in expired CO.

This suggests that when pregnant women use nicotine patches and smoke, they smoke less than they would if they were not using nicotine patches. This is important, as it could influence how women are advised to use NRT in pregnancy, i. We are unaware of any previous studies measuring cotinine or CO in smokers who concurrently use NRT during pregnancy.

Cotinine concentrations were In our study we found that women who were assigned the placebo patch but admitted to smoking also exhibited reduced cotinine concentrations compared to those when smoking alone. Despite this adjustment, there was no significant difference in cotinine concentrations in women who were assigned nicotine patches and admitted to smoking compared to those when smoking alone.

Our findings provide the first data we are aware of which quantifies pregnant women's smoking behaviour when using nicotine patches, and this suggests that when pregnant women use nicotine patches as part of a quit attempt, but also smoke, they smoke less than they did before the quit attempt started. This means that their exposure to the toxic products of burnt tobacco is reduced.

This suggests that clinicians can reassure women that it is alright to smoke and use nicotine patches if, ultimately, they are trying for abstinence. In conclusion, despite having similar cotinine exposure to that from cigarette smoking, pregnant women who use nicotine patches and smoke, smoke less and exhale less CO, so their exposure to other tobacco smoke toxins is also likely to be lower.

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If the address matches an existing account you will receive an email with instructions to retrieve your username. Research Report Open Access. Ravinder Claire Corresponding Author E-mail address: ravinder. Tools Request permission Export citation Add to favorites Track citation. Share Give access Share full text access. Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article.

Abstract Background and Aims Due to concerns about increased exposure to nicotine, pregnant women using nicotine replacement therapy NRT to stop smoking are usually advised to stop using NRT if they relapse to smoking.

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Figure 1 Open in figure viewer PowerPoint. The higher the total score, the more intense is the patient's physical dependence on cigarettes; i. At one point I observed to him that he is less likely than previous presidents to axiomatically side with Saudi Arabia in its dispute with its archrival, Iran. And that would be in the interest neither of the United States nor of the Middle East. One of the most destructive forces in the Middle East, Obama believes, is tribalism—a force no president can neutralize.

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While flying to Kuala Lumpur with the president, I recalled a passing reference he had once made to me about the Hobbesian argument for strong government as an antidote to the unforgiving state of nature. And if you look at the trajectory of history, I am optimistic. And what has been clear throughout the 20th and 21st centuries is that the progress we make in social order and taming our baser impulses and steadying our fears can be reversed very quickly. Social order starts breaking down if people are under profound stress.

And in those places, the Middle East being Exhibit A, the default position for a lot of folks is to organize tightly in the tribe and to push back or strike out against those who are different. The notion that we are a small group that defines ourselves primarily by the degree to which we can kill others who are not like us, and attempting to impose a rigid orthodoxy that produces nothing, that celebrates nothing, that really is contrary to every bit of human progress—it indicates the degree to which that kind of mentality can still take root and gain adherents in the 21st century.

I asked Obama whether he would have sent the Marines to Rwanda in to stop the genocide as it was happening, had he been president at the time. Obama-administration officials argue that he has a comprehensible approach to fighting terrorism: a drone air force, Special Forces raids, a clandestine CIA-aided army of 10, rebels battling in Syria.


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So why does Obama stumble when explaining to the American people that he, too, cares about terrorism? Does he fear a knee-jerk reaction in the direction of another Middle East invasion? Or is he just inalterably Spockian? I think we have to build resilience and make sure that our political debates are grounded in reality. The plane landed. The president, leaning back in his office chair with his jacket off and his tie askew, did not seem to notice.


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Outside, on the tarmac, I could see that what appeared to be a large portion of the Malaysian Armed Forces had assembled to welcome him. As he continued talking, I began to worry that the waiting soldiers and dignitaries would get hot. The stakes are too high to play those games. But those of us watching from the press section became distracted by news coming across our phones about a new jihadist attack, this one in Mali. Obama, busily mesmerizing adoring Asian entrepreneurs, had no idea.

Only when he got into his limousine with Susan Rice did he get the news. Later that evening, I visited the president in his suite at the Ritz-Carlton hotel in downtown Kuala Lumpur. The streets around the hotel had been sealed. Armored vehicles ringed the building; the lobby was filled with swat teams. Up two flights, to a hallway with more agents. His two-story suite was outlandish: Tara-like drapes, overstuffed couches.

It was enormous and lonely and claustrophobic all at once. When we sat down, I pointed out to the president a central challenge of his pivot to Asia. Earlier in the day, at the moment he was trying to inspire a group of gifted and eager hijab-wearing Indonesian entrepreneurs and Burmese innovators, attention was diverted by the latest Islamist terror attack.

The one that drew so much attention, I suggested, would ultimately be judged less consequential. This was the Gulf summit in May of at Camp David, meant to mollify a crowd of visiting sheikhs and princes who feared the impending Iran deal. This meeting took place only because John Kerry had pushed the White House to violate protocol, since the general secretary was not a head of state.

But the goals trumped decorum: Obama wanted to lobby the Vietnamese on the Trans-Pacific Partnership—his negotiators soon extracted a promise from the Vietnamese that they would legalize independent labor unions—and he wanted to deepen cooperation on strategic issues. Administration officials have repeatedly hinted to me that Vietnam may one day soon host a permanent U. I noted that the or so young Southeast Asians in the room earlier that day—including citizens of Communist-ruled countries—seemed to love America.

When we have strong relations with Indonesia, that helps us when we are going to Paris and trying to negotiate a climate treaty, where the temptation of a Russia or some of these other countries may be to skew the deal in a way that is unhelpful. The alba movement, a group of Latin American governments oriented around anti-Americanism, has significantly weakened during his time as president. Obama said that to achieve this rebalancing, the U. I had been under the impression that Obama viewed Putin as nasty, brutish, and short.

But, Obama told me, Putin is not particularly nasty.

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Our meetings are very businesslike. He never keeps me waiting two hours like he does a bunch of these other folks. So when I talked with the president in the Oval Office in late January, I again raised this question of deterrent credibility. Bush was overly rational or cautious in his use of military force. And the notion that somehow Russia is in a stronger position now, in Syria or in Ukraine, than they were before they invaded Ukraine or before he had to deploy military forces to Syria is to fundamentally misunderstand the nature of power in foreign affairs or in the world generally. Real power means you can get what you want without having to exert violence.

Russia was much more powerful when Ukraine looked like an independent country but was a kleptocracy that he could pull the strings on. I asked Obama whether his position on Ukraine was realistic or fatalistic. In what way did that strategy promote our interests? But what if Putin were threatening to move against, say, Moldova—another vulnerable post-Soviet state? Now, if there is somebody in this town that would claim that we would consider going to war with Russia over Crimea and eastern Ukraine, they should speak up and be very clear about it. The idea that talking tough or engaging in some military action that is tangential to that particular area is somehow going to influence the decision making of Russia or China is contrary to all the evidence we have seen over the last 50 years.

When you think of the military actions that Reagan took, you have Grenada—which is hard to argue helped our ability to shape world events, although it was good politics for him back home.