Relating individual differences in the reinforcing value of smoking and dependence severity to nicotine exposure levels in vulnerable populations

Cigarette smoking is overrepresented in populations with psychiatric conditions and socioeconomic disadvantage. Greater understanding of the role of reinforcement and nicotine dependence in smoking among vulnerable populations may facilitate development of better targeted interventions to reduce smoking. Prior research demonstrated that individual differences in the reinforcing value of smoking and nicotine-dependence severity predicted total nicotine-exposure in vulnerable populations. The present study uses multivariate regression to address two aims: (1) Quantify the degree to which the reinforcing value of smoking, assessed using the Cigarette Purchase Task (CPT), and dependence severity assessed using the Fagerström Test of Nicotine Dependence and Brief Wisconsin Inventory of Smoking Dependence Motives (B-WISDM) each account for individual differences in cotinine-plus-3'-hydroxycotinine (COT+3HC) levels. (2) Explore whether there is overlap in the variance accounted for by the CTP, FTND, and B-WISDM. Participants were 628 adults with co-morbid psychiatric conditions or socioeconomic disadvantage who smoked daily. The CPT, FTND, and B-WISDM models accounted for 23.76%, 32.45%, and 29.61% of the variance in COT+3HC levels, respectively. Adding CPT to the FTND model failed to increase the variance accounted for and adding it to the B-WISDM model did so by only 1.2% demonstrating considerable overlap in the variance in nicotine exposure levels accounted for by these three instruments. These results provide new knowledge on the relationship between individual differences in the reinforcing value of smoking and nicotine-exposure levels and suggest differences in reinforcing value may underpin a considerable portion of the variance in nicotine exposure accounted for by dependence severity.

A review of research on cigarette smoking in Preventive Medicine in recognition of the journal's 50th anniversary

This report reviews the literature on cigarette smoking published in Preventive Medicine over the past 50 years. The goal is twofold. First, to acknowledge the 50th anniversary of Preventive Medicine and its role in disseminating research on cigarette smoking by providing an abridged summary of smoking research published in the journal from inception through June 23, 2022. Second, to review experimental reports to identify contributions to innovations in tobacco control and regulatory efforts to reduce cigarette smoking. We searched PubMed using the search terms cigarette/cigarettes, tobacco products, smoking, smoking cessation, Preventive Medicine. Titles and abstracts were reviewed in duplicate, excluding reports not addressing cigarette smoking. Included reports were categorized by study type (original study, commentary, review). Experimental articles were assessed for impact using iCite, a National Institutes of Health web application that provides bibliometric information for articles in defined topic areas. The review identified 1181 articles on cigarette smoking: 1018 original studies (86.2%), 107 literature reviews (9.1%), and 56 commentaries (4.7%); 166 of the 1018 original studies (16%) were experimental reports. In the iCite analysis these 166 experimental articles received 6366 total citations, a mean (standard error) citation rate/article of 38.35 (±3.21) and mean relative citation ratio of 1.85 (±0.17) which is at the 73rd percentile for NIH-funded field- and time-normalized reports. Overall, this review demonstrates an ongoing and impactful contribution of Preventive Medicine to efforts to reduce cigarette smoking, the most preventable cause of premature death.

Predictors of Adherence Among Vulnerable Populations of Adults Assigned to Smoke Very Low Nicotine Content Cigarettes

INTRODUCTION

Regulators are considering reducing the nicotine content in cigarettes to a minimally addictive level. This could particularly benefit smokers from populations vulnerable to heavy smoking and difficulties quitting. We assessed predictors of adherence among adults from vulnerable populations assigned to use very low nicotine content cigarettes (VLNCs) in randomized clinical trials, to identify characteristics of those who require additional assistance if a nicotine reduction policy were implemented.

AIMS AND METHODS

Data came from three populations of vulnerable adult smokers assigned to use VLNC cigarettes (0.4 mg/g nicotine) during 12-week randomized controlled trials (n = 286): Socioeconomically disadvantaged women of reproductive age, opioid-maintained adults, and adults with affective disorders. Logistic and linear regressions modeled predictors of adherence based on changes in cotinine at week-6 and week-12 assessments relative to baseline, and as a 90% reduction in cotinine relative to baseline (full adherence: yes/no). Predictors included satisfaction with study cigarettes, craving, nicotine dependence severity, withdrawal, population membership, baseline affective-disorder symptoms, and sociodemographic characteristics.

RESULTS

Dependence severity was negatively associated with both adherence measures at week 6 (p < .01), whereas increased satisfaction with study cigarettes and age were positively associated with both measures at weeks 6 and 12 (p < .01). Opioid-maintained adults exhibited reduced adherence and were less likely to reach full adherence at week 12 compared to disadvantaged women (p = .02).

CONCLUSIONS

Factors associated with VLNC adherence in vulnerable populations are similar to those in the general population of smokers. Furthermore, studies are indicated investigating nicotine supplements (e.g., e-cigarettes, NRT) to support highly dependent adults faced with using VLNCs.

IMPLICATIONS

This study identified factors predicting difficulty maintaining adherence to a regimen of very low nicotine content cigarettes (VLNC) among adults from vulnerable populations. Findings suggested that factors predicting difficulty maintaining adherence (greater nicotine dependence and low satisfaction with study-provided VLNC) were common across vulnerable smokers and the general population of adults who smoke. Furthermore, research should investigate alternatives to support highly dependent adults, such as pairing VLNC with supplemental, noncombusted nicotine. Some vulnerable populations (e.g., opioid-maintained adults) may be especially in need of supplemental, noncombusted nicotine.

The Impact of the Covid-19 Pandemic on Smoking Among Vulnerable Populations

AIM

While accumulating evidence suggests that people modified their smoking during the ongoing COVID-19 pandemic, it remains unclear whether those most at risk for tobacco-related health disparities did so. The current study examined changes in smoking among several vulnerable smoker populations during the COVID-19 pandemic.

METHODS

A web-based survey was distributed in 2020 to 709 adults with socioeconomic disadvantage, affective disorders, or opioid use disorder who participated in a previous study investigating the effects of very low nicotine content (VLNC) cigarettes on smoking. Current smoking status and rate, and adoption of protective health behaviors in response to the pandemic (eg social distancing, mask wearing) were examined.

RESULTS

Among 332 survey respondents (46.8% response rate), 84.6% were current smokers. Repeated measures ANOVA showed that current cigarettes/day (CPD) was higher during COVID than pre-COVID (12.9 ± 1.0 versus 11.6 ± 1.0; p < .001). Most respondents had adopted protective health behaviors to prevent infection (>79% for all behaviors). More than half indicated that they were still leaving their homes specifically to buy cigarettes (64.6%) and were buying more packs per visit to the store (54.5%) than pre-COVID. Individuals unemployed at the time of the survey experienced greater increases in CPD (from 11.4 ± 1.4 to 13.3 ± 1.4, p = .024) as did those with higher levels of anxiety (from 11.5 ± 1.1 to 13.6 ± 1.1, p < .001).

CONCLUSIONS

Smoking increased during the COVID-19 pandemic in this sample of adults from vulnerable populations, even while most adopted protective health measures to prevent infection. Unemployment and anxiety might identify those at greatest risk for increases in tobacco use.

IMPLICATIONS

Individuals from populations especially vulnerable to smoking might be at risk for greater harm from cigarette smoking during times of pandemic-related stress. Public health interventions are warranted to ameliorate increases in smoking among these populations. Special attention should be paid to those experiencing unemployment and high anxiety.

Effect of Smartphone-Based Financial Incentives on Peripartum Smoking Among Pregnant Individuals: A Randomized Clinical Trial

This randomized clinical trial assesses the effect of a smartphone-based intervention with financial incentive on peripartum smoking among pregnant individuals.

Delay discounting and narcissism: A meta-analysis with implications for narcissistic personality disorder

Several psychiatric conditions (e.g., substance use, mood, and personality disorders) are characterized, in part, by greater delay discounting (DD)-a decision-making bias in the direction of preferring smaller, more immediate over larger, delayed rewards. Narcissistic personality disorder (NPD) is highly comorbid with substance use, mood, and other personality disorders, suggesting that DD may be a process underpinning risk for NPD as well. This meta-analysis examined associations between DD and theoretically distinct, clinically relevant dimensions of narcissism (i.e., grandiosity, entitlement, and vulnerability). Literature searches were conducted and articles were included if they were written in English, published in a peer-reviewed journal, contained measures of DD and narcissism and reported their association, and used an adult sample. Narcissism measures had to be systematically categorized according to clinically relevant dimensions (Grijalva et al., 2015; Wright & Edershile, 2018). Seven studies met inclusion criteria (N = 2,705). DD was positively associated with narcissism (r = .21; 95% confidence interval [.10, .32]), with this association being largely attributable to measures of trait grandiosity that were used in each study (r = .24; 95% confidence interval [.11, .37]). No studies included diagnostic NPD assessments. These findings provide empirical evidence that DD is related to trait narcissism and perhaps risk for NPD (e.g., grandiosity listed in Criterion B of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, alternative model of personality disorders). Considering the positive evidence from this review, and the dearth of research examining DD in individuals with NPD, investigators studying NPD may consider incorporating DD measures in future studies to potentially inform clinical theory and novel adjunctive treatment options. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Loss aversion and risk for cigarette smoking and other substance use

BACKGROUND

Cigarette smoking is among the leading preventable causes of global morbidity and mortality. We aimed to determine whether individual differences in loss aversion, a bias in decision-making wherein losses are valued greater than gains, predicts smoking and other addiction risk.

METHODS

We recruited current daily cigarette smokers (n = 181; > 10 cigarettes per day) and never-smokers (n = 237; < 100 cigarettes lifetime) from the United States using Amazon Mechanical Turk. Groups were matched on gender, educational attainment, and age. All completed items related to current cigarette smoking, alcohol use, other drug use, sleep problems, and depressed mood, and task-based measures of loss aversion and delay discounting, a decision-making bias associated with cigarette smoking.

RESULTS

Smokers were less loss averse than never-smokers (F(1, 411) = 24.19, η² = 0.02, p < .0001) even after accounting for delay discounting (F(1, 410) = 20.53, η² = 0.02, p < .0001). Loss aversion was also a significant independent risk factor for alcohol (F(1, 410) = 21.47, η² = 0.02, p < .0001) and other drug use (F(1, 410) = 54.12, η² = 0.04, p < .0001), although not other behavioral-health conditions (i.e., sleep disturbance, depressed mood). Further analyses revealed that co-occurring low loss aversion and high delay discounting were independently associated with greater risk for all patterns of substance use.

CONCLUSIONS

Loss aversion was associated with current cigarette smoking and other substance use patterns independent of delay discounting. Loss aversion may warrant attention as a protective factor and potential target for preventive intervention for substance use and addiction.

Effects of Reduced Nicotine Content Cigarettes on Fractional Exhaled Nitric Oxide and Self-Reported Respiratory Health Outcomes Among Smokers With Psychiatric Conditions or Socioeconomic Disadvantage

INTRODUCTION

This study examined whether exposure to reduced-nicotine-content cigarettes (RNCCs) for 12 weeks alters respiratory health using Fractional Exhaled Nitric Oxide (FeNO), a validated biomarker of respiratory epithelial health, and the Respiratory Health Questionnaire (RHQ), a subject-rated questionnaire on respiratory symptoms. Participants were 747 adult daily smokers enrolled in three double-blind, randomized clinical trials evaluating effects of cigarette nicotine content (0.4, 2.4, 15.8 mg nicotine/g tobacco) in people with affective disorders, opioid use disorder (OUD), or socioeconomic disadvantage.

AIMS AND METHODS

FeNO levels and RHQ ratings were collected at baseline and Weeks 6 and 12 following randomization. Multiple regression was used to assess associations of FeNO and RHQ with smoking characteristics. Mixed-model repeated-measures ANOVA was used to evaluate the effects of nicotine content on FeNO and RHQ outcomes over the 12-week study period.

RESULTS

FeNO levels but not RHQ ratings varied inversely with smoking characteristics at baseline (Ps < 0.0001) in smokers with affective disorders and socioeconomic disadvantage but less so in those with OUD. Participants with affective disorders and socioeconomic disadvantage, but not those with OUD, who were assigned to RNCCs had higher FeNO levels at Week 12 than those assigned to the 15.8 mg/g dose [F(2,423) = 4.51, p = .01, Cohen's d = 0.21]. No significant dose-related changes in RHQ scores were identified.

CONCLUSIONS

Use of RNCCs across a 12-week period attenuates smoking-related reductions in FeNO levels in smokers with affective disorders and socioeconomic disadvantage although not those with OUD. FeNO changes were not accompanied by changes in respiratory-health ratings.

TRIAL REGISTRATION

Inclusion and exclusion criteria for the sample and experimental manipulation of the nicotine content of assigned cigarettes are registered: NCT02232737, NCT02250664, NCT02250534. The FeNO measure reported in this manuscript is an exploratory outcome that was not registered.

IMPLICATIONS

Should a reduced nicotine content standard be implemented; these results suggest that reduced nicotine content in cigarettes will not exacerbate and instead may attenuate smoking-related decreases in FeNO. This is significant as NO is an important component in maintaining a healthy respiratory system and necessary to defend against infection. Furthermore, the results of the current study demonstrate that the adoption of the reduced nicotine content standard may result in beneficial impacts on respiratory epithelial health among vulnerable populations that are disproportionally affected by the adverse health outcomes precipitated by combustible tobacco use.

Smoking Cessation Prevalence and Inequalities in the United States: 2014-2019

BACKGROUND

Smoking is a leading cause of premature death and health inequities in the United States.

METHODS

We estimated cross-sectional prevalence of smoking cessation indicators among U.S. adult recent smokers (n = 43,602) overall and by sociodemographic subgroups in the Current Population Survey Tobacco Use Supplement 2014-2015 and 2018-2019 timepoints. Respondents reported past-year quit smoking interest, attempts, sustained (successful) cessation for ≥6 months, and use of e-cigarettes or behavioral/pharmacological cessation treatments to quit smoking.

RESULTS

Past-year quit smoking attempts declined slightly from 2014-2015 (52.9%) to 2018-2019 (51.3%) overall. Quit interest (pooled = 77.1%) and sustained cessation (pooled = 7.5%) did not change across timepoints. Among smokers making past-year quit attempts, 34.4% reported using cessation treatments in 2018-2019 and using e-cigarettes to quit smoking declined from 2014-2015 (33.3%) to 2018-2019 (25.0%). Several non-White (vs. White) racial and ethnic groups had higher prevalence of quit interest and attempts, but lower prevalence of sustained cessation or using e-cigarettes or treatments to quit. Income, education, employment, and metropolitan residence were positively associated with sustained cessation. Sociodemographic inequalities in sustained cessation and most other outcomes did not change across timepoints.

CONCLUSIONS

Although about half of U.S. adult smokers made past-year quit attempts from 2014-2019, only 7.5% reported sustained cessation and most who made quit attempts did not report using cessation treatments. Sociodemographic inequalities in cessation were pervasive and not entirely correspondent with sociodemographic variation in motivation to quit. Smoking cessation prevalence and inequalities did not improve from 2014-2019. Encouraging quit attempts and equitable access to smoking cessation aids are public health priorities.

Use of electronic nicotine delivery systems (ENDS) among U.S. women of reproductive age: Prevalence, reported reasons for use, and toxin exposure

Given the rapidly expanding marketplace for Electronic Nicotine Delivery Systems (ENDS), it is important to monitor patterns of use, particularly among vulnerable populations. This study examined ENDS prevalence, reasons for use (i.e., to help quit smoking and for appealing flavors), and toxin exposure among U.S. women of reproductive age using data from the Population Assessment of Tobacco and Health (PATH) Study (2013-17). Exclusive ENDS users, dual users of ENDS and cigarettes, and exclusive cigarette smokers were compared within and between pregnant and not-pregnant women. Among pregnant women, prevalence of exclusive ENDS and dual use was similar (0.8%; 95%CI = 0.4-1.2% vs. 1.4%; 95%CI = 0.9-2.0%, respectively), but exclusive ENDS use was less prevalent than dual use among not-pregnant women (1.1%; 95%CI = 0.9-1.4% vs. 3.7%; 95%CI = 3.3-4.0%, respectively). Most women reported ENDs were used to help quit smoking (66.5-90.0%) and for appealing flavors (57.6-87.4%), and endorsement rates did not differ by use pattern or pregnancy status. Except for metals, toxin exposure was substantially lower for exclusive ENDS users relative to dual users and exclusive cigarette smokers regardless of pregnancy status. Pregnant and not-pregnant U.S. women regularly report using ENDS for help with quitting smoking and for appealing flavors. Although no type or pattern of tobacco/nicotine use is safe, especially during pregnancy, using ENDS exclusively is consistent with lower overall toxin exposure for pregnant and not-pregnant women. This study advances understanding of ENDS use and toxin exposure in women of reproductive age, a population highly vulnerable to the effects of nicotine/tobacco consumption.

Behavior change, health, and health disparities 2021: Rural addiction and health

This Special Issue of Preventive Medicine (PM) is the 8th in a series on behavior change, health, and health disparities. This is a topic of critical importance to improving U.S. population health. There is broad consensus that personal behavior patterns or lifestyle such as substance abuse, poor food choices, physical inactivity, and non-adherence with medical regimens are among the most important modifiable causes of chronic disease and premature death and contributors to recent decreases in U.S. longevity. While no U.S region is free of these problems, they disproportionately impact rural communities. As in prior Special Issues in this series, we devote considerable space to the ongoing U.S. opioid epidemic while also examining selected issues in rural health disparities involving tobacco use, cancer, and cardiovascular disease. Across each of these topics we have recruited contributions from accomplished investigators, clinicians, and policymakers to acquaint readers with recent advances while also noting knowledge gaps and unresolved challenges.

Cumulative vulnerabilities as a potential moderator of response to reduced nicotine content cigarettes

Risk for smoking increases in a summative manner corresponding to the number of co-occurring vulnerabilities present (cumulative vulnerability). We examined whether cumulative vulnerabilities moderate response to reduced nicotine content cigarettes in a secondary analysis of results from 775 participants in three 12-week randomized clinical trials examining research cigarettes varying in nicotine content (0.4, 2.4, 15.8 mg nicotine/g tobacco). Participants were categorized as having 0-1, 2-3, or ≥ 4 cumulative vulnerabilities. Vulnerabilities included: rural residence, current substance use disorder, current affective disorder, low educational attainment, poverty, unemployment, physical disability. The primary outcome was total cigarettes per day (CPD) during Week 12; secondary outcomes included CPD across weeks, toxin exposure, dependence severity, craving/withdrawal (17 dependent measures). Results were analyzed using repeated measures analysis of covariance and growth-curve modeling. Total CPD during Week 12 increased as cumulative-vulnerability increased (P = 0.004), and decreased as nicotine content decreased (P < 0.001), with no significant interaction of cumulative vulnerability and dose (P = 0.67). Effects on other outcomes generally followed that same pattern. The only exception across the other outcomes was on Questionnaire-on-Smoking-Urges Factor-2 ratings for usual-brand cigarettes where cumulative vulnerability, dose, and time interacted (P = 0.007), with craving at the 0.4 and 2.4 mg/g doses decreasing over time, but inconsistently across vulnerability categories. Overall, we saw little evidence that cumulative vulnerabilities moderate response to reduced nicotine content cigarettes suggesting that a policy reducing nicotine content in cigarettes to minimally addictive levels could benefit even highly vulnerable smokers including those residing in rural or other regions with overrepresentation of co-occurring vulnerabilities. Clinicaltrials.gov identifiers: NCT02232737, NCT02250664, NCT02250534.

Efficacy and Cost-Benefit of Onsite Contraceptive Services With and Without Incentives Among Women With Opioid Use Disorder at High Risk for Unintended Pregnancy: A Randomized Clinical Trial

IMPORTANCE

Rates of in utero opioid exposure continue to increase in the US. Nearly all of these pregnancies are unintended but there has been little intervention research addressing this growing and costly public health problem.

OBJECTIVE

To test the efficacy and cost-benefit of onsite contraceptive services with and without incentives to increase prescription contraceptive use among women with opioid use disorder (OUD) at high risk for unintended pregnancy compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial of 138 women ages 20 to 44 years receiving medication for OUD who were at high risk for an unintended pregnancy at trial enrollment between May 2015 and September 2018. The final assessment was completed in September 2019. Data were analyzed from October 2019 to March 2021. Participants received contraceptive services at a clinic colocated with an opioid treatment program.

INTERVENTIONS

Participants were randomly assigned to receive 1 of 3 conditions: (1) usual care (ie, information about contraceptive methods and community health care facilities) (n = 48); (2) onsite contraceptive services adapted from the World Health Organization including 6 months of follow-up visits to assess method satisfaction (n = 48); or (3) those same onsite contraceptive services plus financial incentives for attending follow-up visits (n = 42).

MAIN OUTCOMES AND MEASURES

Verified prescription contraceptive use at 6 months with a cost-benefit analysis conducted from a societal perspective.

RESULTS

In this randomized clinical trial of 138 women (median age, 31 years [range, 20-44 years]), graded increases in verified prescription contraceptive use were seen in participants assigned to usual care (10.4%; 95% CI, 3.5%-22.7%) vs contraceptive services (29.2%; 95% CI, 17.0%-44.1%) vs contraceptive services plus incentives (54.8%; 95% CI, 38.7%-70.2%) at the 6-month end-of-treatment assessment (P < .001 for all comparisons). Those effects were sustained at the 12-month final assessment (usual care: 6.3%; 95% CI, 1.3%-17.2%; contraceptive services: 25.0%; 95% CI, 13.6%-39.6%; and contraceptive services plus incentives: 42.9%; 95% CI, 27.7%-59.0%; P < .001) and were associated with graded reductions in unintended pregnancy rates across the 12-month trial (usual care: 22.2%; 95% CI, 11.2%-37.1%; contraceptive services: 16.7%; 95% CI, 7.0%-31.4%; contraceptive services plus incentives: 4.9%; 95% CI, 0.6%-15.5%; P = .03). Each dollar invested yielded an estimated $5.59 (95% CI, $2.73-$7.91) in societal cost-benefits for contraceptive services vs usual care, $6.14 (95% CI, $3.57-$7.08) for contraceptive services plus incentives vs usual care and $6.96 (95% CI, $0.62-$10.09) for combining incentives with contraceptive services vs contraceptive services alone.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, outcomes with both onsite contraceptive service interventions exceeded those with usual care, but the most efficacious, cost-beneficial outcomes were achieved by combining contraceptive services with incentives. Colocating contraceptive services with opioid treatment programs offers an innovative, cost-effective strategy for preventing unintended pregnancy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02411357.

Contingency Management for Patients Receiving Medication for Opioid Use Disorder: A Systematic Review and Meta-analysis

Importance

Medication treatment for opioid use disorder (MOUD) is efficacious, but comorbid stimulant use and other behavioral health problems often undermine efficacy.

Objective

To examine the association of contingency management, a behavioral intervention wherein patients receive material incentives contingent on objectively verified behavior change, with end-of-treatment outcomes for these comorbid behavioral problems.

Data Sources

A systematic search of PubMed, Cochrane CENTRAL, Web of Science, and reference sections of articles from inception through May 5, 2020. The following search terms were used: vouchers OR contingency management OR financial incentives.

Study Selection

Prospective experimental studies of monetary-based contingency management among participants receiving MOUD.

Data Extraction and Synthesis

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline, 3 independent investigators extracted data from included studies for a random-effects meta-analysis.

Main Outcomes and Measures

Primary outcome was the association of contingency management at end-of-treatment assessments with 6 clinical problems: stimulant use, polysubstance use, illicit opioid use, cigarette smoking, therapy attendance, and medication adherence. Random-effects meta-analysis models were used to compute weighted mean effect size estimates (Cohen d) and corresponding 95% CIs separately for each clinical problem and collapsing across the 3 categories assessing abstinence and the 2 assessing treatment adherence outcomes.

Results

The search identified 1443 reports of which 74 reports involving 10 444 unique adult participants met inclusion criteria for narrative review and 60 for inclusion in meta-analyses. Contingency management was associated with end-of-treatment outcomes for all 6 problems examined separately, with mean effect sizes for 4 of 6 in the medium-large range (stimulants, Cohen d = 0.70 [95% CI, 0.49-0.92]; cigarette use, Cohen d = 0.78 [95% CI, 0.43-1.14]; illicit opioid use, Cohen d = 0.58 [95% CI, 0.30-0.86]; medication adherence, Cohen d = 0.75 [95% CI, 0.30-1.21]), and 2 in the small-medium range (polysubstance use, Cohen d = 0.46 [95% CI, 0.30-0.62]; therapy attendance, d = 0.43 [95% CI, 0.22-0.65]). Collapsing across abstinence and adherence categories, contingency management was associated with medium effect sizes for abstinence (Cohen d = 0.58; 95% CI, 0.47-0.69) and treatment adherence (Cohen d = 0.62; 95% CI, 0.40-0.84) compared with controls.

Conclusions and Relevance

These results provide evidence supporting the use of contingency management in addressing key clinical problems among patients receiving MOUD, including the ongoing epidemic of comorbid psychomotor stimulant misuse. Policies facilitating integration of contingency management into community MOUD services are sorely needed.

Household-smoking bans are associated with reduced nicotine exposure, increased smoking abstinence, and improved birth outcomes among pregnant women enrolled in smoking-cessation treatment

Data indicate household-smoking bans aid cessation and reduce secondhand smoke exposure. This study assessed prevalence of antepartum (AP) and postpartum (PP) household-smoking bans and associations with nicotine exposure, abstinence, and birth weight among pregnant women. The current study is a secondary analysis of clinical trials examining the efficacy of financial incentives for smoking-cessation among pregnant women (N = 284). Participants were current smokers at the start of prenatal care and followed from ∼10 weeks gestational age through 24 weeks PP. Household-smoking rules and biochemically verified urinary cotinine were measured repeatedly. Nicotine exposure and birth weight were analyzed using analysis of covariance. Association with abstinence was analyzed using backward elimination logistic regressions. Prevalence of household-smoking bans increased from ∼ 45% to 55% AP and then increased to ∼80% PP. Women with a ban exhibited lower nicotine exposure in early and late pregnancy compared to smokers without a ban. Women with a ban at baseline or who adopted a ban early in treatment were more likely to be abstinent at late pregnancy and 24 weeks PP compared to women without a ban. There was a dose-response relationship between combined exposure (i.e., smoking and ban status) and infant birth weight, with infants of women who quit and reported a ban having the highest adjusted mean birth weight (3426 ± 63 g), while infants of women who continued smoking without a ban having the lowest (3153 ± 37 g). These results provide an empirical rationale for prospectively investigating whether adopting a household-smoking ban can reduce fetal exposure among pregnant smokers. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Looking to the empirical literature on the potential for financial incentives to enhance adherence with COVID-19 vaccination

COVID-19 vaccination efforts are underway offering hope for saving lives and eliminating the pandemic. The most promising vaccines require two injections separated 3-4 weeks apart. To achieve heard immunity, 70-90% of the population or perhaps more must be inoculated. Anticipation of adherence challenges has generated commentaries on strategies to enhance adherence including financial incentives. A notable gap in these commentaries is any discussion of the scientific evidence regarding the efficacy of financial incentives for increasing vaccine adherence. This commentary addresses that gap. There is a body of controlled trials on incentivizing vaccine adherence, mostly to the hepatitis B virus (HBV) vaccine among injection drug users (IDUs). Prevalence of HBV infection is increasing as part of the opioid addiction crisis. The HBV vaccine entails a three-dose regimen (typically 0, 1, and 6 months) which has created adherence challenges among IDUs. Systematic literature reviews document significant benefit of financial incentives. For example, a 2019 meta-analysis (Tressler & Bhandari, 2019) examined 11 controlled trials examining HBV-vaccine adherence strategies, including financial incentives, accelerated dosing schedules, and case-management/enhanced services. Financial incentives were most effective resulting in a 7-fold increase in adherence to the vaccination regimen relative to no financial incentives (OR, 7.01; 95% CI, 2.88-17.06). Additional reviews provide further support for the efficacy of financial incentives for promoting adherence with vaccination (HBV & influenza). Overall, this literature suggests that financial incentives could be helpful in promoting the high levels of adherence to COVID-19 vaccines that experts project will be necessary for herd immunity.

Neural Correlates of Adolescent Irritability and Its Comorbidity With Psychiatric Disorders

OBJECTIVE

Irritable mood, a common and impairing symptom in psychopathology, has been proposed to underlie the developmental link between oppositional problems in youth and depression in adulthood. We examined the neural correlates of adolescent irritability in IMAGEN, a sample of 2,024 14-year-old adolescents from 5 European countries.

METHOD

The Development and Well-Being Assessment (DAWBA) was used to assess attention-deficit/hyperactivity disorder, major depressive disorder, oppositional defiant disorder, and generalized anxiety disorder. Three items from the DAWBA, selected as close matches to the Affective Reactivity Index, were used to assess irritability. Structural magnetic resonance imaging was examined using whole-brain voxel-based morphometry analysis, and functional magnetic resonance imaging was examined during a stop signal task of inhibitory control. Imaging data were included in structural equation models to examine the direct and indirect associations between irritable mood and comorbid DSM diagnoses.

RESULTS

Whole-brain voxelwise analysis showed that adolescent irritable mood was associated with less gray matter volume and less neural activation underlying inhibitory control in frontal and temporal cortical areas (cluster-correction at p < .05). Structural equation models suggested that part of the observed smaller gray matter volume was exclusively driven by irritability separate from direct relationships between generalized anxiety disorder (or attention-deficit/hyperactivity disorder, major depressive disorder, or oppositional defiant disorder) and gray matter volume.

CONCLUSION

This study identifies adolescent irritability as an independent construct and points to a neurobiological correlate to irritability that is an important contributing feature to many psychopathological disorders.

Behavioral economic measurement of cigarette demand: A descriptive review of published approaches to the cigarette purchase task

The cigarette purchase task (CPT) is a behavioral economic method for assessing demand for cigarettes. Growing interest in behavioral correlates of tobacco use in clinical and general populations as well as empirical efforts to inform policy has seen an increase in published articles employing the CPT. Accordingly, an examination of the published methods and procedures for obtaining these behavioral economic metrics is timely. The purpose of this investigation was to provide a review of published approaches to using the CPT. We searched specific Boolean operators (["behavioral economic" AND "purchase task"] OR ["demand" AND "cigarette"]) and identified 49 empirical articles published through the year 2018 that reported administering a CPT. Articles were coded for participant characteristics (e.g., sample size, population type, age), CPT task structure (e.g., price framing, number and sequence of prices; vignettes, contextual factors), and data analytic approach (e.g., method of generating indices of cigarette demand). Results of this review indicate no standard approach to administering the CPT and underscore the need for replicability of these behavioral economic measures for the purpose of guiding clinical and policy decisions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Using the Cigarette Purchase Task to examine the relative reinforcing value of cigarettes among mothers with versus without opioid dependence

The Cigarette Purchase Task (CPT), in which participants estimate the number of cigarettes they would smoke across increasing cigarette prices, measures the relative reinforcing value of cigarettes. Although opioid-dependent individuals are particularly vulnerable to tobacco addiction, more research is needed to elucidate whether and to what extent their motivation to smoke differs from not-opioid-dependent smokers controlling for potential sociodemographic differences. Participants were 173 women (65 opioid-dependent) in an ongoing clinical trial for smoking cessation. Baseline CPT responses were compared between opioid-dependent and not-opioid-dependent women using five demand indices: Demand Intensity; O_max; P_max; Breakpoint (BP); and α, and two latent factors: Amplitude and Persistence. Final regression models adjusted for sociodemographic characteristics differing between the two groups. Opioid-dependent women had greater demand Intensity (i.e., number of cigarettes they would smoke if they were free) than not-opioid dependent women in the adjusted model, F(1, 156) = 6.93, p = .016. No other demand indices differed significantly. Regarding latent factors, demand Amplitude (i.e., volumetric consumption), but not Persistence (i.e., price insensitivity), was greater for opioid-dependent women in the adjusted model, F(1, 146) = 4.04, p = .046. These results further demonstrate that the CPT is a highly sensitive task that can illuminate potentially important individual and population differences in the relative reinforcing value of smoking. Greater demand Intensity and Amplitude differentiated smokers with comorbid opioid dependence; thus, decreasing smoking prevalence among opioid-dependent populations may require policies and interventions that can decrease cigarette demand Intensity and Amplitude. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Investigating tobacco withdrawal in response to reduced nicotine cigarettes among smokers with opioid use disorder and other vulnerabilities

Individuals with opioid use disorder (OUD) have high prevalence of smoking and poor cessation outcomes. Data suggest that smokers with OUD may experience heightened nicotine reinforcement and more severe tobacco withdrawal compared to smokers without OUD. The Food and Drug Administration is currently considering reducing the nicotine content of cigarettes to reduce smoking prevalence and smoking-related disease. It is critical to understand the effects of reduced nicotine content cigarettes (RNCCs) on tobacco withdrawal in this subgroup. In this secondary analysis, we investigated the ability of RNCCs to attenuate acute tobacco withdrawal and craving severity in smokers with OUD versus those without substance use disorders (SUDs). Smokers maintained on methadone or buprenorphine (opioid-maintained [OM]; n = 65) versus without other SUDs (i.e., non-SUD; n = 135) completed 5 laboratory sessions wherein they smoked their usual brand (UB) or a research cigarette varying in nicotine content (0.4, 2.4, 5.2, 15.8 mg/g of tobacco) under double-blind, acute abstinence conditions. Participants completed the Minnesota Tobacco Withdrawal Scale, including a desire to smoke (craving) item, before and every 15 min for 1 hr following smoking each cigarette. Tobacco withdrawal and craving did not differ significantly by OM status in response to UB or RNCCs. In addition to the Dose × Time interaction, greater depression and cigarette dependence consistently predicted withdrawal and craving (ps < .05). Across all cigarettes, tobacco withdrawal and craving did not significantly differ by OM status, suggesting that smokers receiving opioid agonist treatment may respond favorably to RNCCs. Additional studies with larger and more diverse samples are needed to address this question more definitively. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Smartphone-based financial incentives to promote smoking cessation during pregnancy: A pilot study

Cigarette smoking during pregnancy increases risk for pregnancy complications, growth restriction, and other adverse health outcomes. The most effective intervention for reducing smoking during pregnancy is financial incentives contingent on biochemically-verified smoking abstinence. The present study examined the efficacy of a smartphone-based intervention whereby smoking monitoring and incentive delivery occurred remotely using a mobile app. If efficacious, this remote intervention would allow pregnant women residing in geographically remote areas to benefit from incentives-based cessation interventions. Sixty U.S. pregnant smokers were recruited between May 2018 to May 2019 via obstetrical clinics, Women, Infants, and Children (WIC) offices, and Facebook. Participants were assigned sequentially to one of two treatments: best practices alone (N = 30) or best practices plus financial incentives (N = 30). Outcomes were analyzed using repeated measures analysis based on generalized estimating equations (GEE). Seven-day point prevalence abstinence rates were greater in the incentives versus best practices arms early- (46.7% vs 20.0%, OR = 3.50, 95%CI = 1.11,11.02) and late-antepartum (36.7% vs 13.3%, OR = 3.76, 95%CI = 1.04,13.65), and four- (36.7% vs 10.0%, OR = 5.21, 95%CI = 1.28,21.24) and eight-weeks postpartum (40.0% vs 6.7%, OR = 9.33, 95%CI = 1.87,46.68), although not at the 12- (23.3% vs 10.0%, OR = 2.74, 95%CI = 0.63,11.82) or 24-week (20.0% vs 6.7%, OR = 3.50, 95%CI = 0.65,18.98) postpartum assessments likely due to this pilot study being underpowered for discerning differences at the later assessments, especially 24-weeks postpartum which was three months after treatment completion. These results support the efficacy of this remote, incentives-based intervention for pregnant smokers. Further research evaluating its efficacy and cost-effectiveness in a well-powered, randomized controlled trial appears warranted.

Abuse liability of cigarettes with very low nicotine content in pregnant cigarette smokers

The U.S. Food and Drug Administration has proposed reducing the nicotine content of cigarettes to a minimally-addictive level. To our knowledge, this study is the first to examine how pregnant smokers respond to very low nicotine content (VLNC) cigarettes. In Phase 1, participants blindly sampled two VLNC cigarettes (0.4 and 2.4 mg/g of tobacco) and their usual brand (UB) cigarette in separate sessions, then completed a behavioral economic simulation task and measures of subjective effects, craving/withdrawal, and smoking topography. Phase 2 directly compared the relative reinforcing effects of the cigarettes using concurrent choice testing. All possible dose-pair combinations were tested in separate sessions where puffs were earned ad libitum by clicking the code associated with their preferred cigarette 10 times. Phase 3 tested the 0.4 mg/g-UB dose-pair where UB puffs could be earned with a progressively incremented number of clicks (maximum 8400). Ten pregnant smokers in Burlington, VT and Baltimore, MD participated in 2017-2018. Regarding abuse liability, participants chose the 0.4-mg/g dose less than UB (22% vs. 78%) during concurrent choice testing and the 0.4-mg/g dose sustained less demand than the 2.4-mg/g and UB doses on the simulation task. Positive subjective effects were also lower for both VLNC cigarettes vs. UB. Each cigarette reduced nicotine craving/withdrawal and no significant changes indicative of compensatory smoking were noted. Reducing the nicotine content of cigarettes may decrease their abuse liability in pregnant smokers without causing untoward craving/withdrawal or compensatory smoking. Studies of extended exposure to VLNCs in pregnant women are warranted.