Determinants of tobacco use and renaming the FTND to the Fagerstrom Test for Cigarette Dependence

If at first you don't succeed: characterization of smokers with late smoking abstinence onset

INTRODUCTION

Most cigarette smoking cessation research has aimed to clarify characteristics associated with initial and sustained abstinence, with less attention paid to predictors of gaining abstinence following an initial failure.

METHODS

The current investigation explored pre-treatment demographic, smoking, and psychiatric characteristics related to gaining abstinence among smokers who failed to attain initial abstinence. Participants were 809 individuals enrolled in extended, 52-week, smoking cessation interventions. Of these, 287 (62.4%) failed to achieve initial abstinence. Gaining abstinence following initial abstinence failure was defined as achieving seven-day point prevalent abstinence at any post-initial abstinence assessment.

RESULTS

Those who gained abstinence (Gainers) were more likely to have a live-in partner (χ(2)(1, N=283)=3.8, p=.05, Cramér's V=.12), identify as Hispanic (χ(2)(1, N=281)=7.8, p<.01, Cramér's V=.17), evidence lower baseline expired breath carbon monoxide (F(1, 284)=5.7, p=.02, η(2)=.02), report less cigarette dependence (F(1, 278)=7.1, p<.01, η(2)=.03), and report past week cannabis use (χ(2)(1, N=284)=5.6, p=.02, Cramér's V=.14). A logistic regression model suggested that having a live-in partner (OR=5.14, 95% CI=1.09-3.02, p=.02) and identifying as Hispanic (OR=4.93, 95% CI=1.20-18.77, p=.03) increased the odds of gaining abstinence.

DISCUSSION

Having a live-in partner, Hispanic status, greater cigarette dependence, and recent cannabis use were associated with gaining abstinence. These findings provide insight into an understudied area, contributing an initial framework toward understanding gaining abstinence following initial failure.

A Comparison of the Fagerström Test for Cigarette Dependence and Cigarette Dependence Scale in a Treatment-Seeking Sample of Pregnant Smokers

INTRODUCTION

Valid and reliable brief measures of cigarette dependence are essential for research purposes and effective clinical care. Two widely-used brief measures of cigarette dependence are the six-item Fagerström Test for Cigarette Dependence (FTCD) and five-item Cigarette Dependence Scale (CDS-5). Their respective metric characteristics among pregnant smokers have not yet been studied.

METHODS

This was a secondary analysis of data of pregnant smokers (N = 476) enrolled in a smoking cessation study. We assessed internal consistency, reliability, and examined correlations between the instruments and smoking-related behaviors for construct validity. We evaluated predictive validity by testing how well the measures predict abstinence 2 weeks after quit date.

RESULTS

Cronbach's alpha coefficient for the CDS-5 was 0.62 and for the FTCD 0.55. Measures were strongly correlated with each other, although FTCD, but not CDS-5, was associated with saliva cotinine concentration. The FTCD, CDS-5, craving to smoke, and withdrawal symptoms failed to predict smoking status 2 weeks following the quit date.

CONCLUSIONS

Suboptimal reliability estimates and failure to predict short-term smoking call into question the value of including either of the brief measures in studies that aim to explain the obstacles to smoking cessation during pregnancy.

The PROMIS Smoking Initiative: initial validity evidence for six new smoking item banks

INTRODUCTION

The Patient-Reported Outcomes Measurement Information System (PROMIS) Smoking Initiative has developed 6 item banks for assessing smoking behaviors and biopsychosocial correlates of smoking among daily and nondaily adult cigarette smokers. This paper presents descriptive information and preliminary validity evidence for the item banks (Nicotine Dependence, Coping Expectancies, Emotional and Sensory Expectancies, Health Expectancies, Psychosocial Expectancies, and Social Motivations).

METHODS

Using data from a large sample of daily (N = 4,201) and nondaily (N = 1,183) smokers, we generated mean daily and nondaily smoking bank scores according to select demographic groups. We also examined correlations among the 6 banks and examined the associations of bank scores with smoking behavior items (e.g., quantity of smoking, interest in quitting) and select health-related quality of life measures (i.e., physical functioning, anxiety, alcohol consumption).

RESULTS

Correlations among the 6 banks are moderate (daily mean r = .48, range = .04-.80; nondaily mean r = .47, range = .12-.75). The pattern of associations between bank scores and other measures provides validity evidence for the bank domains (e.g., nicotine dependence is most strongly associated with smoking quantity and time to first cigarette of the day; health and psychosocial expectancies are most related to quitting recency and interest; coping expectancies are strongly associated with anxiety).

CONCLUSIONS

These analyses provide useful descriptive information about the 6 smoking item banks as well as preliminary evidence for their validity. Independent sample data are currently being collected to replicate these findings, to establish test-retest reliability, and to develop crosswalks to existing smoking measures (e.g., nicotine dependence to Fagerström Test for Nicotine Dependence). Future research will also evaluate the bank scores' sensitivity to change.

An Exploratory Analysis of the Smoking and Physical Activity Outcomes From a Pilot Randomized Controlled Trial of an Exercise Assisted Reduction to Stop Smoking Intervention in Disadvantaged Groups

INTRODUCTION

Economically disadvantaged smokers not intending to stop may benefit from interventions aimed at reducing their smoking. This study assessed the effects of a behavioral intervention promoting an increase in physical activity versus usual care in a pilot randomized controlled trial.

METHODS

Disadvantaged smokers who wanted to reduce but not quit were randomized to either a counseling intervention of up to 12 weeks to support smoking reduction and increased physical activity (n = 49) or usual care (n = 50). Data at 16 weeks were collected for various smoking and physical activity outcomes. Primary analyses consisted of an intention to treat analysis based on complete case data. Secondary analyses explored the impact of handling missing data.

RESULTS

Compared with controls, intervention smokers were more likely to initiate a quit attempt (36 vs. 10%; odds ratio 5.05, [95% CI: 1.10; 23.15]), and a greater proportion achieved at least 50% reduction in cigarettes smoked (63 vs. 32%; 4.21 [1.32; 13.39]). Postquit abstinence measured by exhaled carbon monoxide at 4-week follow-up showed promising differences between groups (23% vs. 6%; 4.91 [0.80; 30.24]). No benefit of intervention on physical activity was found. Secondary analyses suggested that the standard missing data assumption of "missing" being equivalent to "smoking" may be conservative resulting in a reduced intervention effect.

CONCLUSIONS

A smoking reduction intervention for economically disadvantaged smokers which involved personal support to increase physical activity appears to be more effective than usual care in achieving reduction and may promote cessation. The effect does not appear to be influenced by an increase in physical activity.

Validity and reliability of the Internalized Stigma of Smoking Inventory: An exploration of shame, isolation, and discrimination in smokers with mental health diagnoses

BACKGROUND AND OBJECTIVES

De-normalization of smoking as a public health strategy may create shame and isolation in vulnerable groups unable to quit. To examine the nature and impact of smoking stigma, we developed the Internalized Stigma of Smoking Inventory (ISSI), tested its validity and reliability, and explored factors that may contribute to smoking stigma.

METHODS

We evaluated the ISSI in a sample of smokers with mental health diagnoses (N = 956), using exploratory and confirmatory factor analysis, and assessed construct validity.

RESULTS

Results reduced the ISSI to eight items with three subscales: smoking self-stigma related to shame, felt stigma related to social isolation, and discrimination experiences. Discrimination was the most commonly endorsed of the three subscales. A multivariate generalized linear model predicted 21-30% of the variance in the smoking stigma subscales. Self-stigma was greatest among those intending to quit; felt stigma was highest among those experiencing stigma in other domains, namely ethnicity and mental illness-based; and smoking-related discrimination was highest among women, Caucasians, and those with more education.

DISCUSSION AND CONCLUSION

Smoking stigma may compound stigma experiences in other areas. Aspects of smoking stigma in the domains of shame, isolation, and discrimination were related to modeled stigma responses, particularly readiness to quit and cigarette addiction, and were found to be more salient for groups where tobacco use is least prevalent.

SCIENTIFIC SIGNIFICANCE

The ISSI measure is useful for quantifying smoking-related stigma in multiple domains.

The comparative efficacy of first- versus second-generation electronic cigarettes in reducing symptoms of nicotine withdrawal

BACKGROUND AND AIMS

Currently, electronic cigarettes (e-cigarettes) are studied as though they are a homogeneous category. However, there are several noteworthy differences in the products that fall under this name, including potential differences in the efficacy of these products as smoking cessation aids. The current study examined the comparative efficacy of first- and second-generation e-cigarettes in reducing nicotine withdrawal symptoms in a sample of current smokers with little or no experience of using e-cigarettes.

DESIGN

Twenty-two mildly to moderately nicotine-dependent individuals were randomized to a cross-over design in which they used first- and second-generation e-cigarettes on separate days with assessment of withdrawal symptoms directly prior to and after product use.

SETTING AND PARTICIPANTS

A community-based sample recruited in the Midwest region of the United States reported a mean age of 28.6 [standard deviation (SD) = 12.9]. The majority were male (56.5%), Caucasian (91.3%), reported smoking an average of 15.2 (SD = 9.6) tobacco cigarettes per day, and a mean baseline carbon monoxide (CO) level of 18.7 parts per million (p.p.m.).

MEASUREMENTS

Symptoms of withdrawal from nicotine were measured via the Mood and Physical Symptoms Scale.

FINDINGS

Analysis of changes in withdrawal symptoms revealed a significant time × product interaction F(1, 21)  = 5.057, P = 0.036, n(2) P  = 0.202. Participants experienced a larger reduction in symptoms of nicotine withdrawal after using second-generation compared with first-generation e-cigarettes.

CONCLUSIONS

Second-generation e-cigarettes seem to be more effective in reducing symptoms of nicotine withdrawal than do first-generation e-cigarettes.

Biochemically verified smoking cessation and vaping beliefs among vape store customers

AIMS

To evaluate biochemically verified smoking status and electronic nicotine delivery systems (ENDS) use behaviors and beliefs among a sample of customers from vapor stores (stores specializing in ENDS).

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey of 215 adult vapor store customers at four retail locations in the Midwestern United States; a subset of participants (n = 181) also completed exhaled carbon monoxide (CO) testing to verify smoking status.

MEASUREMENTS

Outcomes evaluated included ENDS preferences, harm beliefs, use behaviors, smoking history and current biochemically verified smoking status.

FINDINGS

Most customers reported starting ENDS as a means of smoking cessation (86%), using newer-generation devices (89%), vaping non-tobacco/non-menthol flavors (72%) and using e-liquid with nicotine strengths of ≤20 mg/ml (72%). There was a high rate of switching (91.4%) to newer-generation ENDS among those who started with a first-generation product. Exhaled CO readings confirmed that 66% of the tested sample had quit smoking. Among those who continued to smoke, mean cigarettes per day decreased from 22.1 to 7.5 (P <0.001). People who reported vaping longer [odds ratio (OR) = 4.659, 95% confidence interval (CI) = 2.001-10.846], using newer-generation devices (OR = 2.950, 95% CI = 1.037-8.395) and using non-tobacco and non-menthol flavors (OR = 2.626, 95% CI = 1.133-6.085) were more likely to have quit smoking.

CONCLUSIONS

Among vapor store customers in the United States who use electronic nicotine delivery devices to stop smoking, vaping longer, using newer-generation devices and using non-tobacco and non-menthol flavored e-liquid appear to be associated with higher rates of smoking cessation.

Paths to tobacco abstinence: A repeated-measures latent class analysis

OBJECTIVE

Knowledge of smoking change processes may be enhanced by identifying pathways to stable abstinence. We sought to identify latent classes of smokers based on their day-to-day smoking status in the first weeks of a cessation attempt. We examined treatment effects on class membership and compared classes on baseline individual differences and 6-month abstinence rates.

METHOD

In this secondary analysis of a double-blind randomized placebo-controlled clinical trial (N = 1,433) of 5 smoking cessation pharmacotherapies (nicotine patch, nicotine lozenge, bupropion SR, patch and lozenge, or bupropion SR and lozenge), we conducted repeated-measures latent class analysis of daily smoking status (any smoking vs. none) for the first 27 days of a quit attempt. Treatment and covariate relations with latent class membership were examined. Distal outcome analysis compared confirmed 6-month abstinence rates among the latent classes.

RESULTS

A 5-class solution was selected. Three-quarters of smokers were in stable smoking or abstinent classes, but 25% were in classes with unstable abstinence probabilities over time. Active treatment (compared to placebo), and particularly the patch and lozenge combination, promoted early quitting. Latent classes differed in 6-month abstinence rates and on several baseline variables, including nicotine dependence, quitting history, self-efficacy, sleep disturbance, and minority status.

CONCLUSIONS

Repeated-measures latent class analysis identified latent classes of smoking change patterns affected by treatment, related to known risk factors, and predictive of distal outcomes. Tracking behavior early in a change attempt may identify prognostic patterns of change and facilitate adaptive treatment planning.

First- versus second-generation electronic cigarettes: predictors of choice and effects on urge to smoke and withdrawal symptoms

AIMS

To (1) estimate predictors of first- versus second-generation electronic cigarette (e-cigarette) choice; and (2) determine whether a second-generation device was (i) superior for reducing urge to smoke and withdrawal symptoms (WS) and (ii) associated with enhanced positive subjective effects.

DESIGN

Mixed-effects experimental design. Phase 1: reason for e-cigarette choice was assessed via questionnaire. Phase 2: participants were allocated randomly to first- or second-generation e-cigarette condition. Urge to smoke and WS were measured before and 10 minutes after taking 10 e-cigarette puffs.

SETTING

University of East London, UK.

PARTICIPANTS

A total of 97 smokers (mean age 26; standard deviation 8.7; 54% female).

MEASUREMENTS

Single-item urge to smoke scale to assess craving and the Mood and Physical Symptoms Scale (MPSS) to assess WS. Subjective effects included: satisfaction, hit, 'felt like smoking' and 'would use to stop smoking' (yes versus no response).

FINDINGS

Equal numbers chose each device, but none of the predictor variables (gender, age, tobacco dependence, previous e-cigarette use) accounted for choice. Only baseline urge to smoke/WS predicted urge to smoke/WS 10 minutes after use (B =0.38; P <0.001 and B =0.53; P <0.001). E-cigarette device was not a significant predictor. Those using the second-generation device were more likely to report satisfaction and use in a quit attempt (χ(2)  = 12.10, P =0.001 and χ(2)  = 5.53, P =0.02).

CONCLUSIONS

First- and second-generation electronic cigarettes appear to be similarly effective in reducing urges to smoke during abstinence, but second-generation devices appear to be more satisfying to users.

Withdrawal: Expanding a Key Addiction Construct

Withdrawal is an essential component of classical addiction theory; it is a vital manifestation of dependence and motivates relapse. However, the traditional conceptualization of withdrawal as a cohesive collection of symptoms that emerge during drug deprivation and decline with either the passage of time or reinstatement of drug use, may be inadequate to explain scientific findings or fit with modern theories of addiction. This article expands the current understanding of tobacco withdrawal by examining: (1) withdrawal variability; (2) underlying causes of withdrawal variability, including biological and person factors, environmental influences, and the influence of highly routinized behavioral patterns; (3) new withdrawal symptoms that allow for enhanced characterization of the withdrawal experience; and (4) withdrawal-related cognitive processes. These topics provide guidance regarding the optimal assessment of withdrawal and illustrate the potential impact modern withdrawal conceptualization and assessment could have on identifying treatment targets.

Smoking cessation abstinence goal in treatment-seeking smokers

INTRODUCTION

Baseline abstinence goal is a robust predictor of cigarette abstinence. However, important questions about goal remain unanswered. These include variables correlating with goal, changes in goal, relationship of goal and abstinence status over time, and predictors of change. The current study aimed to address these questions.

METHOD

Participants were treatment-seeking volunteers in two clinical trials. In Clinical Trial 1 (N=402), participants smoked ≥10 cigarettes per day (CPD) and were ≥50years of age. In Clinical Trial 2 (N=406), participants smoked ≥10 CPD, smoked within 30min of arising, and were ≥18years of age. The outcome variables were biochemically verified 7-day abstinence from cigarettes at weeks 12, 24, 52, and 104. Abstinence goal, demographic, psychological, and smoking related variables were assessed via standard instruments.

RESULTS

At baseline, the greater the desire to quit and one's expectations of success, and the lesser the educational level, the more likely participants were to have a quit forever goal. Throughout the two-year study, abstinence from cigarettes and a lower educational level were correlated with a goal of quit forever; 37% of participants changed goal. There were no predictors of goal change. Abstinence goal was related to abstinence status across the study period. The goal predicted abstinence status at subsequent assessments, even when status was controlled.

CONCLUSION

Lesser educational levels were consistent predictors of a more stringent goal. Abstinence goal changes over time. These findings suggest that repeated counseling about goal is advisable and participants would benefit from such counseling, independent of demographic characteristics and smoking status.

Predictors, indicators, and validated measures of dependence in menthol smokers

This article presents a comprehensive review of the menthol cigarette dependence-related literature and results from an original analysis of the Total Exposure Study (TES), which included 1,100 menthol and 2,400 nonmenthol adult smokers. The substantial scientific evidence available related to age of first cigarette, age of regular use, single-item dependence indicators (smoking frequency, cigarettes per day, time to first cigarette, night waking to smoke), smoking duration, numerous validated and widely accepted measures of nicotine/cigarette dependence, and our analysis of the TES do not support that menthol smokers are more dependent than nonmenthol smokers or that menthol increases dependence.

Lessons learned from recruiting socioeconomically disadvantaged smokers into a pilot randomized controlled trial to explore the role of Exercise Assisted Reduction then Stop (EARS) smoking

BACKGROUND

Research is needed on what influences recruitment to smoking reduction trials, and how to increase their reach. The present study aimed to i) assess the feasibility of recruiting a disadvantaged population, ii) examine the effects of recruitment methods on participant characteristics, iii) identify resource requirements for different recruitment methods, and iv) to qualitatively assess the acceptability of recruitment. This was done as part of a pilot two-arm trial of the effectiveness of a novel behavioral support intervention focused on increasing physical activity and reducing smoking, among disadvantaged smokers not wishing to quit.

METHODS

Smokers were recruited through mailed invitations from three primary care practices (62 participants) and one National Health Stop Smoking Service (SSS) database (31 participants). Six other participants were recruited via a variety of other community-based approaches. Data were collected through questionnaires, field notes, work sampling, and databases. Chi-squared and t-tests were used to compare baseline characteristics of participants.

RESULTS

We randomized between 5.1 and 11.1% of those invited through primary care and SSS, with associated researcher time to recruit one participant varying from 18 to 157 minutes depending on time and intensity invested.Only six participants were recruited through a wide variety of other community-based approaches, with an associated researcher time of 469 minutes to recruit one participant. Targets for recruiting a disadvantaged population were met, with 91% of the sample in social classes C2 to E (NRS social grades, UK), and 41% indicating mental health problems. Those recruited from SSS were more likely to respond to an initial letter, had used cessation aids before, and had attempted to quit in the past year. Overall, initial responders were more likely to be physically active than those who were recruited via follow-up telephone calls. No other demographics or behaviour characteristics were associated with recruitment approach or intensity of effort. Qualitative feedback indicated that participants had been attracted by the prospect of support that focused on smoking reduction rather than abrupt quitting.

CONCLUSIONS

Mailed invitations, and follow-up, from health professionals was an effective method of recruiting disadvantaged smokers into a trial of an exercise intervention to aid smoking reduction. Recruitment via community outreach approaches was largely ineffective.

TRIAL REGISTRATION

ISRCTN identifier: 13837944 , registered on 6 July 2010.

Effect of a mobile phone intervention on quitting smoking in a young adult population of smokers: randomized controlled trial study protocol

Background

Tobacco use remains the number one cause of preventable chronic disease and death in developed countries worldwide. In North America, smoking rates are highest among young adults. Despite that the majority of young adult smokers indicate wanting to quit, smoking rates among this age demographic have yet to decline. Helping young adults quit smoking continues to be a public health priority. Digital mobile technology presents a promising medium for reaching this population with smoking cessation interventions, especially because young adults are the heaviest users of this technology.

Objective

The primary aim of this trial is to determine the effectiveness of an evidence-informed mobile phone app for smoking cessation, Crush the Crave, on reducing smoking prevalence among young adult smokers.

Methods

A parallel randomized controlled trial (RCT) with two arms will be conducted in Canada to evaluate Crush the Crave. In total, 1354 young adult smokers (19 to 29 years old) will be randomized to receive the evidence-informed mobile phone app, Crush the Crave, or an evidence-based self-help guide known as “On the Road to Quitting” (control) for a period of 6 months. The primary outcome measure is a 30-day point prevalence of abstinence at the 6-month follow-up. Secondary outcomes include a 7-day point prevalence of abstinence, number of quit attempts, reduction in consumption of cigarettes, self-efficacy, satisfaction, app utilization metrics, and use of smoking cessation services. A cost-effectiveness analysis is included.

Results

This trial is currently open for recruitment. The anticipated completion date for the study is April 2016.

Conclusions

This randomized controlled trial will provide the evidence to move forward on decision making regarding the inclusion of technology-based mobile phone interventions as part of existing smoking cessation efforts made by health care providers. Evidence from the trial will also inform the development of future apps, provide a deeper understanding of the factors that drive change in smoking behavior using an app, and improve the design of cessation apps. This trial is among the first to assess the effect of a comprehensive and evidence-informed mHealth smoking cessation app on a large sample of young adult smokers. Strengths of the trial include the high-quality research design and in-depth assessment of the implementation of the intervention. If effective, the trial has the potential to demonstrate that including mHealth technology as a population-based intervention strategy can cost-effectively reach a greater proportion of the population and help young adult smokers to quit.

Trial Registration

ClinicalTrials.gov NCT01983150; http://clinicaltrials.gov/ct2/show/NCT01983150 (Archived by WebCite at http://www.webcitation.org/6VGyc0W0i).

Nicotine Dependence, Nicotine Metabolism, and the Extent of Compensation in Response to Reduced Nicotine Content Cigarettes

INTRODUCTION

The Food and Drug Administration has the authority to regulate tobacco product constituents, including nicotine, to promote public health. Reducing the nicotine content in cigarettes may lead to lower levels of addiction. Smokers however may compensate by smoking more cigarettes and/or smoking more intensely. The objective of this study was to test whether individual differences in the level of nicotine dependence (as measured by the Fagerstrom Test of Cigarette Dependence [FTCD]) and/or the rate of nicotine metabolism influence smoking behavior and exposure to tobacco toxicants when smokers are switched to reduced nicotine content cigarettes (RNC).

METHODS

Data from 51 participants from a previously published clinical trial of RNC were analyzed. Nicotine content of cigarettes was progressively reduced over 6 months and measures of smoking behavior, as well as nicotine metabolites and tobacco smoke toxicant exposure, CYP2A6 and nicotinic CHRNA5-A3-B4 (rs1051730) genotype were measured.

RESULTS

Higher baseline FTCD predicted smoking more cigarettes per day (CPD), higher cotinine and smoke toxicant levels while smoking RNC throughout the study, with no interaction by RNC level. Time to first cigarette (TFC) was associated with differences in compensation. TFC within 10 min was associated with a greater increase in CPD compared to TFC greater than 10 min. Neither rate of nicotine metabolism, nor CYP2A6 or nicotinic receptor genotype, had an effect on the outcome variables of interest.

CONCLUSIONS

FTCD is associated with overall exposure to nicotine and other constituents of tobacco smoke, while a short TFC is associated with an increased compensatory response after switching to RNC.

Short-term fluctuations in motivation to quit smoking in a sample of smokers in Hawaii

BACKGROUND

Despite its potential for usefulness in informing the development of smoking cessation interventions, short-term fluctuations in motivation to quit is a relatively understudied topic.

OBJECTIVES

To assess the prevalence of smokers' day-to-day fluctuations in motivation to quit, and to assess associations of day-to-day fluctuations in motivation to quit with several established cessation-related variables.

METHODS

A cross-sectional survey was administered to smokers in Hawaii (N = 1,567). To assess short-term fluctuations in motivation to quit smoking, participants were asked to respond "True" or "False" to the statement: "My motivation to quit smoking changes from one day to the next." Other items measured desire to quit smoking, intention to quit, confidence in quitting, cigarette dependence, and other cessation-related variables.

RESULTS

"My motivation to quit smoking changes from one day to the next" was endorsed as true by 64.7% of smokers, and false by 35.3%. Analyses revealed that smokers who indicated fluctuating motivation were significantly more interested in quitting as compared to smokers without fluctuations. Fluctuations in motivation to quit also were associated with greater confidence in quitting, lesser cigarette dependence, and more recent quitting activity (all p < .01).

CONCLUSIONS

Day-to-day fluctuations in motivation to quit are common. Day-to-day fluctuations in motivation to quit are strongly associated with higher motivation to quit, greater confidence in future quitting, and other positive cessation-relevant trends.

Evaluation of a novel nicotine inhaler device: part 2--effect on craving and smoking urges

INTRODUCTION

Many smokers find currently available nicotine replacement therapies unsatisfactory. The pharmacokinetics of nicotine delivered via a novel inhaler device, and its effect on craving satiation and smoking urges, were compared with the Nicorette® Inhalator (10 mg).

METHODS

Results are reported for Parts B (N = 24) and D (N = 24) of a 4-part Phase I study. Participants (18-55 years, ≥ 10 cigarettes/day within 1 hr of waking, expired carbon monoxide >10 ppm on screening) received single doses of nicotine on consecutive days (0.45 and 0.67 mg [Part B] and 0.45 mg [Part D] via the novel device; 10 mg via Nicorette® [Parts B and D]). Venous pharmacokinetics, craving, and tolerability were assessed.

RESULTS

In Part B, the novel device 0.45 and 0.67 mg produced significantly lower C max, AUClast, and AUCall than Nicorette® (all p ≤ .05), higher AUC0-10 and significantly shorter T max (18.7 and 19.2 min vs. 38.0 min, respectively, p ≤ .05). Craving score AUC was lower for the novel device 0.45 mg than for Nicorette® in Part B (1356.3 vs. 1566.3, p = .029) and approached statistical significance in Part D (1208.5 vs. 1402.3 [p = .059]). Mean craving scores were lower for the novel device 0.45 mg than Nicorette® at 7/8 postdose timepoints in Part B (p ≤ .05 at 180 and 240 min) and at all timepoints in Part D (p ≤ .05 at 2, 4, and 10 min).

CONCLUSIONS

The novel device was at least as effective as the Nicorette® Inhalator (10mg) in relieving craving and smoking urges and was statistically superior at certain timepoints and in an overall craving AUC analysis, despite lower total nicotine exposure.

The effects of nicotine stimulus and response expectancies on male and female smokers' responses to nicotine-free electronic cigarettes

BACKGROUND

Electronic cigarettes (e-cigarettes) have been reported to reduce tobacco craving and withdrawal; however, the mechanisms underlying these effects have not been elucidated.

METHODS

This study examined the contributions of nicotine stimulus and response expectancies to responses to nicotine-free e-cigarettes in 21 e-cigarette naïve smokers (12 male). Participants completed two randomized experimental sessions in which they administered a nicotine-free e-cigarette. During one session they were informed that the e-cigarette contained nicotine and during the other session they were informed that the e-cigarette was nicotine-free. Participants completed subjective assessments before and immediately after sampling ten puffs from the e-cigarette and were then invited to earn additional puffs using a computerized progressive ratio task. Prior to their enrolment in the study, participants provided an estimate of the relative importance of the nicotine content of e-cigarettes for craving relief.

RESULTS

Instructions that the e-cigarette contained nicotine were found to reduce both intention to smoke (p=0.017) and withdrawal-related (p=0.018) craving, regardless of a-priori reported beliefs regarding the relative importance of nicotine. Nicotine content instructions were also found to be associated with a shorter latency to self-administration (p=0.005); however, a Sex×Instructions×Response Expectancy interaction (p=0.008) revealed that this effect was specific to women who had strong a-priori nicotine content craving relief expectations. Neither nicotine content instructions nor response expectancies impacted the number of puffs self-administered.

CONCLUSIONS

Findings suggest that nicotine content expectations contribute to smokers' responses to e-cigarettes, and that a-priori beliefs about nicotine effects may be especially important in women.

Is Action Planning Helpful for Smoking Cessation? Assessing the Effects of Action Planning in a Web-Based Computer-Tailored Intervention

BACKGROUND AND OBJECTIVES

The aim of this study was to examine the efficacy of a web-assisted computer-tailored smoking cessation intervention, an action planning (AP) intervention in which potential quitters were encouraged to form action plans (e.g., plan a quit date) and execute them (e.g., remove ashtrays). We also investigated whether the AP intervention resulted in more AP and plan execution than a similar, control intervention without the supplementary AP component.

METHODS

In a randomized controlled trial, the AP intervention (N = 977) was compared with the control intervention (N = 1,005) in terms of self-reported continued abstinence (CA) and point prevalence abstinence (PPA) six months after baseline. AP, plan execution, and opinion of the intervention were measured one month after baseline.

RESULTS

Complete-case logistic regression analysis showed that the AP intervention had a significant effect on CA (OR = 2.01; CI 1.08-3.84, p = .02), whereas intention-to-treat analysis showed a borderline significant effect (OR = 1.68; CI .96-2.92, p = .07). Sixteen percent of the experimental group achieved CA compared to 10% of the control group. The AP intervention had no effect on PPA. The experimental group also showed significantly more AP and plan execution at one month. Execution of plans was associated with smoking cessation.

CONCLUSIONS

The effects of the AP intervention on CA, AP, and execution of plans were encouraging. The potential for widespread use of web-based interventions means that even small behavioral effects may have an impact on public health. We recommend that the intervention be intensified and improved.

Cytisine versus nicotine for smoking cessation

BACKGROUND

Placebo-controlled trials indicate that cytisine, a partial agonist that binds the nicotinic acetylcholine receptor and is used for smoking cessation, almost doubles the chances of quitting at 6 months. We investigated whether cytisine was at least as effective as nicotine-replacement therapy in helping smokers to quit.

METHODS

We conducted a pragmatic, open-label, noninferiority trial in New Zealand in which 1310 adult daily smokers who were motivated to quit and called the national quitline were randomly assigned in a 1:1 ratio to receive cytisine for 25 days or nicotine-replacement therapy for 8 weeks. Cytisine was provided by mail, free of charge, and nicotine-replacement therapy was provided through vouchers for low-cost patches along with gum or lozenges. Low-intensity, telephone-delivered behavioral support was provided to both groups through the quitline. The primary outcome was self-reported continuous abstinence at 1 month.

RESULTS

At 1 month, continuous abstinence from smoking was reported for 40% of participants receiving cytisine (264 of 655) and 31% of participants receiving nicotine-replacement therapy (203 of 655), for a difference of 9.3 percentage points (95% confidence interval, 4.2 to 14.5). The effectiveness of cytisine for continuous abstinence was superior to that of nicotine-replacement therapy at 1 week, 2 months, and 6 months. In a prespecified subgroup analysis of the primary outcome, cytisine was superior to nicotine-replacement therapy among women and noninferior among men. Self-reported adverse events over 6 months occurred more frequently in the cytisine group (288 events among 204 participants) than in the group receiving nicotine-replacement therapy (174 events among 134 participants); adverse events were primarily nausea and vomiting and sleep disorders.

CONCLUSIONS

When combined with brief behavioral support, cytisine was found to be superior to nicotine-replacement therapy in helping smokers quit smoking, but it was associated with a higher frequency of self-reported adverse events. (Funded by the Health Research Council of New Zealand; Australian New Zealand Clinical Trials Registry number, ACTRN12610000590066.).

Examination of the Wisconsin Inventory of Smoking Dependence Motives (WISDM-68) Factor Structure in a Sample of Pregnant Smokers

INTRODUCTION

Smoking during pregnancy poses known risks to fetal and infant development. Women who continue to smoke during pregnancy exhibit higher levels of nicotine dependence than women who quit. Increased understanding of the construct of nicotine dependence in pregnant smokers may aid in the development of effective treatments. Research has suggested that nicotine dependence is a multifaceted construct, driven not only by withdrawal and tolerance processes, but also by reinforcement, sensory, and contextual processes. The Wisconsin inventory of smoking dependence motives (WISDM-68) assesses 13 varied smoking motives in order to assess processes that may lead to nicotine dependence.

METHODS

The factor structure of the WISDM-68 was explored using an ethnically diverse sample of 294 pregnant women who had been screened and/or enrolled in a smoking cessation treatment study. Confirmatory analyses were conducted with previously published models. An exploratory factor analysis and exploratory structural equation modeling (ESEM) were conducted to develop and validate a measurement model for the WISDM-68 in this sample.

RESULTS

Previously established models were not a good fit for the present data. Using ESEM, a 9-factor model exhibiting both predictive and concurrent validity emerged. Two factors predicted abstinence 6 months posttreatment. Several factors were associated with smoking heaviness, the Fagerström test for cigarette dependence and time to first cigarette.

CONCLUSIONS

In contrast to previously published studies, a 9-factor model best characterizes the WISDM in the present sample. These findings may reflect smoking motivations unique to young, pregnant women who continue to smoke during pregnancy.

Attitudes towards electronic cigarettes regulation in indoor workplaces and selected public and private places: a population-based cross-sectional study

BACKGROUND

Currently, there is an intensive debate about the regulation of the use of electronic cigarettes (e-cigarettes) in indoor places. The aim of this study was to assess the attitudes toward e-cigarette use in indoor workplaces and selected public and private venues among the general population in Barcelona (Spain) in 2013-2014.

METHODS

This is a cross-sectional study of a representative sample of the population of Barcelona (n = 736). The field work was conducted between May 2013 and February 2014. We computed the prevalence and the adjusted odds ratios (OR) derived from multivariable logistic regression models.

RESULTS

The awareness of e-cigarettes was 82.3%. Forty five percent of respondents did not agree with the use of e-cigarettes in public places and 52.3% in workplaces. The proportion of disapproval of the use of e-cigarettes in indoor places was higher at 71.5% for schools and 65.8% for hospitals and health care centers; while the prevalence of disapproval of e-cigarette use in homes and cars was lower (18.0% and 32.5%, respectively). Respondents who disagreed on the use of e-cigarettes in indoor workplaces were more likely to be older (OR = 1.64 and 1.97 for groups 45-64 and ≧65 years old, respectively), those with a high educational level (OR = 1.60), and never and former smokers (OR = 2.34 and 2.16, respectively). Increased scores in the Fagerström test for cigarette dependence were also related to increased support for their use.

CONCLUSIONS

Based on this population based study, half of the general population of Barcelona does not support the use of e-cigarettes in indoor workplaces and public places, with the percentage reaching 65% for use in schools, hospitals and health care centers. Consequently, there is good societal support in Spain for the politicians and legislators to promote policies restricting e-cigarettes use in workplaces and public places, including hospitality venues.

Tobacco dependence, the most important cardiovascular risk factor: treatment in the Czech Republic

Smoking is the most important cardiovascular (CV) risk factor. Stopping smoking halves the CV risk. Every clinician should provide a brief intervention with smokers. Intensive treatment should be available to those who need it. There are 37 Centers for Tobacco Dependence in the Czech Republic, which offer treatment including a psychobehavioral intervention and pharmacotherapy (varenicline, nicotine, bupropion). Czech physicians, pharmacists and nurses are regularly educated about smoking cessation. We describe the results of intensive treatment offered by our centers. Treatment includes screening (1 h), an intervention (2 h), and follow-up visits during the next 12 months. Among 3532 patients, 34.3 % had CO-validated abstinence at 12-months (including 489 patients who attended the screening visit + only the 12-month follow up visit). Among patients who underwent the intervention, the abstinence rate was 38.2 %. The majority of patients who underwent the intervention (N=2470) used some form of pharmacotherapy. After one year, the abstinence rate was 43.4 %, compared to 15.9 % (N=573) without pharmacotherapy. Only 28 % of patients came on the recommendation of a physician. Despite the decrease in CV risk following smoking cessation and the effectiveness of treatment, centers are underutilized.

Opportunity costs of reward delays and the discounting of hypothetical money and cigarettes

Humans are reported to discount delayed rewards at lower rates than nonhumans. However, nonhumans are studied in tasks that restrict reinforcement during delays, whereas humans are typically studied in tasks that do not restrict reinforcement during delays. In nonhuman tasks, the opportunity cost of restricted reinforcement during delays may increase delay discounting rates. The present within-subjects study used online crowdsourcing (Amazon Mechanical Turk, or MTurk) to assess the discounting of hypothetical delayed money (and cigarettes in smokers) under four hypothetical framing conditions differing in the availability of reinforcement during delays. At one extreme, participants were free to leave their computer without returning, and engage in any behavior during reward delays (modeling typical human tasks). At the opposite extreme, participants were required to stay at their computer and engage in little other behavior during reward delays (modeling typical nonhuman tasks). Discounting rates increased as an orderly function of opportunity cost. Results also indicated predominantly hyperbolic discounting, the "magnitude effect," steeper discounting of cigarettes than money, and positive correlations between discounting rates of these commodities. This is the first study to test the effects of opportunity costs on discounting, and suggests that procedural differences may partially account for observed species differences in discounting.

Evaluation of a novel nicotine inhaler device: part 1--arterial and venous pharmacokinetics

Introduction:

In the United Kingdom, licensed nicotine-containing products can be recommended to reduce the harm associated with smoking. Many smokers find currently available nicotine replacement products unsatisfactory. The arterial and venous pharmacokinetics (PK) of nicotine delivered via a novel inhaler device were determined.

Methods:

Results are reported for Parts A (N = 18) and C (N = 18) of a 4-part (A–D) Phase I study. Participants (18–55 years, ≥10 cigarettes/day, smoking within 1hr of waking, expired carbon monoxide >10 ppm on screening) orally inhaled 2 single doses of nicotine (2 of 3 dose levels [0.22, 0.45, and 0.67 mg]) (Part A) and repeated hourly doses of 0.67mg nicotine for 12hr (Part C), via the novel device. Arterial and venous PK and tolerability were assessed.

Results:

In Part A, mean arterial plasma nicotine concentrations at 2min after the start of inhalation were 1.10, 2.06, and 2.59ng/mL for the 0.22, 0.45, and 0.67mg doses, respectively. Mean maximum arterial plasma nicotine concentrations (C_max) were 2.11, 3.73, and 4.38ng/mL and mean times to C_max were 10.2, 7.3, and 6.5min after the start of inhalation for the 0.22, 0.45, and 0.67mg doses, respectively. In Part C, the mean pre- and postdose venous plasma nicotine concentration increased steadily and fluctuated in the range 8–10mg/mL after 9hr. The novel device was well tolerated; most adverse events were mild.

Conclusion:

The novel inhaler device delivers nicotine rapidly into the systemic circulation and offers a viable alternative to cigarettes for those finding it difficult to quit the behavioral and sensorial aspects of smoking.

Time to First Use Among Daily Smokers and Smokeless Tobacco Users

INTRODUCTION

Time to the first cigarette after waking up in the morning is the most validated measure of dependence among smokers, and its complement is also a good indicator of dependence for smokeless tobacco (ST) users. However, no studies have directly compared these measures.

METHODS

We used a multivariate logistic regression model to compare the time to first use (TTFU) of cigarettes and ST among white men 18+ years of age who were daily users in the 2003 Tobacco Use Supplement of the Current Population Survey. Smokers were classified as light (1-14 cigarettes per day [cpd]), moderate (15-24 cpd), and heavy (25+ cpd) and ST users were classified as former smokers or exclusive users.

RESULTS

There was no difference in TTFU within 5min between light smokers and exclusive ST users (Odds ratio [OR] = 1.3, CI = 0.95-1.7), but the latter were less likely to use tobacco within 30min (OR = 0.75, CI = 0.62-0.89). ST former smokers were more likely than light smokers to have a TTFU within 5min (OR = 1.5, CI = 1.1-2.0) but not within 30min. Moderate and heavy smokers had significantly higher odds of TTFU within both time points than light smokers.

CONCLUSION

Compared to light smokers, the likelihood of TTFU within 5min was similar among exclusive ST users and was slightly higher among ST former smokers, offering some support for the Fagerström-Eissenberg hypothesis that the dependence level of cigarettes is higher than that of ST.

Pilot study of the 5-HT2AR agonist psilocybin in the treatment of tobacco addiction

Despite suggestive early findings on the therapeutic use of hallucinogens in the treatment of substance use disorders, rigorous follow-up has not been conducted. To determine the safety and feasibility of psilocybin as an adjunct to tobacco smoking cessation treatment we conducted an open-label pilot study administering moderate (20 mg/70 kg) and high (30 mg/70 kg) doses of psilocybin within a structured 15-week smoking cessation treatment protocol. Participants were 15 psychiatrically healthy nicotine-dependent smokers (10 males; mean age of 51 years), with a mean of six previous lifetime quit attempts, and smoking a mean of 19 cigarettes per day for a mean of 31 years at intake. Biomarkers assessing smoking status, and self-report measures of smoking behavior demonstrated that 12 of 15 participants (80%) showed seven-day point prevalence abstinence at 6-month follow-up. The observed smoking cessation rate substantially exceeds rates commonly reported for other behavioral and/or pharmacological therapies (typically <35%). Although the open-label design does not allow for definitive conclusions regarding the efficacy of psilocybin, these findings suggest psilocybin may be a potentially efficacious adjunct to current smoking cessation treatment models. The present study illustrates a framework for future research on the efficacy and mechanisms of hallucinogen-facilitated treatment of addiction.

Effectiveness of the electronic cigarette: An eight-week Flemish study with six-month follow-up on smoking reduction, craving and experienced benefits and complaints

Background: Smoking reduction remains a pivotal issue in public health policy, but quit rates obtained with traditional quit-smoking therapies remain disappointingly low. Tobacco Harm Reduction (THR), aiming at less harmful ways of consuming nicotine, may provide a more effective alternative. One promising candidate for THR are electronic cigarettes (e-cigs). The aim of this study was to investigate the efficacy of second-generation e-cigs both in terms of acute craving-reduction in the lab and in terms of smoking reduction and experienced benefits/complaints in an eight-month Randomized Controlled Trial (RCT). Design: RCT with three arms. Methods: Participants (N = 48) unwilling to quit smoking were randomized into two e-cig groups and one control group. During three lab sessions (over two months) participants, who had been abstinent for four hours, vaped/smoked for five minutes, after which we monitored the effect on craving and withdrawal symptoms. eCO and saliva cotinine levels were also measured. In between lab sessions, participants in the e-cig groups could use e-cigs or smoke ad libitum, whereas the control group could only smoke. After the lab sessions, the control group also received an e-cig. The RCT included several questionnaires, which repeatedly monitored the effect of ad libitum e-cig use on the use of tobacco cigarettes and the experienced benefits/complaints up to six months after the last lab session. Results: From the first lab session on, e-cig use after four hours of abstinence resulted in a reduction in cigarette craving which was of the same magnitude as when a cigarette was smoked, while eCO was unaffected. After two months, we observed that 34% of the e-cig groups had stopped smoking tobacco cigarettes, versus 0% of the control group (difference p < 0.01). After five months, the e-cig groups demonstrated a total quit-rate of 37%, whereas the control group showed a quit rate of 38% three months after initiating e-cig use. At the end of the eight-month study, 19% of the e-cig groups and 25% of the control group were totally abstinent from smoking, while an overall reduction of 60% in the number of cigarettes smoked per day was observed (compared to intake). eCO levels decreased, whereas cotinine levels were the same in all groups at each moment of measurement. Reported benefits far outweighed the reported complaints. Conclusion: In a series of controlled lab sessions with e-cig naïve tobacco smokers, second generation e-cigs were shown to be immediately and highly effective in reducing abstinence induced cigarette craving and withdrawal symptoms, while not resulting in increases in eCO. Remarkable (>50 pc) eight-month reductions in, or complete abstinence from tobacco smoking was achieved with the e-cig in almost half (44%) of the participants.

Global Adult Tobacco Survey (GATS): a case for change in definition, analysis and interpretation of "cigarettes" and "cigarettes per day" in completed and future surveys

BACKGROUND

The Global Adult Tobacco Survey has 15 key indicators, cigarettes smoked per day (CPD) among daily smokers being one of them. The first wave of GATS in 14 countries indicated that mean CPD use is higher in women than men in India only, which is contrary to the current understanding of tobacco use globally. This study was undertaken to understand the unusual findings for mean CPD use in the GATS-India survey.

MATERIALS AND METHODS

Items B06a and B06b of the GATS India survey questionnaire that collected information on daily consumption of manufactured and rolled cigarettes were analyzed using SPSS software. Exclusive users were identified from these items after excluding the concurrent users of other tobacco products. Cigarette type, exclusive use and gender stratified analyses were made. Consumption of different types of cigarettes among the mixed users of manufactured and rolled cigarettes were correlated.

RESULTS

Higher mean number of CPD use among male daily-smokers was observed than their female counterparts in product specific analysis. Mean CPD as per GATS cigarette definition was higher in males than females for exclusive users but a reverse trend was observed in case of non-exclusive users. Use of manufactured cigarettes increased with increase in use of rolled cigarette among the mixed users and around half of these users reported equal CPD frequency for the both types of cigarettes.

CONCLUSIONS

The anomaly in mean CPD estimate in GATS-India data was due to inclusion of two heterogeneous products to define cigarettes, variation in cigarette product specific user proportions contributing to the average and non-exclusive concurrent use of other tobacco products. The consumption pattern of cigarettes among the mixed users highlights bias in CPD reporting. Definition, analysis and interpretation of 'cigarettes per day' in the GATS India survey need to be improved by redefining cigarettes and making product specific analyses.

An economic evaluation of a video- and text-based computer-tailored intervention for smoking cessation: a cost-effectiveness and cost-utility analysis of a randomized controlled trial

Background

Although evidence exists for the effectiveness of web-based smoking cessation interventions, information about the cost-effectiveness of these interventions is limited.

Objective

The study investigated the cost-effectiveness and cost-utility of two web-based computer-tailored (CT) smoking cessation interventions (video- vs. text-based CT) compared to a control condition that received general text-based advice.

Methods

In a randomized controlled trial, respondents were allocated to the video-based condition (N = 670), the text-based condition (N = 708) or the control condition (N = 721). Societal costs, smoking status, and quality-adjusted life years (QALYs; EQ-5D-3L) were assessed at baseline, six-and twelve-month follow-up. The incremental costs per abstinent respondent and per QALYs gained were calculated. To account for uncertainty, bootstrapping techniques and sensitivity analyses were carried out.

Results

No significant differences were found in the three conditions regarding demographics, baseline values of outcomes and societal costs over the three months prior to baseline. Analyses using prolonged abstinence as outcome measure indicated that from a willingness to pay of €1,500, the video-based intervention was likely to be the most cost-effective treatment, whereas from a willingness to pay of €50,400, the text-based intervention was likely to be the most cost-effective. With regard to cost-utilities, when quality of life was used as outcome measure, the control condition had the highest probability of being the most preferable treatment. Sensitivity analyses yielded comparable results.

Conclusion

The video-based CT smoking cessation intervention was the most cost-effective treatment for smoking abstinence after twelve months, varying the willingness to pay per abstinent respondent from €0 up to €80,000. With regard to cost-utility, the control condition seemed to be the most preferable treatment. Probably, more time will be required to assess changes in quality of life. Future studies with longer follow-up periods are needed to investigate whether cost-utility results regarding quality of life may change in the long run.

Trial Registration

Nederlands Trial Register NTR3102

How low should you go? Determining the optimal cutoff for exhaled carbon monoxide to confirm smoking abstinence when using cotinine as reference

INTRODUCTION

Confirming abstinence during smoking cessation clinical trials is critical for determining treatment effectiveness. Several biological methods exist for verifying abstinence (e.g., exhaled carbon monoxide [CO], cotinine), and while cotinine provides a longer window of detection, it is not easily used in trials involving nicotine replacement therapy. The Society for Research on Nicotine and Tobacco's Subcommittee on Biochemical Verification cite 8-10 parts per million (ppm) for CO as a viable cutoff to determine abstinence; however, recent literature suggests this cutoff is likely too high and may overestimate the efficacy of treatment.

METHODS

This study examined the relationship between CO and cotinine in a sample of 662 individuals participating in a smoking cessation clinical trial. A receiver operating characteristics curve was calculated to determine the percentage of false positives and false negatives at given CO levels when using cotinine as confirmation of abstinence. Differences were also examined across race and gender.

RESULTS

A CO cutoff of 3 ppm (97.1% correct classification) most accurately distinguished smokers from nonsmokers. This same cutoff was accurate for both racial and gender groups. The standard cutoffs of 8 ppm (14.0% misclassification of smokers as abstainers) and 10 ppm (20.6% misclassification of smokers as abstainers) produced very high false-negative rates and inaccurately identified a large part of the sample as being abstinent when their cotinine test identified them as still smoking.

CONCLUSIONS

It is recommended that researchers and clinicians adopt a more stringent CO cutoff in the range of 3-4 ppm when complete abstinence from smoking is the goal.

Steeper delay and probability discounting of potentially real versus hypothetical cigarettes (but not money) among smokers

There is a strong relationship between drug use and the tendency to discount the value of outcomes as a function of their delay and probability. Most discounting researchers use hypothetical monetary outcomes to establish discounting patterns among human subjects, who tend to discount the value of hypothetical money and real money similarily. However, no research to date has examined whether hypothetical non-monetary outcomes are discounted similarly to real non-monetary outcomes. In this study, smokers were assigned randomly to complete delay and probability discounting tasks for money and cigarettes that were either potentially real (n=33) or hypothetical (n=31). Consistent with previous research, smokers discounted the value of hypothetical and potentially real money similarly. However, smokers evidenced steeper rates of discounting for potentially real cigarettes in both delay and probability discounting. These findings suggest domain-specific discounting patterns in which potentially real and hypothetical outcomes may be synonymous in the context of monetary outcomes, but not in the context of non-monetary outcomes.

Expectancies for the effectiveness of different tobacco interventions account for racial and gender differences in motivation to quit and abstinence self-efficacy

INTRODUCTION

Racial and gender disparities for smoking cessation might be accounted for by differences in expectancies for tobacco interventions, but few studies have investigated such differences or their relationships with motivation to quit and abstinence self-efficacy.

METHODS

In this cross-sectional study, 673 smokers (African American: n = 443, 65.8%; women: n = 222, 33.0%) under criminal justice supervision who enrolled in a clinical smoking cessation trial in which all received bupropion and half received counseling. All participants completed pretreatment measures of expectancies for different tobacco interventions, motivation to quit, and abstinence self-efficacy. The indirect effects of race and gender on motivation to quit and abstinence self-efficacy through expectancies for different tobacco interventions were evaluated.

RESULTS

African Americans' stronger expectancies that behavioral interventions would be effective accounted for their greater motivation to quit and abstinence self-efficacy. Women's stronger expectancies for the effectiveness of pharmacotherapy accounted for their greater motivation to quit, whereas their stronger expectancies for the effectiveness of behavioral treatments accounted for their greater abstinence self-efficacy.

CONCLUSIONS

Findings point to the mediating role of expectancies for treatment effectiveness and suggest the importance of exploring expectancies among African Americans and women as a way to augment motivation and self-efficacy.

Predictors of successful and unsuccessful quit attempts among smokers motivated to quit

INTRODUCTION

Despite their positive motivation to quit, many smokers do not attempt to quit or relapse soon after their quit attempt. This study investigated the predictors of successful and unsuccessful quit attempts among smokers motivated to quit smoking.

METHODS

We conducted secondary data analysis among respondents motivated to quit within 6 months, randomized to the control group (N=570) of a Web-based smoking cessation intervention study. Using chi-square tests and ANOVA with Tukey post hoc comparisons, we investigated baseline differences by smoking status (successful quitter/relapse/persistent smoker) assessed after 6 weeks (N=214). To identify independent predictors of smoking status, multivariate multinomial logistic regression analyses were conducted.

RESULTS

Successful quitters at 6-week follow-up (26%) had reported significantly higher baseline levels of self-efficacy than relapsers (45%) and persistent smokers (29%). Furthermore, both successful quitters and relapsers had reported a significantly higher baseline intention to quit than persistent smokers and successful quitters had reported significantly more preparatory planning at baseline than persistent smokers. Results from regression analyses showed that smokers' baseline intention to quit positively predicted quit attempts reported after 6 weeks, while self-efficacy positively predicted quit attempt success.

CONCLUSIONS

Different factors appear to play a role in predicting quit attempts and their success. Whereas intention to quit only appeared to play a role in predicting quit attempts, self-efficacy was the main factor predicting quit attempt success. More research is needed to determine the role of preparatory planning and plan enactment and to investigate whether these findings can be replicated on the long term.

Electronic cigarette use among adult population: a cross-sectional study in Barcelona, Spain (2013-2014)

OBJECTIVE

This study seeks to analyse the prevalence and correlates of electronic cigarette (e-cigarette) use, purchase location and satisfaction with its use in a sample of the general population of the city of Barcelona, Spain.

DESIGN, SETTING AND PARTICIPANTS

We used participants from a longitudinal study of a representative sample of the adult (≥16 years old) population of Barcelona (336 men and 400 women). The field work was conducted between May 2013 and February 2014. We computed the prevalence, adjusted odds ratios (ORs) and their corresponding 95% confidence interval (CI).

RESULTS

The prevalence of ever e-cigarette use was 6.5% (95% CI 4.7% to 8.3%): 1.6% current use, 2.2% past use and 2.7% only e-cigarette experimentation. 75% (95% CI 62.8% to 87.3%) of ever e-cigarette users were current cigarette smokers at the moment of the interview. E-cigarette use was more likely among current smokers (OR=54.57; 95% CI 7.33 to 406.38) and highly dependent cigarette smokers (OR=3.96; 95% CI 1.60 to 9.82). 62.5% of the ever users charged their e-cigarettes with nicotine with 70% of them obtaining the liquids with nicotine in a specialised shop. 39.6% of ever e-cigarette users were not satisfied with their use, a similar percentage of not satisfied expressing the smokers (38.9%) and there were no statistically significant differences in the satisfaction between the users of e-cigarettes with and without nicotine.

CONCLUSIONS

E-cigarette use is strongly associated with current smoking (dual use) and most users continue to be addicted to nicotine. Six out of 10 e-cigarette users preferred devices that deliver nicotine. The satisfaction with e-cigarette use is very low.

Mood, mood regulation, and frontal systems functioning in current smokers, long-term abstinent ex-smokers, and never-smokers

Indices of mood, mood regulation, and executive functioning were examined in 61 current smokers who have smoked daily for at least one year, 36 ex-smokers who had not smoked a cigarette for at least one year, and 86 never-smokers. All participants completed the following measures online: Depression Anxiety Stress Scales (DASS-21), the Negative Mood Regulation (NMR) scale, the Frontal Systems Behavior Scale (FrSBe), the Fagerström Test for Cigarette Dependence (FTCD), and the Alcohol Use Disorders Identification Test (AUDIT). Multivariate analysis of variance (MANOVA) followed by Tukey post-hoc tests revealed significant differences (p < .01) such that current smokers indicated worse functioning than both ex-smokers and never-smokers on DASS, NMR, and FrSBe, as well as heavier drinking as measured by AUDIT. These differences remained significant even after controlling for AUDIT scores. Results most plausibly reflect a return to pre-smoking baseline brain function in long-term abstinent ex-smokers.

Socioeconomic status and the reward value of smoking following tobacco abstinence: a laboratory study

INTRODUCTION

Socioeconomic status (SES) indicators are robustly associated with smoking behaviors. Yet, the psychological mechanisms underlying relations are unclear. This study merged the socioecological construct of SES with laboratory psychological science to investigate how income, education, and employment status predicted the reward value of smoking following tobacco abstinence among a diverse sample of adult daily smokers. We hypothesized that participants with lower SES (i.e., less education, lower income, and unemployed) would experience greater abstinence-induced enhancement of the reward value of smoking.

METHODS

Adult smokers (N = 240; 68.7% male; 51.7% Black, 33.8% White, 7.1% Latino, and 7.5% other) attended 2 laboratory sessions (1 nonabstinent and 1 following 16-hr tobacco abstinence) involving behavioral assessment of (a) latency to smoking when delaying smoking was monetarily rewarded and (b) purchasing individual cigarettes. Generalized estimating equations were used to test the interaction between each SES variable (education, income, and employment) and abstinence state to illustrate whether participants with certain SES characteristics were more sensitive to the abstinence-induced enhancement of the relative reward value of smoking.

RESULTS

Participants who never attended college (vs. college attendees) exhibited greater abstinence-induced enhancement of the reward value of smoking, which was indicated by reduced willingness to delay smoking for money (ps = .03). Income and employment status did not moderate abstinence effects.

CONCLUSIONS

Less-educated smokers were particularly motivated to smoke during acute abstinence. Observed educational disparities in smoking behaviors and smoking cessation might reflect a biased valuation of immediate drug-related (over less immediate alternative) rewards. Future research should explore potential mediators of this association.

Retreatment with varenicline for smoking cessation in smokers who have previously taken varenicline: a randomized, placebo-controlled trial

The efficacy and safety of retreatment with varenicline in smokers attempting to quit were evaluated in this randomized, double-blind, placebo-controlled, multicenter trial (Australia, Belgium, Canada, the Czech Republic, France, Germany, the United Kingdom, and the United States). Participants were generally healthy adult smokers (≥10 cigarettes/day) with ≥1 prior quit attempt (≥2 weeks) using varenicline and no quit attempts in ≤3 months; they were randomly assigned (1:1) to 12 weeks' varenicline (n = 251) or placebo (n = 247) treatment, with individual counseling, plus 40 weeks' nontreatment follow-up. The primary efficacy end point was the carbon monoxide–confirmed (≤10 ppm) continuous abstinence rate for weeks 9–12, which was 45.0% (varenicline; n = 249) vs. 11.8% (placebo; n = 245; odds ratio: 7.08; 95% confidence interval: 4.34, 11.55; P < 0.0001). Common varenicline group adverse events were nausea, abnormal dreams, and headache, with no reported suicidal behavior. Varenicline is efficacious and well tolerated in smokers who have previously taken it. Abstinence rates are comparable with rates reported for varenicline-naive smokers.

The relationship between the nicotine metabolite ratio and three self-report measures of nicotine dependence across sex and race

RATIONALE

Variability in the rate of nicotine metabolism, measured by the nicotine metabolite ratio (NMR), is associated with smoking behavior. However, data linking the NMR with nicotine dependence measured by the Fagerström test for nicotine dependence (FTND) are mixed. Few past studies have examined alternative measures of nicotine dependence and how this relationship may vary by sex and race.

OBJECTIVE

Using data from smokers undergoing eligibility evaluation for a smoking cessation clinical trial (n = 833), this study examined variability in the relationship between NMR and nicotine dependence across sex and race and using three measures of nicotine dependence: FTND, time-to-first-cigarette (TTFC), and the heaviness of smoking index (HSI).

RESULTS

Controlling for sex and race, nicotine metabolism was associated with nicotine dependence only when using the HSI (p < 0.05). Male normal metabolizers of nicotine were more likely to have high nicotine dependence based on the FTND and HSI (p < 0.05), but NMR was not related to measures of nicotine dependence in women. For African Americans, the NMR was associated with nicotine dependence only for the TTFC (p < 0.05), but NMR was not associated with nicotine dependence among Caucasians. Post hoc analyses indicated that the NMR was associated with cigarettes per day, overall, and among men and Caucasians (p < 0.05).

CONCLUSIONS

While there was some variation in the relationship between nicotine metabolism and nicotine dependence across measures and sex and race, the results indicate that this relationship may be more attributable to the association between NMR and cigarettes per day.

Characteristics, perceived side effects and benefits of electronic cigarette use: a worldwide survey of more than 19,000 consumers

Background: Electronic cigarette (EC) use has grown exponentially over the past few years. The purpose of this survey was to assess the characteristics and experiences of a large sample of EC users and examine the differences between those who partially and completely substituted smoking with EC use. Methods: A questionnaire was prepared, translated into 10 different languages and uploaded in an online survey tool. EC users were asked to participate irrespective of their current smoking status. Participants were divided according to their smoking status at the time of participation in two subgroups: former smokers and current smokers. Results: In total, 19,414 participants were included in the analysis, with 88 of them (0.5%) reported not being smokers at the time of EC use initiation. Complete substitution of smoking was reported by 81.0% of participants (former smokers) while current smokers had reduced smoking consumption from 20 to 4 cigarettes per day. They were using ECs for a median of 10 months. They initiated EC use with a median of 18 mg/mL nicotine-concentration liquids; 21.5% used higher than 20 mg/mL. Only 3.5% of participants were using 0-nicotine liquids at the time of the survey. Former smokers were highly dependent (Fagerström Test for Cigarette Dependence = 7) and were heavier smokers (21 cigarettes per day when smoking) compared to current smokers. The most important reasons for initiating EC use for both subgroups was to reduce the harm associated with smoking and to reduce exposure of family members to second-hand smoking. Most considered ECs as less harmful than tobacco cigarettes, while 11.0% considered them absolutely harmless. Side effects were reported by more than half of the participants (59.8%), with the most common being sore/dry mouth and throat; side effects were mild and in most cases were subsequently resolved (partially or completely). Participants experienced significant benefits in physical status and improvements in pre-existing disease conditions (including respiratory disease such as asthma and chronic obstructive lung disease). Being former smoker was independently associated with positive effects in health and improvements in disease conditions. Conclusions: The results of this worldwide survey of dedicated users indicate that ECs are mostly used to avoid the harm associated with smoking. They can be effective even in highly-dependent smokers and are used as long-term substitutes for smoking. High levels of nicotine are used at initiation; subsequently, users try to reduce nicotine consumption, with only a small minority using non-nicotine liquids. Side effects are minor and health benefits are substantial, especially for those who completely substitute smoking with EC use. Further population and interventional studies are warranted.

The acute effects of physical activity on cigarette cravings: exploration of potential moderators, mediators and physical activity attributes using individual participant data (IPD) meta-analyses

RATIONALE

The effects of acute bouts of physical activity (PA) on Strength of Desire (SoD) and Desire to Smoke (DtS) using individual participant data (IPD) from 19 acute randomised controlled studies were quantified. However, there is a need to identify factors influencing this relationship.

OBJECTIVES

To understand who most benefits from PA, whether changes in affect mediate these effects and whether any specific attributes of PA are associated with cigarette cravings.

METHODS

IPD (n = 930) contributed to one-stage IPD meta-analyses. Participants engaging in PA were compared against controls, using post-intervention DtS and SoD (when DtS is not available) with baseline adjustments. The craving scales were linearly rescaled to 0-100 % (a mean difference between groups of -10 would indicate that post-intervention cravings were 10 % lower in the PA compared with the control group). Demographic, smoking and other characteristics were examined as predictors and potential moderators, whereas change in affect was considered as a mediator. PA was categorised according to type, duration and intensity, to determine PA attributes associated with cravings reduction.

RESULTS

None of the included covariates were shown to moderate or mediate the effects of PA. Intensity of PA was significantly associated with a reduction in cravings; moderate and vigorous intensity PA offered the most benefits. A one-stage IPD meta-analysis yielded effect sizes of -9.22 (-15.24; -3.20) for light, -34.57 (-42.64; -26.50) for moderate and -31.29 (-38.00; -24.57) for vigorous intensity in comparison with controls.

CONCLUSIONS

Moderate intensity PA could be recommended to all smokers regardless of demographic, smoking and other characteristics.

Comparison of text and video computer-tailored interventions for smoking cessation: randomized controlled trial

BACKGROUND

A wide range of effective smoking cessation interventions have been developed to help smokers to quit. Smoking rates remain high, especially among people with a lower level of education. Multiple tailoring adapted to the individual's readiness to quit and the use of visual messaging may increase smoking cessation.

OBJECTIVE

The results of video and text computer tailoring were compared with the results of a control condition. Main effects and differential effects for subgroups with different educational levels and different levels of readiness to quit were assessed.

METHODS

During a blind randomized controlled trial, smokers willing to quit within 6 months were assigned to a video computer tailoring group with video messages (n=670), a text computer tailoring group with text messages (n=708), or to a control condition with short generic text advice (n=721). After 6 months, effects on 7-day point prevalence abstinence and prolonged abstinence were assessed using logistic regression analyses. Analyses were conducted in 2 samples: (1) respondents (as randomly assigned) who filled in the baseline questionnaire and completed the first session of the program, and (2) a subsample of sample 1, excluding respondents who did not adhere to at least one further intervention session. In primary analyses, we used a negative scenario in which respondents lost to follow-up were classified as smokers. Complete case analysis and multiple imputation analyses were considered as secondary analyses.

RESULTS

In sample 1, the negative scenario analyses revealed that video computer tailoring was more effective in increasing 7-day point prevalence abstinence than the control condition (OR 1.45, 95% CI 1.09-1.94, P=.01). Video computer tailoring also resulted in significantly higher prolonged abstinence rates than controls among smokers with a low (ready to quit within 4-6 months) readiness to quit (OR 5.13, 95% CI 1.76-14.92, P=.003). Analyses of sample 2 showed similar results, although text computer tailoring was also more effective than control in realizing 7-day point prevalence abstinence. No differential effects were found for level of education. Complete case analyses and multiple imputation yielded similar results.

CONCLUSIONS

In all analyses, video computer tailoring was effective in realizing smoking cessation. Furthermore, video computer tailoring was especially successful for smokers with a low readiness to quit smoking. Text computer tailoring was only effective for sample 2. Results suggest that video-based messages with personalized feedback adapted to the smoker's motivation to quit might be effective in increasing abstinence rates for smokers with diverse educational levels.

TRIAL REGISTRATION

Netherlands Trial Register: NTR3102; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3102 (Archived by WebCite at http://www.webcitation.org/6NS8xhzUV).

Tobacco harm reduction: the need for new products that can compete with cigarettes

Over the last 50 years, the concept of tobacco harm reduction has been well established. It is now understood that nicotine itself is not very harmful and nicotine replacement therapy products have been widely used as an aid to quit, reduce to quit or temporarily abstain from smoking for many years. The popularity of the unlicensed electronic cigarette has increased despite an unknown risk profile and sinus use in Sweden provides strong evidence in support of a harm reduction strategy. The regulatory environment around harm reduction has changed in the UK and is continuing to evolve across the globe. The need for more appealing, licensed nicotine products capable of competing with cigarettes sensorially, pharmacologically and behaviourally is considered by many to be the way forward. The significant positive impact on public health that could be gained from encouraging people to switch from cigarettes to licensed medicinal nicotine products cannot be ignored.

Nicotine absorption from electronic cigarette use: comparison between first and new-generation devices

A wide range of electronic cigarette (EC) devices, from small cigarette-like (first-generation) to new-generation high-capacity batteries with electronic circuits that provide high energy to a refillable atomizer, are available for smokers to substitute smoking. Nicotine delivery to the bloodstream is important in determining the addictiveness of ECs, but also their efficacy as smoking substitutes. In this study, plasma nicotine levels were measured in experienced users using a first- vs. new-generation EC device for 1 hour with an 18 mg/ml nicotine-containing liquid. Plasma nicotine levels were higher by 35-72% when using the new- compared to the first-generation device. Compared to smoking one tobacco cigarette, the EC devices and liquid used in this study delivered one-third to one-fourth the amount of nicotine after 5 minutes of use. New-generation EC devices were more efficient in nicotine delivery, but still delivered nicotine much slower compared to tobacco cigarettes. The use of 18 mg/ml nicotine-concentration liquid probably compromises ECs' effectiveness as smoking substitutes; this study supports the need for higher levels of nicotine-containing liquids (approximately 50 mg/ml) in order to deliver nicotine more effectively and approach the nicotine-delivery profile of tobacco cigarettes.

Acute electronic cigarette use: nicotine delivery and subjective effects in regular users

RATIONALE

Electronic cigarettes are becoming increasingly popular among smokers worldwide. Commonly reported reasons for use include the following: to quit smoking, to avoid relapse, to reduce urge to smoke, or as a perceived lower-risk alternative to smoking. Few studies, however, have explored whether electronic cigarettes (e-cigarettes) deliver measurable levels of nicotine to the blood.

OBJECTIVE

This study aims to explore in experienced users the effect of using an 18-mg/ml nicotine first-generation e-cigarette on blood nicotine, tobacco withdrawal symptoms, and urge to smoke.

METHODS

Fourteen regular e-cigarette users (three females), who are abstinent from smoking and e-cigarette use for 12 h, each completed a 2.5 h testing session. Blood was sampled, and questionnaires were completed (tobacco-related withdrawal symptoms, urge to smoke, positive and negative subjective effects) at four stages: baseline, 10 puffs, 60 min of ad lib use and a 60-min rest period.

RESULTS

Complete sets of blood were obtained from seven participants. Plasma nicotine concentration rose significantly from a mean of 0.74 ng/ml at baseline to 6.77 ng/ml 10 min after 10 puffs, reaching a mean maximum of 13.91 ng/ml by the end of the ad lib puffing period. Tobacco-related withdrawal symptoms and urge to smoke were significantly reduced; direct positive effects were strongly endorsed, and there was very low reporting of adverse effects.

CONCLUSIONS

These findings demonstrate reliable blood nicotine delivery after the acute use of this brand/model of e-cigarette in a sample of regular users. Future studies might usefully quantify nicotine delivery in relation to inhalation technique and the relationship with successful smoking cessation/harm reduction.

A quasi-hyperbolic discounting approach to smoking behavior

Addiction has attracted considerable attention in health and behavioral economics, and economists have attempted to understand addiction from the viewpoint of decision making over time. This paper investigates whether two time preference parameters can successfully predict smoking status, including cigarette dependence. Both the present bias and the constant time preference parameters account for smoking behavior status and cigarette dependence.