Voucher-Based Contingency Management is Efficacious but Underutilized in Treating Addictions

The United States lags far behind other industrialized countries on major markers of population health. Population health experts identify unhealthy behavior patterns (e.g., cigarette smoking, other substance use disorders, physical inactivity and poor food choices, nonadherence with recommended medical regimens) as the largest contributor to the status quo. Because these risk behaviors are overrepresented in socioeconomically disadvantaged and other vulnerable populations, they also increase health disparities. Hence, identifying evidence-based strategies to promote and sustain health-related behavior change is critical to improving U.S. population health. In this report, we review research demonstrating the efficacy of voucher-based contingency management delivered alone or in combination with other interventions for treating substance use disorders and other health-related behavior problems. The efficacy supporting these interventions is robust and discernible at the level of controlled randomized clinical trials and meta-analyses. Unfortunately, these evidence-based interventions are being underutilized in routine clinical care for substance use disorders, although they are used broadly in private-sector wellness programs and international programs to reduce chronic poverty. This report reviews the evidence supporting the efficacy of voucher-based contingency management using projects developed at the University of Vermont as exemplars and discusses dissemination of the model to public and private sector efforts to improve individual and population health.

Association of Cumulative Socioeconomic and Health-Related Disadvantage With Disparities in Smoking Prevalence in the United States, 2008 to 2017

IMPORTANCE

Understanding emerging patterns of smoking disparities among disadvantaged populations can guide tobacco control policy.

OBJECTIVE

To estimate disparities in smoking prevalence associated with the number of socioeconomic and health-related disadvantages faced by a population among US adults from 2008 to 2017.

DESIGN, SETTING, AND PARTICIPANTS

Nationally representative cross-sectional annual household-based probability sample of US noninstitutionalized residents. Polytomous regression estimated associations of disadvantage variables, survey year, and their interaction with the following 3 pairwise contrasts: current vs never smoking (estimate of overall disparities), current vs former smoking (unique contribution of disparities in smoking cessation), and former vs never smoking (unique contribution of disparities in smoking initiation). The setting was in-home face-to-face interviews. Participants were respondents in 2008 to 2017 survey years who were aged 25 years or older (N = 279 559).

EXPOSURES

Self-reported past-year unemployment, income below the federal poverty line, absence of high school diploma, disability/limitation interfering with daily functions, serious psychological distress on the Kessler 6-item screen, and at least 60 past-year heavy drinking days, each coded yes or no. These indicators were summed in a cumulative disadvantage index (0, 1, 2, 3, 4, or 5 or 6).

MAIN OUTCOMES AND MEASURES

Self-reported current, former (ever smoked ≥100 cigarettes, had since quit, and not currently smoking), and never (<100 cigarettes) smoking.

RESULTS

Among 278 048 respondents (mean [SD] age, 51.9 [16.8] years; 55.7% female) with data on smoking history (99.5% of the sample), the mean current smoking prevalence across 2008 to 2017 compared with populations without disadvantages was successively higher among populations with 1 disadvantage (21.4% vs 13.8%; current vs never smoking adjusted odds ratio [OR], 2.34; 95% CI, 2.27-2.43), 2 disadvantages (26.6% vs 13.8%; OR, 3.55; 95% CI, 3.39-3.72), 3 disadvantages (35.1% vs 13.8%; OR, 5.35; 95% CI, 5.05-5.66), 4 disadvantages (45.7% vs 13.8%; OR, 8.59; 95% CI, 7.91-9.34), or 5 or 6 disadvantages (58.2% vs 13.8%; OR, 14.70; 95% CI, 12.30-17.50). In current vs former and former vs never smoking status contrasts, ORs were lower but also showed successively greater associations with increasing cumulative disadvantage. Current (vs never) smoking odds significantly declined each year among populations with 0 (OR, 0.95; 95% CI, 0.94-0.96), 1 (OR, 0.96; 95% CI, 0.95-0.97), or 2 (OR, 0.98; 95% CI, 0.97-0.99) disadvantages but did not change across 2008 to 2017 among those with 3 or more disadvantages.

CONCLUSIONS AND RELEVANCE

Results of this study demonstrate that US disparities in smoking prevalence from 2008 to 2017 were successively larger with each additional disadvantage faced, were expressed in higher smoking initiation odds and lower smoking cessation odds, and widened over time.

Financial Incentives to Increase Cardiac Rehabilitation Participation Among Low-Socioeconomic Status Patients: A Randomized Clinical Trial

OBJECTIVES

This study sought to examine the efficacy of financial incentives to increase Medicaid patient participation in and completion of cardiac rehabilitation (CR).

BACKGROUND

Participation in CR reduces morbidity, mortality, and hospitalizations while improving quality of life. Lower-socioeconomic status (SES) patients are much less likely to attend and complete CR, despite being at increased risk for recurrent cardiovascular events.

METHODS

A total of 130 individuals enrolled in Medicaid with a CR-qualifying cardiac event were randomized 1:1 to receive financial incentives on an escalating schedule ($4 to $50) for completing CR sessions or to receive usual care. Primary outcomes were CR participation (number of sessions completed) and completion (≥30 sessions completed). Secondary outcomes included changes in sociocognitive measurements (depressive/anxious symptoms, executive function), body composition (waist circumference, body mass index), fitness (peak VO₂) over 4 months, and combined number of hospitalizations and emergency department (ED) contacts over 1 year.

RESULTS

Patients randomized to the incentive condition completed more sessions (22.4 vs. 14.7, respectively; p = 0.013) and were almost twice as likely to complete CR (55.4% vs. 29.2%, respectively; p = 0.002) as controls. Incentivized patients were also more likely to experience improvements in executive function (p < 0.001), although there were no significant effects on other secondary outcomes. Patients who completed ≥30 sessions had 47% fewer combined hospitalizations and ED visits (p = 0.014), as reflected by a nonsignificant trend by study condition with 39% fewer hospital contacts in the incentive condition group (p = 0.079).

CONCLUSIONS

Financial incentives improve CR participation among lower-SES patients following a cardiac event. Increasing participation among lower-SES patients in CR is critical for positive longer-term health outcomes. (Increasing Cardiac Rehabilitation Participation Among Medicaid Enrollees; NCT02172820).

Examining interrelationships between the Cigarette Purchase Task and delay discounting among pregnant women

Two common behavioral economic simulation tasks used to study cigarette smoking are the Cigarette Purchase Task, a measure of cigarette demand, and delay discounting, a measure of the subjective value of rewards as a function of delays to delivery. Few studies have evaluated whether combining these tasks enhances understanding of smoking beyond either alone. The current study represents an initial evaluation of the intersection between cigarette demand indices and delay discounting among pregnant smokers by examining associations between these measures and whether a woman makes antepartum quit attempts before entering prenatal care (a reliable predictor of eventual quitting). Participants were 159 pregnant women enrolled in a smoking-cessation trial. Low O max and shallow discounting were each associated with antepartum quit attempts. Participants were next categorized into four subgroups (low O max , shallow discounting; low O max , steep discounting; high O max , shallow discounting; high O max , steep discounting) using median splits. Those with shallow discounting and low O max were more likely to have made quit attempts than each of the other three subgroups. That is, steep discounting appears to undermine the association of low O max and efforts to quit smoking during pregnancy while high O max overshadows any protective influence associated with shallow discounting.

A multicomponent behavioral intervention for smoking cessation during pregnancy: a nonconcurrent multiple-baseline design

Given serious consequences of maternal smoking, we aimed to develop and test a multicomponent behavioral intervention to enhance smoking cessation during pregnancy. In this nonconcurrent, multiple-baseline intervention pilot study, 48 daily smoking pregnant women (mean 13.7 weeks of gestation) were recruited from Buffalo, NY, USA. Upon completion of the repeated baseline smoking monitoring (up to 3 weeks), 30 continuous smokers received a contingent financial incentive-based intervention with three additional components (education and counseling, monitoring and feedback, and family support). After the quit date, participants met with counselors (~1 hr/visit) daily for 2 weeks and twice a week for another 6 weeks. Twenty-one out of 30 participants quit smoking completely (verified by urine cotinine) after receiving the intervention, and the other nine nonquitters decreased smoking substantially. The estimated smoking cessation rate was 70.0% (21/30) at the second week of the intervention, and 63.3% (19/30) at the conclusion of the 8-week intervention assuming the dropouts as smoking. In interrupted time series analysis, the mean daily number of cigarettes smoked among quitters decreased by 6.52, 5.34, and 4.67 among early, delayed, and late intervention groups, respectively. Quitters' mean urine cotinine level maintained stably high before the intervention but decreased rapidly to the nonsmoking range once the intervention was initiated. Most participants (85.7%) reported meeting or exceeding expectations, and 100% would recommend the program to others. This pilot multicomponent intervention was feasible and acceptable to most participants, resulting in a high smoking cessation rate among pregnant smokers who were unlikely to quit spontaneously.

Evaluating the utility of the modified cigarette evaluation questionnaire and cigarette purchase task for predicting acute relative reinforcing efficacy of cigarettes varying in nicotine content

BACKGROUND

Nicotine is the addictive component in cigarettes that maintain cigarette smoking that subsequently leads to morbidity and mortality. Methods for assessing the abuse liability of cigarettes are essential to inform new tobacco product standards. This secondary analysis evaluated the utility of one subjective effects measure, the modified Cigarette Evaluation Questionnaire (mCEQ), and one behavioral economic task, the Cigarette Purchase Task (CPT), for predicting acute relative reinforcing efficacy measured by concurrent choice Self-Administration (SA).

METHODS

Smokers (N = 169) belonging to one of three vulnerable populations participated in a multi-site, double-blind study evaluating research cigarettes with varying levels of nicotine (0.4, 2.4, 5.2, 15.8 mg/g). Participants sampled cigarettes and completed the mCEQ and CPT. In subsequent sessions, cigarette preference was assessed using a concurrent choice SA procedure. Mixed-model repeated measures analysis of variance tests were used to evaluate the utility of the mCEQ subscales and CPT indices for predicting preference for the higher compared to lower nicotine content cigarettes. In addition, stepwise regressions were used to determine which subscales and indices independently predicted concurrent choice SA.

RESULTS

Greater increases on the Satisfaction and Enjoyment of Respiratory Tract Sensations mCEQ subscales independently predicted higher dose preference in concurrent choice testing. Elasticity was the only CPT index that predicted choice. However, its predictive utility differed by dose among opioid-maintained individuals.

CONCLUSION

The mCEQ and CPT predict behavioral measures of relative reinforcing efficacy as assessed in concurrent choice SA, with the mCEQ Satisfaction and Enjoyment of Respiratory Tract Sensations subscales being the strongest independent predictors.

Low Smoking Exposure, the Adolescent Brain, and the Modulating Role of CHRNA5 Polymorphisms

BACKGROUND

Studying the neural consequences of tobacco smoking during adolescence, including those associated with early light use, may help expose the mechanisms that underlie the transition from initial use to nicotine dependence in adulthood. However, only a few studies in adolescents exist, and they include small samples. In addition, the neural mechanism, if one exists, that links nicotinic receptor genes to smoking behavior in adolescents is still unknown.

METHODS

Structural and diffusion tensor magnetic resonance imaging data were acquired from a large sample of 14-year-old adolescents who completed an extensive battery of neuropsychological, clinical, personality, and drug-use assessments. Additional assessments were conducted at 16 years of age.

RESULTS

Exposure to smoking in adolescents, even at low doses, is linked to volume changes in the ventromedial prefrontal cortex and to altered neuronal connectivity in the corpus callosum. The longitudinal analyses strongly suggest that these effects are not preexisting conditions in those who progress to smoking. There was a genetic contribution wherein the volume reduction effects were magnified in smokers who were carriers of the high-risk genotype of the alpha 5 nicotinic receptor subunit gene, rs16969968.

CONCLUSIONS

These findings give insight into a mechanism involving genes, brain structure, and connectivity underlying why some adolescents find nicotine especially addictive.

Combined financial incentives and behavioral weight management to enhance adherence with gestational weight gain guidelines: a randomized controlled trial

BACKGROUND

Excessive gestational weight gain, particularly among overweight and obese women, is associated with adverse perinatal outcomes. Current interventions to limit gestational weight gain have achieved only modest success.

OBJECTIVE

We sought to improve adherence to gestational weight gain guidelines with a dual intervention of financial incentives and antenatal behavioral weight management.

STUDY DESIGN

This was a prospective randomized controlled trial at a single academic medical center in which women were assigned randomly to the intervention group or standard care. The primary outcome was adherence to gestational weight gain guidelines. Secondary outcomes included total gestational weight gain, mode of delivery, birthweight, neonatal intensive care unit admission, and development of gestational diabetes mellitus and hypertensive disorders of pregnancy.

RESULTS

A total of 136 women were assigned randomly, with data available for analysis of 124 women. Gestational weight gain within the Institutes of Medicine guidelines was similar (30% vs 29%) in the intervention and standard care groups, respectively. There were no statistically significant differences in total gestational weight gain or perinatal outcomes. There was a nonstatistically significant decrease in macrosomia in the intervention compared with standard care condition.

CONCLUSION

A combined financial incentive and behavioral weight management intervention did not improve adherence to gestational weight gain guidelines. Modifications to the intervention may achieve improved results.

Leveraging technology to address the problem of cigarette smoking among women of reproductive age

Women of reproductive age and particularly pregnant women underutilize evidence-based smoking cessation services such as counseling and quit lines. Mobile health (mHealth) may constitute an unexplored and innovative avenue for providing smoking cessation support to a population that is otherwise difficult to reach with evidence-based interventions. Female respondents aged 18-44 years (N = 10,023) were drawn from the first wave of the Population Assessment of Tobacco and Health (PATH) study (2013-2014). We examined prevalence of use of various digital forms of communication (e.g., social media, text messaging, smartphone ownership) among non-pregnant women of reproductive age, pregnant women, and among smokers versus non-smokers within these groups. Multiple logistic regression modeling was conducted to identify correlates of using each digital form adjusting for smoking status, pregnancy, and demographic characteristics. Over two thirds of women overall and within subgroups of non-pregnant and pregnant smokers reported using social media, owning a cell phone, owning a smartphone, downloading apps, and sending/receiving text messages. Current smokers and those with lower educational attainment generally had lower odds of using each digital form relative to non-smokers and those with higher educational attainment, the exception being that smokers had higher odds of using social media relative to non-smokers. The high prevalence of using various digital forms among both non-pregnant smokers of reproductive age and pregnant smokers suggests that leveraging technology to expand access to prevention, education, and treatment resources may reduce smoking-attributable adverse health effects among reproductive-aged women and their offspring.

Tobacco Use and Cessation Behaviors in Young Adults: 2016 National Health Interview Survey

OBJECTIVES

To examine differences in tobacco use and cessation between young adults (aged 18-24 years) and adults aged 25 years or older.

METHODS

We used data from the 2016 US National Health Interview Survey (n = 33 028) to identify 13 494 current and former cigarette smokers (562 aged 18-24 years; 12 932 aged 25 years or older). We analyzed correlations between age group, cigarette smoking, cessation behaviors, and other tobacco and nicotine use.

RESULTS

Among current and former smokers, those aged 18 to 24 years had lower odds of having quit for 1 year or longer and higher odds of having tried e-cigarettes, cigars, pipes, and smokeless tobacco compared with adults aged 25 years or older, as well as higher odds of daily e-cigarette and smokeless tobacco use. Young adult smokers used fewer cigarettes per day than did those aged 25 years or older (mean = 8.8 vs 12.3), had higher odds of making a past-year quit attempt (adjusted odds ratio [AOR] = 1.42), and had lower odds of having a health professional talk to them about smoking (AOR = 0.44).

CONCLUSIONS

Greater experimentation with noncigarette products, lower cigarette consumption, and greater interest in quitting smoking invite novel intervention approaches to tobacco reduction, cessation, and relapse prevention in young adults.

Tobacco use in cardiac patients: Perceptions, use, and changes after a recent myocardial infarction among US adults in the PATH study (2013-2015)

Smoking status following cardiac events strongly predicts future morbidity and mortality. Using a nationally representative sample of United States adults, aims of this study were (1) to estimate use of, and attitudes towards, tobacco products as a function of level of cardiac risk, and (2) to explore changes in attitudes and tobacco use among adults experiencing a recent myocardial infarction (MI). Data were obtained from the first and second waves of the Population Assessment of Tobacco and Health (PATH) study. Use and attitudes towards tobacco products were examined at Wave 1 among adults with no chronic health condition (n = 18,026), those with risk factors for heart disease (n = 4593), and those who reported ever having had an MI (n = 643). Changes in perceived risk of tobacco and use between the two waves and having an MI in the last 12 months (n = 240) were also examined. Those who reported lifetime MI were more likely to believe that smoking/using tobacco was causing/worsening a health problem. Having had a recent MI event increased perceived tobacco-related risk and attempts at reduction/quitting, but did not significantly impact combusted tobacco cessation/reduction or uptake of non-combusted tobacco products. Sociodemographic characteristics and use of other tobacco products were associated with change in use of tobacco products. Those who have an MI are sensitized to the harm of continued smoking. Nonetheless, having an MI does not predict quitting combusted tobacco use or switching to potentially reduced harm products. Intense intervention is necessary to reduce combusted use in this high-risk population.

Understanding individual differences in vulnerability to cigarette smoking is enhanced by attention to the intersection of common risk factors

While smoking prevalence in the U.S. and other industrialized countries has decreased substantially, this change has been unevenly distributed, with dramatic decreases in certain subpopulations but little change or even increases in others. Accordingly, considerable attention has been fruitfully devoted to identifying important risk factors for smoking (e.g., mental illness, other substance use disorders). However, there has been little research on the intersection of these risk factors. As risk factors rarely occur in isolation, it is important to examine risk-factor profiles as is commonly done in studying other chronic conditions (e.g., cardiovascular disease). The purpose of this Commentary is to encourage greater interest in the intersection of multiple risk factors using cigarette smoking as an exemplar. We focus on the intersection of eight well-established risk factors for smoking (age, gender, race/ethnicity, educational attainment, poverty, drug abuse/dependence, alcohol abuse/dependence, mental illness). Studying the intersection of risk factors is likely to require use of innovative data-analytic methods. We illustrate, using years 2011-2016 of the US National Household Survey on Drug Use and Health, how Classification and Regression Tree (CART) analysis can be an effective tool for identifying risk profiles for smoking. Examination of the intersection of these risk factors elucidates a series of risk profiles with associated, orderly gradations in vulnerability to current smoking, including the striking and reliable strength of a college education as a stand-alone profile predicting low risk for current smoking, and illustrating the potentially increasing importance of drug abuse/dependence as a risk factor.

Tobacco and nicotine delivery product use in a U.S. national sample of women of reproductive age

This study examined prevalence and correlates of using cigarettes, e-cigarettes, and other tobacco/nicotine delivery products in a U.S. national sample of women of reproductive age. Weighted data were obtained from women aged 15-44 years who were not currently pregnant in the first wave of the Population Assessment of Health and Tobacco (PATH, 2013-2014) study (N = 12,848). 20.1% of women were current cigarette smokers, 5.9% current e-cigarette users, 4.9% current cigar smokers, and 6.5% current hookah users. Prevalence of current use of other tobacco products was <1.0%. Current cigarette smoking was the strongest correlate of current e-cigarette use (OR = 65.7, 95% CI = 44.8-96.5), cigar smoking (OR = 19.2, 95% CI = 14.1-26.1), and hookah use (OR = 6.6, 95% CI = 5.1-8.5). Among former cigarette smokers, 3.8%, 6.9%, and 3.2% were also currently using e-cigarettes, hookah, and cigars, respectively. Use of other tobacco and nicotine delivery products was low among those who never smoked tobacco cigarettes: 2.5% used hookah and <1.0% used other products. Cigarette smoking prevalence remains relatively high among women of reproductive age and strongly correlated with use of other tobacco products. Monitoring tobacco and nicotine use in this population is important due to the additional risk of adverse health impacts should they become pregnant. Clinicians working with cigarette smokers should assess for use of other tobacco products. Among women of reproductive age, use of emerging tobacco and nicotine products appears to be largely, although not exclusively, restricted to current cigarette smokers.

Trend differences in men and women in rural and urban U.S. settings

BACKGROUND

Smoking prevalence is declining at a slower rate in rural than urban settings in the United States (U.S.), and known predictors of smoking do not readily account for this trend difference. Given that socioeconomic and psychosocial determinants of health disparities accumulate in rural settings and that life-course disadvantages are often greater in women than men, we examined whether smoking trends are different for rural and urban men and women.

METHOD

We used yearly cross-sectional data (n = 303,311) from the U.S. National Survey on Drug Use and Health (NSDUH) from 2007 through 2014 to compare cigarette smoking trends in men and women across rural and urban areas. Current smoking status was modelled using logistic regression controlling for confounding risk factors.

RESULTS

Regression derived graphs predicting unadjusted prevalence estimates and 95% confidence bands revealed that whereas the smoking trends of rural men, urban men, and urban women significantly declined from 2007 to 2014, the trend for rural women was flat. Controlling for demographic, socioeconomic and psychosocial predictors of smoking did not explain rural women's significantly different trend from those of the other three groups.

CONCLUSION

Rural women lag behind rural men, urban men and urban women in decreasing smoking, a health disparity finding that supports the need for tobacco control and regulatory policies and interventions that are more effective in reducing smoking among rural women.

Editorial: 5th Special Issue on behavior change, health, and health disparities

This Special Issue of Preventive Medicine (PM) is the 5th in a series on behavior change, health, and health disparities. Unhealthy behavior patterns (i.e., lifestyle choices) including cigarette smoking and other substance abuse, physical inactivity, unhealthy food choices, and non-adherence with recommended medical regimens, undermine U.S. population health by increasing risk for chronic disease and premature death. This Special Issue brings together scholarly contributions from the emerging area of tobacco regulatory science to examine current topics of critical importance to reducing the burden of cigarette smoking on U.S. population health. More specifically, three related topics are examined including (a) the potential for reducing smoking by adopting a national policy that would cap the nicotine content of cigarettes at minimally-addictive levels; (b) increasing scientific understanding of cigarette smoking and other tobacco use among populations that are especially vulnerable to initiating smoking, tobacco addiction, and its adverse health consequences; and (c) the potential of a harm-reduction strategy for reducing the burden of smoking by advocating that those who are unwilling or unable to quit nicotine use substitute electronic cigarettes or other non-combusted sources of nicotine for cigarettes in order to avoid exposure to the other toxins in tobacco smoke that are most responsible for smoking morbidity and mortality. While tremendous progress has been made in reducing overall U.S. smoking prevalence and its adverse health impacts, more needs to be done. This Special Issue offers some ideas that have the potential to make a substantive contribution towards that goal.

Are we guilty of errors of omission on the potential role of electronic nicotine delivery systems as less harmful substitutes for combusted tobacco use?

Two of the more controversial tobacco control and regulatory strategies in recent years are the nicotine reduction and tobacco harm reduction (THR) strategies. They have become inextricably intertwined as a successful nicotine reduction policy might only be possible in an environment in which alternative, noncombusted forms of nicotine like electronic nicotine delivery systems (ENDS) are available to address the needs of those who were unable or unwilling to completely give up nicotine. Unfortunately, ENDS have emerged as particularly controversial, in part, because they are the first product to carry reduced risk potential while being broadly appealing to cigarette smokers across demographic groups and subpopulations, and to a much smaller extent nonsmokers including, and most controversial, adolescents. In an effort to better understand some of the reasons that make this a controversial topic, we review some of the relevant history and discuss a broader dilemma that faces practitioners and policy developers of medical and public health interventions, namely, weighing the potential consequences of errors of commission versus omission. Commission errors involve a salient, direct link between an action and associated adverse or unintended consequences while omission errors are typically less salient with a more indirect link between inaction and associated adverse consequences. Decision-making research demonstrates that humans have a bias towards avoidance of commission errors and insensitivity to omission errors. This bias may be contributing to some of the aforementioned difficulties in finding common ground regarding the potential contribution of ENDS to reducing the harm of combusted tobacco use.

Response to reduced nicotine content cigarettes among smokers differing in tobacco dependence severity

This study examines whether tobacco dependence severity moderates the acute effects of reducing nicotine content in cigarettes on the addiction potential of smoking, craving/withdrawal, or smoking topography. Participants (N = 169) were daily smokers with mild, moderate, or high tobacco-dependence severity using the Heaviness of Smoking Index. Following brief abstinence, participants smoked research cigarettes varying in nicotine content (0.4, 2.4, 5.2, 15.8 mg nicotine/g tobacco) in a within-subject design. Results were analyzed using repeated measures analysis of co-variance. No main effects of dependence severity or interactions with nicotine dose were noted in relative reinforcing effects in concurrent choice testing or subjective effects on the modified Cigarette Evaluation Questionnaire. Demand for smoking in the Cigarette Purchase Task was greater among more dependent smokers, but reducing nicotine content decreased demand independent of dependence severity. Dependence severity did not significantly alter response to reduced nicotine content cigarettes on the Minnesota Tobacco Withdrawal Scale nor Questionnaire of Smoking Urges-brief (QSU) Factor-2 scale; dependence severity and dose interacted significantly on the QSU-brief Factor-1 scale, with reductions dependent on dose among highly but not mildly or moderately dependent smokers. Dependence severity and dose interacted significantly on only one of six measures of smoking topography (i.e., maximum flow rate), which increased as dose increased among mildly and moderately but not highly dependent smokers. These results suggest that dependence severity has no moderating influence on the ability of reduced nicotine content cigarettes to lower the addiction potential of smoking, and minimal effects on relief from craving/withdrawal or smoking topography.

Co-occurring vulnerabilities and menthol use in U.S. young adult cigarette smokers: Findings from Wave 1 of the PATH Study, 2013-2014

This study incorporates intersectionality theory to address potential effects of age on other documented risk factors for current smoking and menthol cigarette use in young adults aged 18-34 using Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2014). We explored known correlates of current cigarette and menthol cigarette smoking and interaction analyses by age group (18-24 vs. 25-34), accounting for survey weighting. Use of non-cigarette tobacco products and e-cigarettes was characterized among current cigarette smokers. Young adults experience multiple vulnerabilities to smoking beyond age and some of these known risk factors for smoking place those aged 18-24 at different risk of cigarette smoking compared to their 25-34 year old counterparts. These include lower odds of cigarette smoking by age for sex (female; AOR = 0.62 in those aged 18-24 vs. 0.72 in those aged 25-34) and Hispanic ethnicity (vs. White; AOR = 0.77 vs. 0.45), and higher odds of smoking among past 30-day alcohol users aged 18-24 vs. 25-34 (AOR = 1.62 vs. 1.32). Correlations between lower education and smoking were nearly two-fold higher in 25-34 than 18-24 year olds. Having any medical comorbidity had opposite effects on current smoking by age (18-24 positive correlation, AOR = 1.17; 25-34 negative correlation, AOR = 0.84). Lower education was correlated with menthol cigarette use among young adult smokers. This study suggests that higher smoking prevalence among young adults is associated with the intersection of multiple vulnerabilities to smoking.

Tobacco Product Harm Perceptions and New Use

: media-1vid110.1542/5839992833001PEDS-VA_2018-1505Video Abstract BACKGROUND: Researchers in several studies have examined correlations between tobacco harm perceptions and tobacco use in youth, but none have prospectively addressed the association between harm perceptions and subsequent new use across multiple noncigarette products.

METHODS

Product-specific absolute and relative harm perceptions for cigarettes, electronic cigarettes (e-cigarettes), cigars, pipes, hookah, and smokeless tobacco were collected at wave 1 (W1) (2013-2014) among youth in the nationally representative US Population Assessment of Tobacco and Health Study (12-17 years of age; n = 10 081). At wave 2 (W2) (2014-2015), product-specific new use was calculated. Adjusted relative risks were used to estimate if harm perceptions at W1 predicted W2 new tobacco use.

RESULTS

The proportion of youth who endorsed "a lot of harm" was highest for cigarettes (84.8%) and lowest for e-cigarettes (26.6%); the proportion of youth who thought products were "more harmful" than cigarettes was highest for cigars (30.6%) and lowest for e-cigarettes (5.1%). Among youth who had not used those products at W1, product-specific new use at W2 ranged from 9.1% (e-cigarettes) to 0.6% (pipes). Youth who believed that noncombustible tobacco products posed "no or little harm" at W1 were more likely to have tried those products at W2 (P < .05). Youth who viewed e-cigarettes, hookah, and smokeless tobacco as "less harmful" than cigarettes at W1 were more likely to try those tobacco products at W2 (P < .05).

CONCLUSIONS

Low harm perceptions of noncigarette tobacco products predict new use of these products by youth within the next year. Targeting product-specific harm perceptions may prevent new tobacco use among youth.

Smoking prevalence and trends among a U.S. national sample of women of reproductive age in rural versus urban settings

U.S. smoking prevalence is declining at a slower rate in rural than urban settings and contributing to regional health disparities. Cigarette smoking among women of reproductive age is particularly concerning due to the potential for serious maternal and infant adverse health effects should a smoker become pregnant. The aim of the present study was to examine whether this rural-urban disparity impacts women of reproductive age (ages 15-44) including pregnant women. Data came from the ten most recent years of the U.S. National Survey on Drug Use and Health (2007-2016). We estimated prevalence of current smoking and nicotine dependence among women categorized by rural-urban residence, pregnancy status, and trends using chi-square testing and multivariable modeling while adjusting for common risk factors for smoking. Despite overall decreasing trends in smoking prevalence, prevalence was higher among rural than urban women of reproductive age overall (χ2(1) = 579.33, p < .0001) and among non-pregnant (χ2(1) = 578.0, p < .0001) and pregnant (χ2(1) = 79.69, p < .0001) women examined separately. An interaction between residence and pregnancy status showed adjusted odds of smoking among urban pregnant compared to non-pregnant women (AOR = .58, [.53 -.63]) were lower than those among rural pregnant compared to non-pregnant women (AOR = 0.75, [.62 -.92]), consistent with greater pregnancy-related smoking cessation among urban pregnant women. Prevalence of nicotine dependence was also higher in rural than urban smokers overall (χ2(2) = 790.42, p < .0001) and among non-pregnant (χ2(2) = 790.58, p < .0001) and pregnant women examined separately (χ2(2) = 63.69, p < .0001), with no significant changes over time. Associations involving residence and pregnancy status remained significant in models adjusting for covariates (ps < 0.05). Results document greater prevalence of smoking and nicotine dependence and suggest less pregnancy-related quitting among rural compared to urban women, disparities that have potential for direct, multi-generational adverse health impacts.

Cigarette consumption and biomarkers of nicotine exposure during pregnancy and postpartum

BACKGROUND AND AIMS

Smokers can regulate their nicotine intake by altering the number of cigarettes smoked per day (CPD) and their smoking intensity. The current study aimed to compare the utility of self-reported CPD, total nicotine equivalents (TNE) and urinary cotinine to estimate nicotine intake during pregnancy.

DESIGN

Longitudinal smoking behavior and biomarker data were collected at early pregnancy, late pregnancy and at postpartum as part of a smoking cessation trial to examine voucher-based incentives for decreasing smoking.

SETTING

Obstetric practices in Burlington, Vermont, United States.

PARTICIPANTS

A subset of participants (n = 47) from the parent trial, recruited between December 2006 and June 2012, who provided a urine sample at each assessment during early pregnancy, late pregnancy and postpartum.

MEASUREMENTS

Smoking was assessed using self-reported CPD, TNE, TNE/CPD and urinary cotinine.

FINDINGS

Pregnant smokers reported smoking 10.4 CPD at early pregnancy, 7.2 CPD at late pregnancy (a 31% reduction at late pregnancy, P = 0.001) and 8.6 CPD at postpartum (a 19% increase from late pregnancy, P = 0.08). TNE exposure was 41% (P = 0.07) and 48% (P = 0.03) lower at early and late pregnancy, respectively, compared to postpartum. TNE/CPD was on average 167% higher at late pregnancy compared to early pregnancy (P = 0.01) and remained high at postpartum, where it was 111% higher compared to early pregnancy (P = 0.007). Uriniary cotinine underestimated nicotine intake by 55% during early pregnancy and by 65% during late pregnancy compared to postpartum (P_interaction  < 0.001); the underestimation was greater in slower (P_interaction  < 0.001) versus faster (P_interaction  = 0.04) nicotine metabolizers.

CONCLUSIONS

Neither cigarettes smoked per day (CPD) nor cotinine provides an accurate estimate of nicotine exposure during pregnancy. CPD underestimates nicotine intake substantially due to under-reporting and/or higher intensity of smoking, while cotinine underestimates nicotine intake markedly due to accelerated nicotine (and cotinine) metabolism during pregnancy.

Fentanyl exposure among patients seeking opioid treatment

AIM

Overdoses attributed to the potent opioid agonist fentanyl have substantially increased in recent years. Despite these serious public health consequences, many opioid treatment providers do not currently include a fentanyl assay in their urine toxicology testing. As a result, extent of fentanyl exposure and related risks among individuals with opioid use disorder often remains unknown. We examined the prevalence of fentanyl exposure among patients seeking or enrolled in opioid agonist treatment.

METHODS

Six hundred urine specimens were collected from adults entering (n = 100) or enrolled in (n = 500) opioid agonist treatment and analyzed using the clinic's standard opioid panel, supplemented with a 100 ng/ml fentanyl assay.

RESULTS

Of the 100 specimens collected from patients at treatment intake, 19 (19%) tested positive for fentanyl. Importantly, 17 (90%) of those fentanyl-positive specimens were also positive for heroin. Of the 500 collected from patients in treatment, 17 (3%) of specimens tested positive for fentanyl. Of those, 11 (92%) were also positive for heroin.

CONCLUSION

These data illustrate a concerning degree of fentanyl exposure among patients seeking treatment and suggest that much of this exposure may have stemmed from fentanyl-containing heroin. Given the unprecedented recent surges in fentanyl-related overdoses, efforts to identify fentanyl exposure are critical. In particular, the point of treatment entry permits a rare systematic opportunity for medical and clinical staff to address fentanyl use and risks with incoming patients.

Response to reduced nicotine content cigarettes among smokers with chronic health conditions

Individuals with chronic health conditions persist in smoking despite the presence of smoking-related illness. The aim of this study was to examine whether chronic health conditions moderate response to reduced nicotine content cigarettes (0.4, 2.4, 5.2, 15.8 mg/g of tobacco). This is a secondary analysis of a controlled clinical laboratory study that examined the acute effects of cigarettes varying in nicotine content among individuals especially vulnerable to smoking and tobacco dependence. Participants in the present study were categorized as having 0, 1–2, or ≥3 smoking-related chronic health conditions (i.e., chronic condition severity, CCS). Repeated-measures analysis of variance was used to examine whether CCS moderated response to cigarettes across measures of addiction potential (i.e., concurrent choice testing between nicotine dose pairs, Cigarette Purchase Task (CPT) performance, positive subjective effects), tobacco withdrawal, cigarette craving, and smoking topography. No main effects of CCS or interactions of CCS and nicotine dose were observed for concurrent choice testing, positive subjective effects, tobacco withdrawal, or smoking topography. Main effects of CCS were noted on the CPT with greater CCS being associated with less persistent demand. There was an interaction of CCS and nicotine dose on Factor 1 of the Questionnaire on Smoking Urges with the effects of dose significant only among those with 1–2 chronic conditions. Overall, we see minimal evidence that chronic condition severity affects response to reduced nicotine content cigarettes. A policy that reduces the nicotine content of cigarettes to minimally addictive levels may benefit smokers already experiencing smoking-related chronic conditions.

The initiation of cannabis use in adolescence is predicted by sex-specific psychosocial and neurobiological features

Cannabis use initiated during adolescence might precipitate negative consequences in adulthood. Thus, predicting adolescent cannabis use prior to any exposure will inform the aetiology of substance abuse by disentangling predictors from consequences of use. In this prediction study, data were drawn from the IMAGEN sample, a longitudinal study of adolescence. All selected participants (n = 1,581) were cannabis-naïve at age 14. Those reporting any cannabis use (out of six ordinal use levels) by age 16 were included in the outcome group (N = 365, males n = 207). Cannabis-naïve participants at age 14 and 16 were included in the comparison group (N = 1,216, males n = 538). Psychosocial, brain and genetic features were measured at age 14 prior to any exposure. Cross-validated regularized logistic regressions for each use level by sex were used to perform feature selection and obtain prediction error statistics on independent observations. Predictors were probed for sex- and drug-specificity using post-hoc logistic regressions. Models reliably predicted use as indicated by satisfactory prediction error statistics, and contained psychosocial features common to both sexes. However, males and females exhibited distinct brain predictors that failed to predict use in the opposite sex or predict binge drinking in independent samples of same-sex participants. Collapsed across sex, genetic variation on catecholamine and opioid receptors marginally predicted use. Using machine learning techniques applied to a large multimodal dataset, we identified a risk profile containing psychosocial and sex-specific brain prognostic markers, which were likely to precede and influence cannabis initiation.

Comparing Smoking Topography and Subjective Measures of Usual Brand Cigarettes Between Pregnant and Non-Pregnant Smokers

Introduction

Most pregnant smokers report abruptly reducing their cigarettes per day (CPD) by ~50% after learning of pregnancy and making further smaller reductions over the remainder of their pregnancy. Laboratory and naturalistic studies with non-pregnant smokers have found that these types of reductions often lead to changes in smoking topography (i.e., changes in smoking intensity to maintain a desired blood-nicotine level). If pregnant women smoke more intensely, they may expose themselves and their offspring to similar levels of toxicants despite reporting reductions in CPD.

Methods

Pregnant and non-pregnant female smokers (n = 20 and 89, respectively) participated. At the experimental session, after biochemical confirmation of acute abstinence, participants smoked one usual brand cigarette ad lib through a Borgwaldt CReSS Desktop Smoking Topography device. Carbon monoxide (CO) and measures of nicotine withdrawal, craving, and reinforcement derived from smoking were also collected.

Results

The two groups did not differ on demographic or smoking characteristics at screening, except nicotine metabolism rate, which as expected, was faster in pregnant smokers. Analyses suggest that none of the smoking topography parameters differed between pregnant and non-pregnant smokers, although pregnant smokers had a significantly smaller CO boost. Both groups reported similar levels of relief of withdrawal and craving after smoking, but other subjective effects suggest that pregnant smokers find smoking less reinforcing than non-pregnant smokers.

Conclusions

Pregnant smokers do not smoke cigarettes differently than non-pregnant women, but appear to find smoking comparatively less pleasurable.

Implications

This is the first study to assess smoking topography in pregnant women. Pregnant women appear to be at increased risk for smoking cigarettes with more intensity because of (1) their tendency to make significant abrupt reductions in the number of cigarettes they smoke each day after learning of pregnancy and (2) an increase in nicotine metabolism induced by pregnancy. Despite these changes, the present results suggest that pregnant women do not smoke cigarettes more intensely or in a way that causes more toxicant exposure, perhaps due to a reportedly less pleasurable smoking experience.