Defining a never-smoker: results from the nonsmokers survey

The U.S. Centers for Disease Control defines a never-smoker as someone who has smoked < 100 cigarettes per lifetime. In an attempt to explore differences among nonsmokers and to validate this cutpoint, we surveyed 69 nonsmokers who had smoked between 1 and 200 cigarettes in their lifetime on their experiences during the time they smoked. Of the 7 who classified themselves as ex-smokers, 2 met DSM-IV criteria for nicotine dependence, compared with none who classified themselves as never-smokers. No respondents provided data permitting the computation of a Fagerstrom Test for Nicotine Dependence (FTND) score. Withdrawal effects were minimal, but craving, tolerance, and subjective effects showed a pattern of significant differences that were most prominent between those who smoked only 1 cigarette and those who smoked at least a pack. Our data indicate a graded effect but also suggest that 19 cigarettes per lifetime is a more conservative cutpoint than 99 for defining the never-smoker phenotype. Further investigation of the smoking trajectory and characteristics associated with development of signs of dependence in never- vs. ever-smokers may help refine this cutpoint and shed light on what protects some people who experiment with smoking from becoming chronic users.

Relationship between early experiences with tobacco and early experiences with alcohol

Initial sensitivity to substances may affect patterns of future use and dependence. Because smoking and alcohol use are strongly linked, because animal studies indicate cross-sensitivity, and because genetic determinants of nicotine and alcohol dependence overlap, we studied the relationships between retrospectively reported responses to both substances in current smokers (n = 111) and never-smokers (n = 86). Early smoking experiences were correlated with comparable responses to alcohol in smokers, and to a lesser extent, in never-smokers. Both pleasurable early experiences with nicotine and pleasurable experiences with alcohol predicted current alcohol intake; pleasurable early experiences with alcohol also predicted alcohol dependence. Neither pleasurable nor displeasurable experiences with either substance predicted current amount smoked or degree of nicotine dependence. These preliminary findings may have implications for understanding the mechanisms underlying the smoking-alcohol link.

Nicotine metabolite ratio as a predictor of cigarette consumption

The rate of nicotine metabolism is hypothesized to be a determinant of how much a person smokes. That is, rapid metabolizers would be expected to need more nicotine and, therefore, smoke more than slow metabolizers. Nicotine is metabolized extensively by the liver enzyme CYP2A6, primarily to cotinine. Cotinine is itself metabolized by CYP2A6 to 3'-hydroxycotinine (3-HC). The ratio of metabolite to parent (i.e., 3-HC:cotinine) would be expected to reflect CYP2A6 activity. We measured the ratio of 3-HC:cotinine in the urine of 72 smokers. This ratio was significantly correlated with the number of cigarettes smoked per day (r=.33, p=.005), though not with the Fagerström Test for Nicotine Dependence. This finding supports the hypothesis that the rate of nicotine metabolism is a determinant of the level of cigarette consumption and supports the use of the 3-HC:cotinine ratio as a noninvasive marker of nicotine metabolism.

Development and validation of a self-rating scale for positive- and negative-reinforcement smoking: The Michigan Nicotine Reinforcement Questionnaire

Positive- and negative-reinforcement consequences of smoking were assessed using a self-report inventory. Data from 429 current smokers (348 women, 81 men) were subjected to an exploratory factor analysis, with concurrent validation of resulting scales in 288 current smokers (235 women, 53 men), controlling for sex and age. The solution with three factors--positive reinforcement, negative reinforcement, and smoking patterns--provided the clearest and most interpretable factor solution. The Michigan Nicotine Reinforcement Questionnaire (M-NRQ), which yields positive- and negative-reinforcement scales, was developed based on these results. Positive-reinforcement smoking was associated with higher scores on novelty seeking, reward dependence, alcohol dependence, and pleasurable sensations upon early smoking experimentation, and with lower scores on displeasurable sensations and nausea upon early smoking experimentation. Negative-reinforcement smoking was associated with higher scores for nicotine dependence, depression, anxiety, and harm avoidance. The M-NRQ has potential as a diagnostic tool for individualizing behavioral intervention and pharmacotherapy and also may be useful in identifying new phenotypes for genetic research on smoking.

Agreement between proband and parental self-report of smoking behavior and nicotine dependence

Although investigators have used family history methods to investigate familial clustering of disorders such as depressive disorder, alcoholism, coronary heart disease, and cancer, research of this type is relatively new to the field of smoking. We examined agreement between proband report of parental smoking behavior and parent's self-reported smoking behavior in 126 proband-parent pairs. Probands were either never, current, or exsmokers; parents were either current or exsmokers. Agreement between proband and parent was better for smoking behaviors when the parent was a current smoker. We found good proband-parent agreement for some smoking behaviors when the parent was a current smoker (e.g., age started smoking [mean (SD) difference between proband and parental report, 1.36 years (9.07 years)], and cigarettes per day and brand smoked [kappa=.49 and.56, respectively]) but poor agreement for items that may represent more complex or less observable indicators of nicotine dependence, regardless of parental smoking status. Reliability was excellent for probands of either current- or exsmoker parents for smoking status (kappa=.92). As a result of probands' difficulty in reliably answering several items that comprise the Fagerström Tolerance Questionnaire (FTQ) (e.g., number of minutes to parent's first cigarette of the day, whether parent smoked more in the morning than during the rest of the day) and the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) diagnosis (e.g., sleep difficulties and difficulty concentrating during nicotine withdrawal), reliability for an FTQ score >/=7 (kappa=.067) and the DSM-IV nicotine dependence diagnosis (kappa=.28) was poor. Our findings should aid investigators in defining the limits of proband reports of parental smoking behavior and identify opportunities for the development of better approaches for the assessment of familial nicotine dependence.

Smoking patterns and abstinence effects in smokers with no ADHD, childhood ADHD, and adult ADHD symptomatology

Cigarette smokers are known to be overrepresented among adults with Attention Deficit Hyperactivity Disorder (ADHD). To date, however, no attempt has been made to determine the extent to which a lifetime diagnosis of ADHD may be associated with smoking even in the absence of current symptomatology. We hypothesized that nicotine dependence and abstinence effects-especially effects relevant to ADHD symptomatology-would be more pronounced in adult ADHD smokers in comparison with those who reported childhood ADHD symptoms only. Results indicated that, in contrast to controls without ADHD symptomatology, both adult and childhood ADHD groups were significantly more likely to experience a number of nicotine withdrawal symptoms, including irritability and difficulty concentrating; in no instance did the ADHD groups differ from one another in this regard. Thus, studying people with childhood symptoms of ADHD, even in the absence of an adult diagnosis, may shed light on the known association between smoking and ADHD.

Prolonged nicotine patch use in quitters with past abstinence-induced depressed mood

To test the efficacy of sustained nicotine patch use among at-risk smokers, 55 smokers with a history of abstinence-induced depressed mood were randomly assigned to either Nicotine Maintenance or Standard Treatment following preliminary high-dose patch treatment. The Nicotine Maintenance group received 21 mg transdermal nicotine for 8 additional weeks; the Standard Treatment group followed a tapered dosing regimen. Significant differences favoring the Nicotine Maintenance group were found in self-reported craving but not withdrawal. No difference was observed in continuous abstinence or in relapse rates. When dropouts who did not relapse during patch use were classified as successful, however, the Nicotine Maintenance group had significantly lower relapse rates. Rate of lapse in the Nicotine Maintenance group during post-trial tapering did not differ significantly from that in the Standard Treatment group during tapering in the trial, suggesting that the benefits of sustained dosing may persist only as long as dosing continues.

Race differences in weight concerns among women smokers: results from two independent samples

To investigate attitudes about weight as they interact with smoking in African American women, we analyzed data from two independent samples of white and African American women smokers--one assembled via a national random-digit-dialing survey, the other consisting of candidates for enrollment in local studies. Findings for the two samples were remarkably consistent. African American women were significantly heavier and significantly more likely to have a self-reported BMI > or = 27. Although the preferred weight for African American women was significantly higher than for white women, the percentage by which they exceeded their preferred body weight did not differ significantly between groups, and the difference between actual and preferred weights was actually greater for African American women. African American women were more likely to be satisfied with their body shape and were significantly less likely to exercise to control weight. They did not differ significantly on binge-eating or dieting. African American women were more likely than white women to be unwilling to gain any weight upon quitting smoking but did not differ significantly on any other smoking-related weight concerns. Our results suggest that weight concerns, though differently conceptualized, may motivate African American women as powerfully as white women. They strongly suggest that race differences need to be considered in designing optimal smoking cessation interventions for weight-concerned women smokers. To accomplish this goal, efforts to identify a vocabulary for the expression of weight concerns in African American women will be needed, as will attention to ways to avoid exacerbating obesity and to encourage exercise.

Emergence of depression during early abstinence in depressed and non-depressed women smokers

The emergence of depression early in a quit attempt and its relationship to ability to maintain abstinence were studied in 99 depressed and non-depressed women smokers. Participants rated withdrawal symptomatology during a baseline week and the first two weeks of a quit attempt, during which they used a 21-mg nicotine patch and received behavioral counseling. Depressed women experienced greater difficulty maintaining early abstinence than non-depressed women. They were significantly more likely to smoke on the first day of abstinence and smoked marginally more days during the first week. Among participants who relapsed during the first two weeks, latency to relapse was significantly shorter for depressed women. Although craving and all withdrawal symptoms except insomnia showed significant increases over baseline, only depression showed significant group differences, with trend analyses suggesting that depression asymptotes in non-depressed women after the first week but continues increasing in depressed women. Larger increases in depression on the first day of abstinence were associated with earlier lapse. Because depression is relatively infrequent as a withdrawal symptom, it may not be a "true" withdrawal symptom except in depressed people. Identification of depressed smokers and anticipation of their increased need for support during this period may help to counteract the "first-day effect" and difficulties during early abstinence.

Who gets what symptom? Effects of psychiatric cofactors and nicotine dependence on patterns of smoking withdrawal symptomatology

The present study used logistic regression techniques to examine the extent to which depression, anxiety, disordered eating, and nicotine dependence increased risk of experiencing craving and the eight DSM-IV withdrawal symptoms (depressed mood, insomnia, irritability, anxiety, difficulty concentrating, restlessness, decreased heart rate, increased appetite) during smoking abstinence, assessed retrospectively. Data were provided by a racially diverse sample of 365 male and female smokers recruited to participate in laboratory studies. Results indicate that variables known to be associated with smoking are risk factors for distinct and only somewhat overlapping patterns of symptomatology. Smokers scoring high on measures of anxiety, depression, or disordered eating were at increased risk primarily of experiencing withdrawal symptomatology pathognomonic to their particular disorder, whereas smokers scoring high on nicotine dependence appeared to be at increased risk of experiencing a syndromal pattern of withdrawal, encompassing craving and insomnia as well as cognitive/affective symptoms. Our results support the possibility that some individuals use smoking as a form of self-medication and suggest that elucidation of patterns of withdrawal symptomatology may contribute to improved specification of smoking phenotypes as well as facilitate treatment-matching.

Effects of menstrual phase and smoking abstinence in smokers with and without a history of major depressive disorder

Although considerable progress has been made towards understanding the role of menstrual cycle phase in smoking, little is known about the possible effects of menstrual phase upon nicotine intake, withdrawal symptomatology, and craving in women with psychiatric cofactors. Fourteen women with and without a history of Major Depressive Disorder (MDD) were studied during five biologically-confirmed phases over the course of one menstrual cycle: smoking logs, salivary cotinine, and ratings of craving and withdrawal were collected daily. During a second cycle, subjects remained abstinent for 3 consecutive days during the postmenses and premenstrual phases. Although a significant omnibus F-test emerged for cigarettes per day across phases during ad libitum smoking, only trends were observed post hoc and supported midcycle rather than premenstrual elevations. There were no significant phase differences for cotinine. Withdrawal symptomatology was markedly elevated during smoking abstinence and in women with a history of depression. but showed no evidence of phase effects. Thus, the hypothesis that depressed individuals would be differentially affected by phase and abstinence was not strongly supported by our results, though overall elevations emphasize the need for special attention to withdrawal severity in this population. Craving was significantly elevated during smoking abstinence and was significantly higher during postmenses, consistent with the midcycle elevation in smoking rate, but showed no group differences. Our findings overall lend little support for the need to control for menstrual phase under conditions of ad libitum smoking. The strong association of self-reported menstrually related dysphoria during abstinence with both craving and withdrawal symptoms, however, is consistent with an exacerbation of smoking abstinence effects in women with severe menstrual symptomatology.

Short-term weight gain in abstaining women smokers

Although most studies of weight gain following smoking cessation assess long-term change, weight gain during the critical period immediately following cessation may be more salient to the smoker for whom fear of weight gain constitutes a serious barrier to cessation. The current study examined weight change in 20 highly dependent women smokers provided with monetary incentives to abstain for 1 week, along with concomitant changes in cotinine. Abstaining smokers (n = 7) gained 3.1 pounds, compared with 0.3 pounds in women who continued to smoke (n = 13). Across all subjects, change was significantly negatively correlated with final plasma cotinine concentration and marginally negatively correlated with percent cotinine reduction. Weight gain in women abstainers in the luteal phase of the menstrual cycle exceeded that in women abstainers in the follicular phase; a significant interaction such that continuing smokers showed no phase-related differences in weight suggests that the effect was not an artifact of perimenstrual increases in eating or fluid retention. Although long-term weight gain has been shown to be positively associated with success in quitting, little is known about the effects of short-term weight gain. Since many weight-concerned individuals either do not attempt to quit or terminate their quit attempts very early, it may be that if weight gain can be postponed beyond the first few fragile days of cessation, women with strong weight concerns may actually be good candidates for success.

Abstinence effects and reactivity to nicotine during 11 days of smoking deprivation

The purpose of the present study was to investigate smoking abstinence effects and the dissipation of tolerance (reactivity to nicotine) under controlled laboratory conditions. Seventeen male and female regular smokers were tested first in a session following ad libitum smoking and then in an additional five sessions over the course of 11 days during which they abstained from smoking. A metered dose of nicotine was administered via intranasal spray to ensure standard exposure, and pre- and post-dosing measures of heart rate, blood pressure, cortisol, galvanic skin response (GSR), craving, and several DSM-IV withdrawal symptoms (anxiety, irritability, restlessness, difficulty concentrating, and appetite) were collected. Prior to the nicotine test dose during deprivation sessions, heart rate and systolic blood pressure evinced elements of both an 'offset abstinence pattern' (deflection in a direction opposite to that produced by smoking) and a 'transient abstinence pattern' (deflection followed by a subsequent return); for cortisol, an offset pattern was observed, whereas for GSR and craving, a transient pattern was found. With respect to loss of tolerance, heart rate reactivity was found to increase significantly after 2 days' abstinence from nicotine, and the increase was sustained in subsequent sessions. Cortisol reactivity revealed more gradual dissipation, with significant differences evident only after 9 days of abstinence. These findings extend research on nicotine abstinence effects and on the dissipation of tolerance to nicotine deprivation intervals of nearly 2 weeks and confirm prior observations of variability across different response systems.

Initial exposure to nicotine in college-age women smokers and never-smokers: a replication and extension

Recent research suggests that people who become smokers may be more sensitive to the positive effects of nicotine upon initial exposure than those who do not take up smoking. The present study was designed to extend these findings to a sample of college-age women never-smokers and light smokers. Subjects were asked to rate pleasurable and displeasurable sensations upon first smoking and to indicate the presence or absence of pleasurable rush or buzz, relaxation, dizziness, nausea, and cough. Pleasurable sensations were marginally greater in smokers; pleasurable rush or buzz and dizziness were significantly more likely to be reported by smokers. Relaxation, displeasurable sensations, nausea, and cough did not differ significantly between groups. Fagerstrom Test for Nicotine Dependence scores significantly predicted pleasurable but not displeasurable sensations; Center for Epidemiological Studies-Depression scores predicted neither. These findings lend further support to the following conclusions: (1) people who become cigarette smokers experience more pleasurable sensations upon initial exposure to tobacco than their never-smoking counterparts; and (2) unpleasant reactions to the first cigarette do not protect against subsequent smoking.

Nicotine withdrawal and psychiatric symptoms in cigarette smokers with schizophrenia

The prevalence of smoking is markedly elevated in schizophrenia. Low smoking cessation rates and reports that some smokers with schizophrenia experience an acute increase in symptoms during attempts to quit smoking, suggest a self-medication model. Alternatively, smoking may modulate medication side effects. The effects of treated and untreated smoking abstinence on psychotic symptoms and medication side effects were examined in this study. Nineteen outpatients with schizophrenia or schizoaffective disorder participated in a randomized, double-blind, balanced crossover study: 1 day of ad libitum smoking followed by 3 days of acute smoking abstinence while wearing 22 mg/day active or placebo transdermal nicotine patches, with a return to 3 days of smoking between patch conditions. Daily symptom and side-effect ratings, nicotine and cotinine blood levels were collected. Twelve subjects completed the study. Neither positive symptoms nor mood symptoms changed. An increase in negative symptoms during the first abstinent day occurred in both placebo and active patch conditions, but was not sustained over subsequent abstinent days. Despite physiological signs of withdrawal, completers did not endorse increased nicotine withdrawal symptoms. Dropouts reported higher withdrawal symptoms, but also had no increase in psychiatric symptoms in either phase of the study. Of note, dyskinesias decreased during abstinence and placebo patch treatment, but increased during abstinence and the active patch conditions. Acute exacerbation of psychiatric symptoms is an unlikely explanation for any difficulty smokers with schizophrenia have in early abstinence.

Effects of menstrual phase on reactivity to nicotine

The possible impact of menstrual phase upon reactivity to nicotine was investigated in 12 healthy women smokers. Controlled doses of nicotine were administered via an intranasal aerosol delivery device to overnight-deprived women smokers in four hormonally verified menstrual phases. Physiological, biochemical, and subjective measures were collected. Cycle-related symptomatology differed significantly across phase, with lowest values during the mid-follicular phase. No significant differences were found for baseline variables, including withdrawal measures. Nicotine increment was stable across phase, confirming reliability of the dosing method. No significant menstrual phase differences were found for physiological, subjective, or biochemical responses to nicotine. Pending investigations conducted over longer intervals, in a wider variety of subjects; findings suggest that for this type of study, complex strategies to control for menstrual-cycle phase effects may be unnecessary.

Early experiences with tobacco among women smokers, ex-smokers, and never-smokers

AIMS

Recent research suggests that people who become smokers may be more sensitive to the positive effects of nicotine than those who do not take up smoking.

DESIGN AND SETTING

The present study was designed to investigate this hypothesis by querying initial experiences with cigarette smoking in smokers, ex-smokers and never-smokers recruited from the local community.

PARTICIPANTS

Subjects were 80 women (23 highly-dependent smokers (Fagerstrom Tolerance Questionnaire score > or = 7), 30 less-dependent smokers (FTQ < or = 6), 12 ex-smokers and 15 never-smokers).

MEASUREMENTS

Subjects were asked to rate pleasurable sensations and displeasurable sensations on a scale of 1 = none to 4 = intense, and to indicate the presence or absence of pleasurable rush or buzz, relaxation, dizziness, nausea and cough; social context was also queried. Pleasurable rush or buzz, relaxation, dizziness, nausea and cough were related to ratings of pleasurable and unpleasant sensations to establish their affective valence.

FINDINGS

Pleasurable sensations, pleasurable rush or buzz and relaxation (pleasant effects) were significantly more likely to occur in the smoker categories than in never-smokers. The ratio of pleasurable to unpleasant sensations, computed as an index of overall hedonic impact of initial exposure, also significantly favored the smoker categories. By contrast, unpleasant sensations, nausea and cough (unpleasant effects) did not differ significantly among groups. Dizziness, which did not definitely emerge as either pleasurable or unpleasant, was significantly more likely to be reported among the smoker groups than among never-smokers.

CONCLUSIONS

People who become highly dependent cigarette smokers appear to have more pleasurable sensations at their initial exposure to tobacco; unpleasant reactions to the first cigarette do not seem to protect against subsequent smoking.

Endogenous opioids and smoking: a review of progress and problems

The present report examines efforts to elucidate the role of opioid mechanisms in the reinforcement of smoking. A number of approaches have been used to evaluate nicotine-opioid interactions. Opiate agonists such as heroin or methadone have been found to increase cigarette smoking reliably in humans, and morphine has been shown to increase the potency and efficacy of nicotine in rats. There is also an extensive literature documenting the nicotine-stimulated release of endogenous opioids in various brain regions involved in the mediation of opiate reinforcement. Blockade studies using opioid antagonists have not been as conclusive. Although animal models have demonstrated commonalities between nicotine withdrawal and the opiate abstinence syndrome, including reversibility by morphine, and although the impact of nicotine on certain response systems such as respiratory reflexes has clearly been shown to involve opioid mediation, attempts to demonstrate opioid modulation for the key indicators of smoking reinforcement--cigarette consumption and nicotine self-administration--have been fraught with difficulty. Resolution of the apparent contradictions will require taking into account: (a) the biphasic properties of nicotine-opioid effects at higher doses and anti-opioid effects at lower doses; (b) the contributions of the opioid receptor populations--mu, kappa, sigma--stimulated at various dose levels; (c) the possibility that endogenous-opioid activity is entrained primarily during the acquisition or re-acquisition of nicotine self-administration; (d) the possibility that the endogenous opioid response does contribute to nicotine reinforcement but only as a delimited component of the neuroregulatory cascade of nicotine; and (e) the possibility that opioids contribute primarily to nicotine reinforcement under special conditions such as stress. Taking these considerations into account should allow studies on endogenous opioid effects to begin to do justice to the complexity of both smoking behavior and the actions of nicotine.

Self-reported alcohol use patterns in a sample of male and female heavy smokers

In an attempt to characterize differences among male and female smokers based on past and current alcohol use, we studied patterns of drinking, smoking, caffeine intake, and depression as a function of lifetime history of alcohol dependence and current drinking status in a community sample of current smokers. Subjects were 65 male and 152 female moderate-to-heavy smokers. The CAGE was used to screen for lifetime history of alcohol dependence; current drinking status was classified using self-reported number of alcoholic drinks/week. No significant differences were detected for smoking rate, scores on the Fagerstrom Test for Nicotine Dependence, or either coffee or total caffeine intake. Drinkers with a history of alcohol dependence drank significantly more per week than drinkers with no history, with significant gender differences and interaction effects emerging as well; the phenomenon was particularly pronounced in men. Drinkers of both genders with a history of alcohol dependence scored significantly higher on the Center for Epidemiological Studies-Depression scale, with means exceeding the cutoff of 16 associated with clinical depression. Since comorbidity of depression and alcohol dependence is known to exert a detrimental effect on ability to stop smoking, the number of individuals at risk for smoking cessation treatment failure may be much larger than might be inferred from data based on psychiatric assessments or collected in inpatient settings. Routine screening for depressive symptomatology combined with heavy alcohol use in primary care settings may therefore be helpful in identifying smokers in need of more intensive stop-smoking interventions.

Adult attention deficit hyperactivity disorder: psychological test profiles in a clinical population

Compared to attention deficit hyperactivity disorder (ADHD) in children, relatively little is known about the clinical characteristics of adults with persistent ADHD. We elected to use established tests with age-corrected norms to compare the battery of psychological and neuropsychological tests conducted on outpatients admitted to our Adult ADHD clinic. ADHD patients scored significantly higher than norms on the TPQ novelty seeking and harm avoidance scales and MMPI-2 scales F, 2, 4, 7, and 8. Further, these patients were impaired on the California verbal learning test, the attentional capacity test, and the omissions and variability subtests of the test of variables of attention. Adult ADHD had high comorbidity with current depressive disorder, antisocial personality disorder, and alcohol and drug abuse/dependence. High correlations were found between patients' and independent observers' reports of ADHD symptom severity. Implications for further research are discussed.