Smoker characteristics and smoking-cessation milestones

Retrospective analysis of changing characteristics of treatment-seeking smokers: implications for further reducing smoking prevalence

OBJECTIVE

The goal of the current study was to empirically compare successive cohorts of treatment-seeking smokers who enrolled in randomised clinical trials in a region of the USA characterised by strong tobacco control policies and low smoking prevalence, over the past three decades.

DESIGN

Retrospective treatment cohort comparison.

SETTING

Data were collected from 9 randomised clinical trials conducted at Stanford University and the University of California, San Francisco, between 1990 and 2013.

PARTICIPANTS

Data from a total of 2083 participants were included (Stanford, n=1356; University of California San Francisco, n=727).

PRIMARY AND SECONDARY OUTCOMES

One-way analysis of variance and covariance, χ(2) and logistic regression analyses were used to examine relations between nicotine dependence, cigarettes per day, depressive symptoms and demographic characteristics among study cohorts.

RESULTS

Similar trends were observed at both settings. When compared to earlier trials, participants in more recent trials smoked fewer cigarettes, were less nicotine-dependent, reported more depressive symptoms, were more likely to be male and more likely to be from a minority ethnic/racial group, than those enrolled in initial trials (all p's<0.05). Analysis of covariances revealed that cigarettes per day, nicotine dependence and current depressive symptom scores were each significantly related to trial (all p's<0.001).

CONCLUSIONS

Our findings suggest that more recent smoking cessation treatment-seeking cohorts in a low prevalence region were characterised by less smoking severity, more severe symptoms of depression and were more likely to be male and from a minority racial/ethnic group.

Insomnia symptoms as a risk factor for cessation failure following smoking treatment

Insomnia symptoms are associated with smoking, and may interfere with smoking cessation. Specifically, studies have shown that smoking-related sleep problems are associated with long-term smoking relapse, and longer sleep duration is associated with successful smoking cessation. However, it is currently unclear whether pre- or post-quit insomnia symptoms are associated with smoking cessation outcomes. As such, the current study aimed to extend previous findings by using a measure of insomnia symptoms as a predictor of smoking cessation failure by month 3 following smoking cessation treatment. Additionally, we examined whether post-quit insomnia symptoms predicted cessation outcomes. Results indicated that pre-, but not post-quit insomnia, predicted smoking cessation failure by 3 months post-cessation, after covarying for depressive symptoms, anxiety sensitivity, alcohol use disorder severity, treatment condition, and number of cigarettes per day. These findings add to the literature on insomnia symptoms as a risk factor for difficulties with smoking cessation, and suggest it may be a worthy clinical target for smoking populations who are interested in quitting smoking.

Severity of dependence modulates smokers' functional connectivity in the reward circuit: a preliminary study

RATIONALE

Nicotine dependence is characterized as a neural circuit dysfunction, particularly with regard to the reward circuit. Although dependence severity moderates cue reactivity in the brain regions involved in reward processing, the direction of its influence remains controversial.

OBJECTIVES

Investigating the functional organization of the reward circuit may provide complementary information. Here, we used resting-state functional connectivity (rsFC) to evaluate the integrity of the reward circuit in smokers with different severities of nicotine dependence.

METHODS

Totals of 65 smokers and 37 non-smokers underwent resting-state functional magnetic resonance imaging (fMRI). The smokers were divided into low-dependent (FTND < 5, n = 26) and high-dependent smoker groups (FTND ≥ 5, n = 39) based on their nicotine-dependence severity (as measured by the Fagerström test for nicotine dependence [FTND]). The region of interest (ROI)-wise rsFC within the reward circuit was compared between smokers and non-smokers as well as between low-dependent and high-dependent smokers and then correlated with smokers' FTND scores.

RESULTS

Widespread rsFC attenuation was observed in the reward circuit of smokers compared with non-smokers. Compared with low-dependent smokers, high-dependent smokers showed greater rsFC between the right amygdala and the left nucleus accumbens (NAcc) as well as between the bilateral hippocampus. Furthermore, a positive correlation between the inter-hippocampus rsFC and the severity of nicotine dependence (FTND) was detected among all smokers (r = 0.416, p = 0.001).

CONCLUSIONS

Our results indicate a dysfunction of the reward circuit in nicotine-dependent individuals. Moreover, our study improves the understanding of the neuroplastic changes that occur during the development of nicotine dependence.

Dependence and motivation to stop smoking as predictors of success of a quit attempt among smokers seeking help to quit

INTRODUCTION

It is not known how well motivation to stop smoking predicts abstinence in a clinical sample relative to the most widely used measure of cigarette dependence.

METHODS

A secondary analysis was conducted from a trial with 864 smokers making quit attempt. Fagerström Test of Cigarette Dependence (FTCD), Heaviness of Smoking Index (HSI), and motivation to stop smoking (composite of determination to quit and importance of quitting) were measured at baseline. Continuous smoking abstinence, validated by expired-air carbon monoxide, was assessed at 4weeks, 6months and 12months post-quit date. FTCD, HSI, non-HSI items in FTCD, and motivation were assessed as predictors of abstinence.

RESULTS

In multiple-logistic regressions, controlling for age, gender and medication use, lower scores for FTCD, HSI and non-HSI all significantly predicted abstinence at all follow-ups, while motivation did not predict abstinence at any time. Likelihood ratio tests showed that the FTCD contributed most to the model at 4weeks and 6months; at 12months FTCD and non-HSI equally contributed most to the model. At 4weeks and 6months, predictions were improved by combining HSI and non-HSI components, compared with using these components alone.

CONCLUSIONS

Cigarette dependence, measured by the FTCD, or by its HSI or non-HSI components, predicts both short-term and medium-term outcomes of attempts to stop smoking in treatment-seeking smokers involved in a clinical trial, whereas strength of motivation to stop predicts neither. Both the HSI and non-HSI components may be considered as briefer alternatives to the full FTCD.

Smoking-Specific Experiential Avoidance is Indirectly Associated with Trait Worry and Smoking Processes among Treatment-Seeking Smokers

Limited work has examined worry, or apprehensive anticipation about future negative events, in terms of smoking. One potential explanatory factor is the tendency to respond inflexibly and with avoidance in the presence of smoking-related distress (smoking-specific experiential avoidance). Participants (n = 465) were treatment-seeking daily smokers. Cross-sectional (pre-treatment) self-report data were utilized to assess trait worry, smoking-specific experiential avoidance, and four smoking criterion variables: nicotine dependence, motivational aspects of quitting, perceived barriers to smoking cessation, and severity of problematic symptoms reported in past quit attempts. Trait worry was significantly associated with greater levels of nicotine dependence, motivation to quit smoking, perceived barriers for smoking cessation, and more severe problems while quitting in the past; associations occurred indirectly through higher levels of smoking-specific experiential avoidance. Findings provide initial support for the potential role of smoking-specific experiential avoidance in explaining the association between trait worry and a variety of smoking processes.

Rates and predictors of renewed quitting after relapse during a one-year follow-up among primary care patients

BACKGROUND

Most people who quit smoking relapse within a year of quitting. Little is known about what prompts renewed quitting after relapse or how often this results in abstinence.

PURPOSE

This study seeks to identify rates, efficacy, and predictors of renewed quit attempts after relapse during a 1-year follow-up.

METHODS

Primary care patients in a comparative effectiveness trial of smoking cessation pharmacotherapies reported daily smoking every 6-12 weeks for 12 months to determine relapse, renewed quitting, and 12-month abstinence rates.

RESULTS

Of 894 known relapsers, 291 (33%) renewed quitting for at least 24 h, and 99 (34%) of these were abstinent at follow-up. The average latency to renewed quitting was 106 days and longer latencies predicted greater success. Renewed quitting was more likely for older, male, less dependent smokers, and later abstinence was predicted by fewer depressive symptoms and longer past abstinence.

CONCLUSIONS

Renewed quitting is common and produces meaningful levels of cessation.

Resting-state functional connectivity and nicotine addiction: prospects for biomarker development

Given conceptual frameworks of addiction as a disease of intercommunicating brain networks, examinations of network interactions may provide a holistic characterization of addiction-related dysfunction. One such methodological approach is the examination of resting-state functional connectivity, which quantifies correlations in low-frequency fluctuations of the blood oxygen level-dependent magnetic resonance imaging signal between disparate brain regions in the absence of task performance. Here, evidence of differentiated effects of chronic nicotine exposure, which reduces the efficiency of network communication across the brain, and acute nicotine exposure, which increases connectivity within specific limbic circuits, is discussed. Several large-scale resting networks, including the salience, default, and executive control networks, have also been implicated in nicotine addiction. The dynamics of connectivity changes among and between these large-scale networks during nicotine withdrawal and satiety provide a heuristic framework with which to characterize the neurobiological mechanism of addiction. The ability to simultaneously quantify effects of both chronic (trait) and acute (state) nicotine exposure provides a platform to develop a neuroimaging-based addiction biomarker. While such development remains in its early stages, evidence of coherent modulations in resting-state functional connectivity at various stages of nicotine addiction suggests potential network interactions on which to focus future addiction biomarker development.

Tobacco withdrawal symptoms mediate motivation to reinstate smoking during abstinence

Withdrawal-based theories of addiction hypothesize that motivation to reinstate drug use following acute abstinence is mediated by withdrawal symptoms. Experimental tests of this hypothesis in the tobacco literature are scant and may be subject to methodological limitations. This study utilized a robust within-subject laboratory experimental design to investigate the extent to which composite tobacco withdrawal symptomatology level and 3 unique withdrawal components (i.e., low positive affect, negative affect, and urge to smoke) mediated the effect of smoking abstinence on motivation to reinstate smoking. Smokers (≥10 cigarettes per day; N = 286) attended 2 counterbalanced sessions at which abstinence duration was differentially manipulated (1 hr vs. 17 hr). At both sessions, participants reported current withdrawal symptoms and subsequently completed a task in which they were monetarily rewarded proportional to the length of time they delayed initiating smoking, with shorter latency reflecting stronger motivation to reinstate smoking. Abstinence reduced latency to smoking initiation and positive affect and increased composite withdrawal symptom level, urge, and negative affect. Abstinence-induced reductions in latency to initiating smoking were mediated by each withdrawal component, with stronger effects operating through urge. Combined analyses suggested that urge, negative affect, and low positive affect operate through empirically unique mediational pathways. Secondary analyses suggested similar effects on smoking quantity, few differences among specific urge and affect subtypes, and that dependence amplifies some abstinence effects. This study provides the first experimental evidence that within-person variation in abstinence impacts motivation to reinstate drug use through withdrawal. Urge, negative affect, and low positive affect may reflect unique withdrawal-mediated mechanisms underlying tobacco addiction.

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.

Working memory-related neural activity predicts future smoking relapse

Brief abstinence from smoking impairs cognition, particularly executive function, and this has a role in relapse to smoking. This study examined whether working memory-related brain activity predicts subsequent smoking relapse above and beyond standard clinical and behavioral measures. Eighty treatment-seeking smokers completed two functional magnetic resonance imaging sessions (smoking satiety vs 24 h abstinence challenge) during performance of a visual N-back task. Brief counseling and a short-term quit attempt followed. Relapse during the first 7 days was biochemically confirmed by the presence of the nicotine metabolite cotinine. Mean percent blood oxygen level-dependent (BOLD) signal change was extracted from a priori regions of interest: bilateral dorsolateral prefrontal cortex (DLPFC), medial frontal/cingulate gyrus, posterior cingulate cortex (PCC), and ventromedial prefrontal cortex. Signal from these brain regions and additional clinical measures were used to model outcome status, which was then validated with resampling techniques. Relapse to smoking was predicted by increased withdrawal symptoms, decreased left DLPFC and increased PCC BOLD percent signal change (abstinence vs smoking satiety). Receiver operating characteristic analysis demonstrated 81% area under the curve using these predictors, a significant improvement over the model with clinical variables only. The combination of abstinence-induced decreases in left DLPFC activation and reduced suppression of PCC may be a prognostic marker for poor outcome, specifically early smoking relapse.

Time-varying processes involved in smoking lapse in a randomized trial of smoking cessation therapies

INTRODUCTION

Researchers have increasingly begun to gather ecological momentary assessment (EMA) data on smoking, but new statistical methods are necessary to fully unlock information from such data. In this paper, we use a new technique, the logistic time-varying effect model (logistic TVEM), to examine the odds of smoking in the 2 weeks after a quit attempt.

METHODS

Data are from a subsample of participants from a randomized, placebo-controlled trial of smoking cessation pharmacotherapies who achieved initial abstinence (N = 1,106, 58% female). Participants completed up to 4 EMA assessments per day during the 2 weeks after their quit day. Predictors include baseline nicotine dependence, EMA measures of craving and negative affect, and whether an individual was assigned to a placebo, monotherapy, or combination therapy condition. Time-varying effects of these predictors were estimated using logistic TVEM.

RESULTS

Cravings were a significant predictor of smoking throughout the entire 2 weeks postquit, whereas the effect of baseline dependence became nonsignificant by the second week, and the effect of negative affect increased over time. Individuals in the monotherapy and combination therapy conditions had decreased odds of smoking compared with placebo in the first week postquit, but these differences were nonsignificant in the second week.

CONCLUSIONS

Findings suggest that pharmacotherapies are more effective compared with placebo earlier in a quit attempt, when the effect of baseline nicotine dependence on smoking is stronger, whereas the effect of craving and negative affect increased over time. Future cessation therapies may be more successful by providing additional support in the second week after quit attempt.

Reasons for smoking cessation attempts among Japanese male smokers vary by nicotine dependence level: a cross-sectional study after the 2010 tobacco tax increase

OBJECTIVES

To examine the association between smoking cessation attempts during the previous 12 months, motivators to quit smoking and nicotine dependence levels among current male smokers after Japan's massive 2010 tobacco tax increase.

DESIGN

Cross-sectional study.

SETTING

A self-reported questionnaire about smoking habits, nicotine dependence levels and factors identified as motivators to quit smoking was administered to 9378 employees working at a company located in Fukuoka Prefecture in Japan (as of 1 October 2011).

PARTICIPANTS

A total of 2251 male current smokers 20-69 years old.

PRIMARY AND SECONDARY OUTCOME MEASURES

Nicotine dependence level assessed by Fagerström Test for Cigarette Dependence (FTCD), smoking cessation attempts during the previous 12 months and motivators for smoking cessation.

RESULTS

The proportion of current smokers who had attempted to quit smoking within the previous 12 months was 40.6%. Nicotine dependence level of current smokers was negatively associated with cessation attempts during the previous 12 months. Motivators for smoking cessation differed by nicotine dependence levels. 'The rise in cigarette prices since October 2010' as a smoking cessation motivator increased significantly at the medium nicotine dependence level (OR 1.44, 95% CI 1.09 to 1.90); however, this association was not statistically significant for individuals with high nicotine dependence (OR 1.24, 95% CI 0.80 to 1.92). 'Feeling unhealthy' was significantly negatively associated for medium (OR 0.42, 95% CI 0.27 to 0.65) and high (OR 0.31, 95% CI 0.14 to 0.71) nicotine dependence levels. Trend associations assessed by assigning ordinal numbers to total FTCD score for those two motivators were statistically significant.

CONCLUSIONS

The efficacy of smoking cessation strategies can be improved by considering the target group's nicotine dependence level. For smokers with medium and high nicotine dependence levels, more effective strategies aimed at encouraging smoking cessation, such as policy interventions including increasing tobacco taxes, are needed.

Using ecological measures of smoking trigger exposure to predict smoking cessation milestones

This study used ecological momentary assessment data from adult daily smokers attempting to quit smoking to assess relations between exposure to contextual risk factors and cessation failure, latency to a first smoking lapse, or progression from lapse to relapse (smoking 7 days in a row). Participants were adult, daily smokers enrolled in a randomized controlled clinical trial of bupropion SR and individual counseling who were followed to 1 year postquit. Participants reported exposure to high-risk contexts and behaviors, including being where cigarettes were available or smoking was permitted, being around others smoking in prospective, real-time assessment for 2 weeks pre- and 4 weeks postquit. Results showed that greater exposure to contextual risk factors during the prequit did not predict cessation failure. However, Cox regression survival analyses revealed that spending a greater proportion of time where cigarettes were easily available following at least 1 day of abstinence predicted shorter latency to a first lapse, even after controlling for baseline risk factors such as gender, nicotine dependence, depressive symptoms, and living with a smoker. Greater cigarette availability following a lapse was not associated with progression from lapse to relapse with or without baseline risk factors in the model. This suggests that postquit environmental risk factors, such as cigarette availability, increase lapse risk, and stable risk factors, such as living with smokers and higher baseline carbon monoxide level or depressive symptoms, remain potent predictors of progression to relapse. Real-time contextual risk assessments postquit predict lapse above and beyond stable, baseline risk factors. (PsycINFO Database Record

With others or alone? Adolescent individual differences in the context of smoking lapses

OBJECTIVE

Although a great deal of adolescent smoking research has investigated predictors of initiation, much less has focused on predictors of lapsing during a quit attempt. In particular, the role of social context may deserve greater attention in models of adolescent smoking cessation. Therefore, the present investigation aimed to use ecological momentary assessment (EMA) to examine individual differences in social lapsing--the extent to which lapses occur around others versus when alone.

METHODS

Analyses focused on 179 adolescent smokers (aged 14-18 years) engaged in an unassisted quit attempt. There were 2 general EMA assessment intervals: prequit (1 week) and postquit (2 weeks). Participants reported every time that they smoked a cigarette and at random, nonsmoking times; in each assessment, participants responded to questions about their current environment, behaviors, and psychological state. A 3-month follow-up assessed longer-term smoking-related outcomes.

RESULTS

Consistent with other adolescent research, the overall rate of lapsing was very high (93%). Social lapsing rates were likewise high (among those who lapsed, 73% reported their first lapse was social), but they also varied continuously across individuals. We computed a social lapsing coefficient for each youth and found that it related to smoking factors at baseline (e.g., lower smoking intensity and dependence) and follow-up (e.g., lower cotinine levels).

CONCLUSIONS

These results suggest that higher rates of social lapsing are associated with being a lighter, less dependent smoker and having better eventual cessation prospects. Findings provide evidence that accounting for variability in social lapsing may improve theory and treatment.

Combining varenicline and nicotine patches: a randomized controlled trial study in smoking cessation

BACKGROUND

Some smokers may benefit from a therapy that combines different nicotine replacement therapies (NRT) or drugs with different mechanisms of action.The aim of this study was to determine the efficacy of the combined therapy of varenicline and nicotine patches versus varenicline monotherapy.

METHODS

Three hundred forty-one smokers who smoked 20 or more cigarettes per day were recruited from a smoking cessation clinic between February 2012 and June 2013. The participants were randomized to receive a varenicline plus nicotine patch of 21 mg every 24 hours (170) or varenicline plus a placebo patch (171). All of the smokers received a standard 12-week course of varenicline and an 11-week course of either the placebo patch or the active patch after the target quit day. Both groups received behavioral support. The primary outcome was continuous abstinence for weeks 2 through 12 confirmed by exhaled levels of carbon monoxide. Post hoc subgroup analyses were performed to evaluate the treatment effects for a specific endpoint in subgroups of smokers.

RESULTS

The combination of the nicotine patch with varenicline was not associated with higher rates of continuous abstinence at 12 weeks (39.1% versus 31.8%; odds ratio (OR) 1.24; 95% confidence interval (CI) 0.8 to 2.6) and 24 weeks (32.8% versus 28.2%; OR 1.17; 95% CI 0.4 to 1.9). When participants were analyzed by subgroups according to cigarette consumption, the abstinence rates among smokers who smoked more than 29 cigarettes per day at 12 weeks (OR 1.39; 95% CI 1.2 to 2.5) and 24 weeks (OR 1.46; 95% CI 1.2 to 2.8) were significantly higher in the combination group. Other post hoc analyses based on level of dependence and previous quit attempts did not show subgroup differences. No differences between the groups for the reported adverse events were observed (χ2 value 0.07; P 0.79).

CONCLUSIONS

The combination of varenicline with the nicotine patch does not improve abstinence rates at 12 and 24 weeks compared with varenicline used as monotherapy when all smokers were analyzed as a whole, independent of consumption level.

TRIAL REGISTRATION

This study is registered at clinicaltrial.gov (NCT01538394).

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.

Do ethnicity and gender moderate the influence of posttraumatic stress disorder on time to smoking lapse?

BACKGROUND

Following a smoking cessation attempt, smokers with posttraumatic stress disorder (PTSD) experience smoking relapse at a higher and faster rate. Black ethnicity and female gender are also associated with lower success rates following smoking cessation. No study to date has prospectively examined how ethnicity and gender may moderate the effect of PTSD on smoking relapse. It was hypothesized that female gender and Black ethnicity would significantly predict early lapse after quitting; further, it was predicted that ethnicity and gender would moderate the effect of PTSD on relapse rate.

METHODS

Smokers with PTSD (n=48) and without PTSD (n=56) completed ecological momentary assessment (EMA) the week after a quit date, and self-initiated EMA entries after smoking lapse. Smoking abstinence was biologically verified. The sample included Black (62%) and White (38%) participants, and was 50% female. Study hypotheses were tested with Cox proportional hazards regression modeling time to first smoking lapse.

RESULTS

Study results confirmed the main hypothesis, with a significant PTSD × Ethnicity interaction emerging. The effect of PTSD on smoking relapse was significant for White participants but not for Black participants. No significant gender moderation was found.

CONCLUSION

Taken together, study results support previous research, and suggest that the relationship between smoking and PTSD is stronger for White smokers than for minorities. This study has significant implications for research in smoking and mental disease, as well as for smoking cessation treatments for Black smokers.

Brain nicotinic acetylcholine receptor availability and response to smoking cessation treatment: a randomized trial

IMPORTANCE

Cigarette smoking leads to upregulation of nicotinic acetylcholine receptors (nAChRs) in the human brain, including the common α4β2* nAChR subtype. While subjective aspects of tobacco dependence have been extensively examined as predictors of quitting smoking with treatment, no studies to our knowledge have yet reported the relationship between the extent of pretreatment upregulation of nAChRs and smoking cessation.

OBJECTIVE

To determine whether the degree of nAChR upregulation in smokers predicts quitting with a standard course of treatment.

DESIGN, SETTING, AND PARTICIPANTS

Eighty-one tobacco-dependent cigarette smokers (volunteer sample) underwent positron emission tomographic (PET) scanning of the brain with the radiotracer 2-FA followed by 10 weeks of double-blind, placebo-controlled treatment with nicotine patch (random assignment). Pretreatment specific binding volume of distribution (VS/fP) on PET images (a value that is proportional to α4β2* nAChR availability) was determined for 8 brain regions of interest, and participant-reported ratings of nicotine dependence, craving, and self-efficacy were collected. Relationships between these pretreatment measures, treatment type, and outcome were then determined. The study took place at academic PET and clinical research centers.

MAIN OUTCOMES AND MEASURES

Posttreatment quit status after treatment, defined as a participant report of 7 or more days of continuous abstinence and an exhaled carbon monoxide level of 3 ppm or less.

RESULTS

Smokers with lower pretreatment VS/fP values (a potential marker of less severe nAChR upregulation) across all brain regions studied were more likely to quit smoking (multivariate analysis of covariance, F8,69 = 4.5; P < .001), regardless of treatment group assignment. Furthermore, pretreatment average VS/fP values provided additional predictive power for likelihood of quitting beyond the self-report measures (stepwise binary logistic regression, likelihood ratio χ21 = 19.8; P < .001).

CONCLUSIONS AND RELEVANCE

Smokers with less upregulation of available α4β2* nAChRs have a greater likelihood of quitting with treatment than smokers with more upregulation. In addition, the biological marker studied here provided additional predictive power beyond subjectively rated measures known to be associated with smoking cessation outcome. While the costly, time-consuming PET procedure used here is not likely to be used clinically, simpler methods for examining α4β2* nAChR upregulation could be tested and applied in the future to help determine which smokers need more intensive and/or lengthier treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01526005.

Associations of attention-deficit hyperactivity disorder symptom dimensions with smoking deprivation effects in adult smokers

Identifying relations of attention deficit hyperactivity disorder (ADHD) symptom dimensions to individual facets of the tobacco withdrawal syndrome could elucidate the mechanisms linking ADHD and regular smoking. This study examined the unique relations of inattention (IN) and hyperactivity-impulsivity (HI) symptom dimensions of ADHD to a variety of tobacco withdrawal symptoms. One hundred thirty-two community-dwelling adult smokers recruited without regard to ADHD status completed a self-report measure of ADHD symptoms experienced over the past 6 months at a baseline visit. At two subsequent experimental sessions (one following overnight tobacco deprivation and one nondeprived; order counterbalanced), participants completed measures of tobacco withdrawal symptoms, mood, and desire to smoke. Preliminary analyses showed that higher levels of IN and HI symptoms were both associated with higher levels of negative affect and concentration difficulties during nondeprived ("baseline") states (ps < .01). Over and above nondeprived ratings, higher levels of HI symptoms were associated with larger deprivation-induced increases in negative affect, concentration problems, and desire to smoke, particularly for negative affect relief, during deprived states (ps < .01). ADHD symptoms, particularly HI symptoms, are associated with more severe exacerbations in abstinence-induced withdrawal symptoms, which could be an important mechanism of ADHD-smoking comorbidity. These findings suggest the need for clinical studies examining the role of these unique and potentially more severe withdrawal profiles experienced by smokers with high-levels of ADHD symptoms in smoking reinstatement and cessation outcomes.

Antidepressants for smoking cessation

BACKGROUND

There are at least three reasons to believe antidepressants might help in smoking cessation. Firstly, nicotine withdrawal may produce depressive symptoms or precipitate a major depressive episode and antidepressants may relieve these. Secondly, nicotine may have antidepressant effects that maintain smoking, and antidepressants may substitute for this effect. Finally, some antidepressants may have a specific effect on neural pathways (e.g. inhibiting monoamine oxidase) or receptors (e.g. blockade of nicotinic-cholinergic receptors) underlying nicotine addiction.

OBJECTIVES

The aim of this review is to assess the effect and safety of antidepressant medications to aid long-term smoking cessation. The medications include bupropion; doxepin; fluoxetine; imipramine; lazabemide; moclobemide; nortriptyline; paroxetine; S-Adenosyl-L-Methionine (SAMe); selegiline; sertraline; St. John's wort; tryptophan; venlafaxine; and zimeledine.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register which includes reports of trials indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO, and other reviews and meeting abstracts, in July 2013.

SELECTION CRITERIA

We considered randomized trials comparing antidepressant medications to placebo or an alternative pharmacotherapy for smoking cessation. We also included trials comparing different doses, using pharmacotherapy to prevent relapse or re-initiate smoking cessation or to help smokers reduce cigarette consumption. We excluded trials with less than six months follow-up.

DATA COLLECTION AND ANALYSIS

We extracted data and assessed risk of bias using standard methodological procedures expected by the Cochrane Collaboration.The main outcome measure was abstinence from smoking after at least six months follow-up in patients smoking at baseline, expressed as a risk ratio (RR). We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

Twenty-four new trials were identified since the 2009 update, bringing the total number of included trials to 90. There were 65 trials of bupropion and ten trials of nortriptyline, with the majority at low or unclear risk of bias. There was high quality evidence that, when used as the sole pharmacotherapy, bupropion significantly increased long-term cessation (44 trials, N = 13,728, risk ratio [RR] 1.62, 95% confidence interval [CI] 1.49 to 1.76). There was moderate quality evidence, limited by a relatively small number of trials and participants, that nortriptyline also significantly increased long-term cessation when used as the sole pharmacotherapy (six trials, N = 975, RR 2.03, 95% CI 1.48 to 2.78). There is insufficient evidence that adding bupropion (12 trials, N = 3487, RR 1.9, 95% CI 0.94 to 1.51) or nortriptyline (4 trials, N = 1644, RR 1.21, 95% CI 0.94 to 1.55) to nicotine replacement therapy (NRT) provides an additional long-term benefit. Based on a limited amount of data from direct comparisons, bupropion and nortriptyline appear to be equally effective and of similar efficacy to NRT (bupropion versus nortriptyline 3 trials, N = 417, RR 1.30, 95% CI 0.93 to 1.82; bupropion versus NRT 8 trials, N = 4096, RR 0.96, 95% CI 0.85 to 1.09; no direct comparisons between nortriptyline and NRT). Pooled results from four trials comparing bupropion to varenicline showed significantly lower quitting with bupropion than with varenicline (N = 1810, RR 0.68, 95% CI 0.56 to 0.83). Meta-analyses did not detect a significant increase in the rate of serious adverse events amongst participants taking bupropion, though the confidence interval only narrowly missed statistical significance (33 trials, N = 9631, RR 1.30, 95% CI 1.00 to 1.69). There is a risk of about 1 in 1000 of seizures associated with bupropion use. Bupropion has been associated with suicide risk, but whether this is causal is unclear. Nortriptyline has the potential for serious side-effects, but none have been seen in the few small trials for smoking cessation.There was no evidence of a significant effect for selective serotonin reuptake inhibitors on their own (RR 0.93, 95% CI 0.71 to 1.22, N = 1594; 2 trials fluoxetine, 1 paroxetine, 1 sertraline) or as an adjunct to NRT (3 trials of fluoxetine, N = 466, RR 0.70, 95% CI 0.64 to 1.82). Significant effects were also not detected for monoamine oxidase inhibitors (RR 1.29, 95% CI 0.93 to 1.79, N = 827; 1 trial moclobemide, 5 selegiline), the atypical antidepressant venlafaxine (1 trial, N = 147, RR 1.22, 95% CI 0.64 to 2.32), the herbal therapy St John's wort (hypericum) (2 trials, N = 261, RR 0.81, 95% CI 0.26 to 2.53), or the dietary supplement SAMe (1 trial, N = 120, RR 0.70, 95% CI 0.24 to 2.07).

AUTHORS' CONCLUSIONS

The antidepressants bupropion and nortriptyline aid long-term smoking cessation. Adverse events with either medication appear to rarely be serious or lead to stopping medication. Evidence suggests that the mode of action of bupropion and nortriptyline is independent of their antidepressant effect and that they are of similar efficacy to nicotine replacement. Evidence also suggests that bupropion is less effective than varenicline, but further research is needed to confirm this finding. Evidence suggests that neither selective serotonin reuptake inhibitors (e.g. fluoxetine) nor monoamine oxidase inhibitors aid cessation.

Influence of a dopamine pathway additive genetic efficacy score on smoking cessation: results from two randomized clinical trials of bupropion

AIMS

To evaluate the associations of treatment and an additive genetic efficacy score (AGES) based on dopamine functional polymorphisms with time to first smoking lapse and point prevalence abstinence at end of treatment among participants enrolled into two randomized clinical trials of smoking cessation therapies.

DESIGN

Double-blind pharmacogenetic efficacy trials randomizing participants to active or placebo bupropion. Study 1 also randomized participants to cognitive-behavioral smoking cessation treatment (CBT) or this treatment with CBT for depression. Study 2 provided standardized behavioural support.

SETTING

Two hospital-affiliated clinics (study 1), and two university-affiliated clinics (study 2).

PARTICIPANTS

A total of 792 self-identified white treatment-seeking smokers aged ≥18 years smoking ≥10 cigarettes per day over the last year.

MEASUREMENTS

Age, gender, Fagerström Test for Nicotine Dependence, dopamine pathway genotypes (rs1800497 [ANKK1 E713K], rs4680 [COMT V158M], DRD4 exon 3 variable number of tandem repeats polymorphism [DRD4 VNTR], SLC6A3,3' VNTR) analyzed both separately and as part of an AGES, time to first lapse and point prevalence abstinence at end of treatment.

FINDINGS

Significant associations of the AGES (hazard ratio [HR] = 1.10, 95% confidence interval [CI] = 1.06-1.14, P = 0.009) and of the DRD4 VNTR (HR = 1.29, 95% CI = 1.17-1.41, P = 0.0073) were observed with time to first lapse. A significant AGES by pharmacotherapy interaction was observed (β standard error = -0.18 [0.07], P = 0.016), such that AGES predicted risk for time to first lapse only for individuals randomized to placebo.

CONCLUSIONS

A score based on functional polymorphisms relating to dopamine pathways appears to predict lapse to smoking following a quit attempt, and the association is mitigated in smokers using bupropion.

Anhedonia, depressed mood, and smoking cessation outcome

OBJECTIVE

Although the relation between lifetime depression and smoking cessation outcome has been well studied, the proposition that different symptomatic expressions of depression exert disparate predictive effects on risk of smoking cessation failure has largely gone uninvestigated. This study analyzed the individual contributions of depression's 2 hallmark affective symptoms, anhedonia (i.e., diminished interest in normally enjoyable activities) and depressed mood (i.e., elevated sadness), to the prediction of smoking cessation outcome.

METHOD

Participants were adult daily smokers (N = 1,469; mean age = 45 years, 58% female, 84% White) enrolled in a smoking cessation treatment study. Lifetime history of anhedonia and depressed mood were classified via structured interview prior to quit day. Seven-day point prevalence smoking abstinence was assessed at 8 weeks and 6 months postquit.

RESULTS

When examined separately, both lifetime anhedonia, OR (95% CI) = 1.42 (1.16, 1.73), p = .004, and depressed mood, OR (95% CI) = 1.35 (1.11, 1.63), p = .002, predicted increased odds of relapse. These relations remained after adjusting for covariates, including lifetime depressive disorder, which did not predict outcome. After controlling for the covariation between lifetime anhedonia and depressed mood, anhedonia predicted cessation outcome, OR (95% CI) = 1.31 (1.05, 1.62), p = .02, while depressed mood did not (p = .19). Symptom duration (>2 weeks), treatment, and substance use disorder did not modify relations of lifetime anhedonia and depressed mood with cessation outcome.

CONCLUSIONS

Results suggest that (1) symptoms of affective disturbance capture depression-relevant risk of cessation failure, which is not adequately demarcated by the lifetime depressive disorder diagnosis, and (2) anhedonia is a more sensitive index of this affective disturbance than depressed mood per se. Clinical attention to anhedonia may facilitate smoking cessation.

Early lapses in a cessation attempt: lapse contexts, cessation success, and predictors of early lapse

INTRODUCTION

The great majority of smokers relapse when they make quit attempts. Therefore, understanding the process of relapse may guide the development of more effective smoking cessation or relapse prevention treatments. The goal of this research is to extend our understanding of the context of initial lapses that occur within 8 weeks of quitting by using more comprehensive assessments of context, a contemporary sample, and sophisticated analytic techniques.

METHODS

Participants from a randomized controlled smoking cessation trial completed baseline assessments of demographics and tobacco dependence, a daily smoking calendar to determine latency to lapse and relapse (7 consecutive days of smoking), and an assessment of initial lapse context (affect, location, activity, interpersonal, smoke exposure, and cigarette availability). Latent class analysis (LCA) was used to analyze the 6 early lapse (within the first 8 weeks; N = 551) context dimensions; logistic regression and Cox regression were used to relate context to cessation outcomes.

RESULTS

LCA revealed 5 distinct initial lapse context classes (talking, with friends, angry; social; alone; with spouse, angry; and with smoking spouse) that were differentially related to cessation outcome. The easy availability of cigarettes characterized almost 75% of lapses, but being with friends, drinking, and not being at home were associated with a lower likelihood of progression to relapse.

CONCLUSIONS

Early lapsing is highly related to ultimate relapse, and lapsing in frequently experienced contexts seemed most strongly linked with progression to full relapse.

Advancing the understanding of craving during smoking cessation attempts: a demonstration of the time-varying effect model

INTRODUCTION

Advancing the understanding of smoking cessation requires a complex and nuanced understanding of behavior change. To this end, ecological momentary assessments (EMA) are now being collected extensively. The time-varying effect model (TVEM) is a statistical technique ideally suited to model processes that unfold as behavior and nicotine dependence change. Coefficients are expressed dynamically over time and are represented as smooth functions of time.

METHODS

The TVEM approach is demonstrated using data from a smoking-cessation trial. Time-varying effects of baseline nicotine dependence (a time-invariant covariate) and negative affect (a time-varying covariate) on urge to smoke during a quit attempt were estimated for monotherapy, combination therapy, and placebo groups. SAS syntax for conducting TVEM is provided so that readers can adapt it for their research.

RESULTS

During the first 2 days after quitting, the association between negative affect and craving was significantly stronger among individuals in the placebo group, suggesting an early positive impact of treatment. For the monotherapy and combination therapy groups, during the second week of the quit attempt, baseline dependence was less strongly related to craving compared with the placebo group, indicating a different positive impact of treatments later in the quit attempt.

CONCLUSIONS

The results reveal information about the underlying dynamics that unfold during a quit attempt and how monotherapy and combination therapy impact those processes. This suggests possible mechanisms to target in an intervention and indicates timepoints that hold the greatest promise for effective treatment. TVEM is a straightforward approach to examining time-varying processes embedded in EMA.

Sex differences in negative affect and lapse behavior during acute tobacco abstinence: a laboratory study

Heightened negative affect during acute tobacco abstinence in women relative to men could be an important factor underlying sex differences in smoking motivation. However, little controlled experimental work addresses this hypothesis. The current study investigated sex differences in withdrawal-related negative affect, time to start smoking on a lab analogue smoking lapse task, and the interrelation between sex, withdrawal-related negative affect, and smoking lapse behavior. Following a baseline session, current smokers (women: n = 68, men: n = 131) attended two counterbalanced lab sessions (16 hours smoking abstinence and ad libitum smoking) during which they completed self-report measures of mood and withdrawal symptoms followed by a laboratory analogue smoking lapse task. In this task participants are monetarily rewarded for delaying smoking. Performance on this task serves as an analogue model of smoking lapse behavior by measuring smoker's capability to resist temptation to smoke under conditions where abstinence is advantageous. Females showed greater abstinence induced increases in composite negative affect as well as several particular negative affect states (i.e., POMS Anger, Anxiety, Depression, and Confusion, ps < .05) but no differences in abstinence induced changes in other forms of affect or craving. Females also exhibited marginally greater abstinence induced decreases in their willingness to delay smoking for money (p = .10), which was mediated by abstinence induced increases in anger (p < .05). These results suggest that differential sensitivity to abstinence induced negative affect, particularly anger, could underlie sex specific smoking patterns. Negative affect during tobacco abstinence may be an important factor for understanding and treating nicotine addiction in women.

Development and preliminary randomized controlled trial of a distress tolerance treatment for smokers with a history of early lapse

INTRODUCTION

An inability to tolerate distress is a significant predictor of early smoking lapse following a cessation attempt. We conducted a preliminary randomized controlled trial to compare a distress tolerance (DT) treatment that incorporated elements of exposure-based therapies and Acceptance and Commitment Therapy to standard smoking cessation treatment (ST).

METHODS

Smokers with a history of early lapse in prior quit attempts received either DT (N = 27; 9 2-hr group and 6 50-min individual sessions) or ST (N = 22; 6 90-min group and 1 20-min individual session), plus 8 weeks of transdermal nicotine patch.

RESULTS

At the end of behavioral treatment, odds of abstinence among participants receiving DT were 6.46 times greater than among participants receiving ST (66.7% vs. 31.8%), equivalent to a medium- to large-effect size. Odds of abstinence for DT were still 1.73 times greater at 8 weeks, corresponding to a small- to medium-effect size, although neither this difference nor those at 13 and 26 weeks were statistically significant. Furthermore, of those who lapsed to smoking during the first week postquit, DT participants had more than 4 times greater odds of abstinence than ST participants at the end of treatment. Relative to ST, DT participants also reported a larger decrease in experiential avoidance, a hypothesized DT treatment mediator, prior to quit day. The trajectory of negative mood and withdrawal symptoms in DT differed from ST and was largely consistent with hypotheses.

CONCLUSIONS

Reasons for the decrease in abstinence in DT after treatment discontinuation and suggestions for future research are discussed.

Treatment for tobacco dependence: effect on brain nicotinic acetylcholine receptor density

Cigarette smoking leads to upregulation of brain nicotinic acetylcholine receptors (nAChRs), including the common α4β2* nAChR subtype. Although a substantial percentage of smokers receive treatment for tobacco dependence with counseling and/or medication, the effect of a standard course of these treatments on nAChR upregulation has not yet been reported. In the present study, 48 otherwise healthy smokers underwent positron emission tomography (PET) scanning with the radiotracer 2-FA (for labeling α4β2* nAChRs) before and after treatment with either cognitive-behavioral therapy, bupropion HCl, or pill placebo. Specific binding volume of distribution (VS/fP), a measure proportional to α4β2* nAChR density, was determined for regions known to have nAChR upregulation with smoking (prefrontal cortex, brainstem, and cerebellum). In the overall study sample, significant decreases in VS/fP were found for the prefrontal cortex, brainstem, and cerebellum of -20 (±35), -25 (±36), and -25 (±31)%, respectively, which represented movement of VS/fP values toward values found in non-smokers (mean 58.2% normalization of receptor levels). Participants who quit smoking had significantly greater reductions in VS/fP across regions than non-quitters, and correlations were found between reductions in cigarettes per day and decreases in VS/fP for brainstem and cerebellum, but there was no between-group effect of treatment type. Thus, smoking reduction and cessation with commonly used treatments (and pill placebo) lead to decreased α4β2* nAChR densities across brain regions. Study findings could prove useful in the treatment of smokers by providing encouragement with the knowledge that decreased smoking leads to normalization of specific brain receptors.

The first 7 days of a quit attempt predicts relapse: validation of a measure for screening medications for nicotine dependence

OBJECTIVES

There is a critical need for the development of novel treatments for nicotine dependence. Because the majority of smokers who make a quit attempt fail within 7 days, medication screening procedures that focus on this early cessation period may provide an indicator of treatment efficacy. To establish the clinical validity of this paradigm, it is critical to demonstrate the association of early abstinence with longer-term abstinence. We tested the number of days of abstinence during the first week after the target quit date (TQD) as a predictor of point prevalence abstinence in 3 independent pharmacotherapy trials for nicotine dependence.

METHODS

This was a secondary data analysis of 3 randomized clinical trials: a placebo-controlled trial of transdermal nicotine (N = 545); an open-label nicotine replacement therapy (patch vs spray) trial (N = 566); and a bupropion placebo-controlled trial (N = 538). In separate logistic regression models, the maximum number of consecutive days of abstinence during the first week after the TQD was used to predict biochemically verified 7-day point prevalence abstinence at the end of treatment (EOT) and 6 months post-TQD.

RESULTS

Across the 3 trials, the number of days of abstinence significantly predicted abstinence at EOT and 6 months (odds ratios > 1.4; Ps < 0.0001). Likewise, not having any lapse during the first week predicted abstinence at EOT and 6 months (odds ratios > 4.7; Ps < 0.0001).

CONCLUSIONS

The first week of abstinence was highly predictive of EOT and long-term abstinence. Medication screening procedures that focus on this early abstinence period (ie, 6 or 7 days of consecutive abstinence) represent a valid tool for assessing the presence of a signal for medication efficacy.

Self-reported major depressive symptoms at baseline impact abstinence prognosis in smoking cessation program. A one-year prospective study

OBJECTIVE

The association between major depressive symptoms and smoking has been extensively documented. However, previous studies report conflicting findings about the impact of depression on lapse of smoking cessation. We hypothesize that smokers with self-reported major depressive symptoms at baseline are at higher risk of a lapse.

METHODS

One thousand and twenty participants aged, 18 years and over, were recruited in a smoking-cessation unit. All participants were assessed for their smoking status six times during one year of follow-up. Participants were classified as "euthymic", presenting "minor depressive symptomatology" or "major depressive symptomatology" according to their baseline score on the Hospitalization Anxiety and Depression Scale.

RESULTS

Using Cox's proportional hazard regression modeling, adjusted for potential confounding factors (nicotine dependence, number of cigarettes/day, previous cessation attempt, alcohol misuse, socio-demographic variables), it was shown that lapse is associated with major depressive symptoms (Hazard Ratio: HR=1.23 [1.02;1.47]; p=0.03).

CONCLUSION

Our results suggest the importance for clinicians to deal with depression and to discriminate minor from major depressive symptoms at preliminary smoking cessation consultations.

Smoking cessation in Taiwanese male smokers with coronary artery disease: influencing factors and policy implications

AIM

To investigate factors affecting smoking cessation in male smokers with coronary artery disease.

DESIGN

A descriptive, correlation, cross-sectional study was conducted.

METHODS

Data were collected using a questionnaire constructed by a literature review of research on smoking cessation in male smokers including demographics and smoking background, as well as psychological, interpersonal and environmental factors. A total of 130 male patients with coronary artery disease were recruited from the cardiac clinic at a regional hospital in Taiwan from August to December 2008. The response rate was 93% (n = 121). Descriptive statistics, chi-square, t-tests and logistic regression analysis were conducted.

RESULTS

During the survey, 64.5% of the respondents reported that they had stopped smoking after a coronary event. Five factors were significantly associated with smoking cessation after diagnosis of coronary artery disease: age, the severity of heart diagnoses, antismoking norms (perceived that smoking was against the social norms), nicotine dependence level, and contrary views of smoking (perceived negative expectancy of smoking). Multivariate analysis revealed antismoking norms to be the most important predictor (AOR = 4.27; P < .05) after adjusting age.

CONCLUSION

The study highlights the need to develop smoking cessation interventions that specifically counsel patients with coronary artery disease about these information, such as the disease risk and development, health consequences of smoking, and dependence therapy. Additionally, government support for tobacco control programmes in hospitals and elsewhere is designed to have a beneficial effect on patients' smoking behaviours primarily by increasing antismoking norms.

Who participates in Web-assisted tobacco interventions? The QUIT-PRIMO and National Dental Practice-Based Research Network Hi-Quit studies

INTRODUCTION

Smoking is the most preventable cause of death. Although effective, Web-assisted tobacco interventions are underutilized and recruitment is challenging. Understanding who participates in Web-assisted tobacco interventions may help in improving recruitment.

OBJECTIVES

To understand characteristics of smokers participating in a Web-assisted tobacco intervention (Decide2Quit.org).

METHODS

In addition to the typical Google advertisements, we expanded Decide2Quit.org recruitment to include referrals from medical and dental providers. We assessed how the expanded recruitment of smokers changed the users' characteristics, including comparison with a population-based sample of smokers from the national Behavioral Risk Factors Surveillance Survey (BRFSS). Using a negative binomial regression, we compared demographic and smoking characteristics by recruitment source, in particular readiness to quit and association with subsequent Decide2Quit.org use.

RESULTS

The Decide2Quit.org cohort included 605 smokers; the 2010 BRFSS dataset included 69,992. Compared to BRFSS smokers, a higher proportion of Decide2Quit.org smokers were female (65.2% vs 45.7%, P=.001), over age 35 (80.8% vs 67.0%, P=.001), and had some college or were college graduates (65.7% vs 45.9%, P=.001). Demographic and smoking characteristics varied by recruitment; for example, a lower proportion of medical- (22.1%) and dental-referred (18.9%) smokers had set a quit date or had already quit than Google smokers (40.1%, P<.001). Medical- and dental-referred smokers were less likely to use Decide2Quit.org functions; in adjusted analysis, Google smokers (predicted count 17.04, 95% CI 14.97-19.11) had higher predicted counts of Web page visits than medical-referred (predicted count 12.73, 95% CI 11.42-14.04) and dental-referred (predicted count 11.97, 95% CI 10.13-13.82) smokers, and were more likely to contact tobacco treatment specialists.

CONCLUSIONS

Recruitment from clinical practices complimented Google recruitment attracting smokers less motivated to quit and less experienced with Web-assisted tobacco interventions.

Gender differences in personality patterns and smoking status after a smoking cessation treatment

BACKGROUND

The lack of conclusive results and the scarce use of the Millon Clinical Multiaxial Inventory-III (MCMI-III) in the study of the relationship between smoking and personality are the reasons that motivated the study reported here. The aim of the present study was to analyze the influence of personality patterns, assessed with the MCMI-III, and of nicotine dependence on treatment outcomes at the end of the treatment and at 12 months follow-up in men and women smokers receiving cognitive-behavioral treatment for smoking cessation.

METHODS

The sample was made up of 288 smokers who received cognitive-behavioral treatment for smoking cessation. Personality patterns were assessed with the Millon Clinical Multiaxial Inventory-III (MCMI-III). Abstinence at the end of the treatment and at 12-month follow-up was validated with the test for carbon monoxide in expired air.

RESULTS

The results showed significant differences by personality patterns that predict nicotine dependence (Narcissistic and Antisocial in men and Schizoid in women). At the end of the treatment it is more likely that quit smoking males with a Compulsive pattern and less likely in those scoring high in Depressive, Antisocial, Sadistic, Negativistic, Masochistic, Schizotypal and Borderline. In women, it is less likely that quit smoking those with the Schizoid pattern. At 12 months follow-up it is more likely that continue abstinent those males with a high score in the Compulsive pattern. Furthermore, nicotine dependence was an important variable for predicting outcome at the end of the treatment and smoking status at 12 months follow-up in both men and women.

CONCLUSIONS

We found substantial differences by gender in some personality patterns in a sample of smokers who received cognitive-behavioral treatment for smoking cessation. We should consider the existence of different personality patterns in men and women who seek treatment for smoking cessation.

Factors predicting smoking in a laboratory-based smoking-choice task

This study aimed to expand the current understanding of smoking maintenance mechanisms by examining how putative relapse risk factors relate to a single behavioral smoking choice using a novel laboratory smoking-choice task. After 12 hr of nicotine deprivation, participants were exposed to smoking cues and given the choice between smoking up to two cigarettes in a 15-min window or waiting and receiving four cigarettes after a delay of 45 min. Greater nicotine dependence, higher impulsivity, and lower distress tolerance were hypothesized to predict earlier and more intensive smoking. Out of 35 participants (n = 9 women), 26 chose to smoke with a median time to a first puff of 1.22 min (SD = 2.62 min, range = 0.03-10.62 min). Survival analyses examined latency to first puff, and results indicated that greater pretask craving and smoking more cigarettes per day were significantly related to smoking sooner in the task. Greater behavioral disinhibition predicted shorter smoking latency in the first 2 min of the task, but not at a delay of more than 2 min. Lower distress tolerance (reporting greater regulation efforts to alleviate distress) was related to more puffs smoked and greater nicotine dependence was related to more time spent smoking in the task. This novel laboratory smoking-choice paradigm may be a useful laboratory analog for the choices smokers make during cessation attempts and may help identify factors that influence smoking lapses.

Interventions for tobacco smoking

Around 19% of US adults smoke cigarettes, and smoking remains the leading avoidable cause of death in this country. Without treatment only ~5% of smokers who try to quit achieve long-term abstinence, but evidence-based cessation treatment increases this figure to 10% to 30%. The process of smoking cessation comprises different pragmatically defined phases, and these can help guide smoking treatment development and evaluation. This review evaluates the effectiveness of smoking interventions for smokers who are unwilling to make a quit attempt (motivation phase), who are willing to make a quit attempt (cessation phase), who have recently quit (maintenance phase), and who have recently relapsed (relapse recovery phase). Multiple effective treatments exist for some phases (cessation), but not others (relapse recovery). A chronic care approach to treating smoking requires effective interventions for every phase, especially interventions that exert complementary effects both within and across phases and that can be disseminated broadly and cost-effectively.

An ecological momentary assessment analysis of prequit markers for smoking-cessation failure

This study aimed to identify correlates of smoking-cessation failure, a failure to establish abstinence during a quit-smoking attempt. Identifying risk factors for early failure could facilitate the development of tailored interventions to promote cessation. The current study used existing ecological momentary assessment (EMA) data to investigate the extent to which prequit craving, negative affect, and recent smoking were associated with cessation failure in 374 smokers (189, 50.5% female). Subjects were prompted to complete 4-7 real-time reports of craving, negative affect, and recent smoking daily in the four days prior to quitting. Multilevel models of craving and negative affect (mean level, growth, volatility, and association with smoking) were estimated. Results indicated that recent smoking was associated with significantly lower craving among smokers who failed to quit than those who achieved a full day of cessation, but this held only among smokers who reduced smoking by at least 10% in the days preceding the quit attempt. Smokers who failed to quit on the quit day also experienced slower increases in negative affect in the days preceding the quit attempt than did initial abstainers, but delayed quitters and delayed cessation failures did not differ in negative-affect trajectories. These results suggest that successful abstainers and cessation failures can be differentiated by specific dimensions of prequit craving and negative-affect experiences, but the effects hold only in certain circumstances.

Nicotine dependence among clients receiving publicly funded substance abuse treatment

BACKGROUND

Smoking and nicotine dependence (ND) are prevalent among substance abusers but little is known about characteristics of ND in this population. This information would help identify those most in need of smoking cessation programs. This study evaluated the associations of socio-demographic, tobacco- and substance use-related, and health/mental health factors to ND in adults receiving publicly funded substance abuse treatment in Tennessee.

METHODS

All Tennessee residents who received federal block grant-funded substance abuse treatment during July-December, 2004 were invited to participate in a 6 month post-intake telephone follow-up interview. Socio-demographic characteristics, perceived health and mental health, tobacco use history and patterns, and ND, assessed by the Fagerstrom Test of Nicotine Dependence (FTND), were obtained at follow-up. Alcohol and illicit drug use and smoking status prior to treatment were assessed at intake. This paper analyzes data for 855 clients who were current cigarette smokers at both intake and follow-up.

RESULTS

Sixty three percent of smokers were ND (FTND score ≥ 4). Correlates of ND included older age, poorer self-rated overall health, earlier age of onset of cigarette smoking and substance abuse, fewer smoking quit attempts in past year, single substance use (alcohol or illicit drug, vs. multiple substances) at intake, use of opiates/narcotics and sedatives, and past month self-reported depression.

CONCLUSION

ND was highly prevalent and correlated with specific types and patterns of substance abuse and depression. These results suggest that intensive smoking cessation interventions, involving behavioral support, pharmacotherapy, and mood management, are needed to effectively assist this population.

Association between ovarian hormones and smoking behavior in women

Studies examining the association between menstrual cycle phases and smoking behavior in women have yielded mixed results. The purpose of this study was to elucidate the associations between ovarian hormones and smoking by directly measuring ovarian hormone levels and obtaining a laboratory assessment of smoking behaviors. Four hypotheses were tested: Increased smoking will be associated with (1) low absolute levels of estradiol and progesterone; (2) decreasing (i.e., dynamic changes in) estradiol and progesterone; (3) lower ratios of progesterone to estradiol; and (4) higher ratios of estradiol to progesterone. Female smokers (≥10 cigarettes/day) with regular menstrual cycles were recruited as part of a larger, ongoing study examining the influence of ovarian hormones on smoking cessation treatment. Participants completed 2 study visits, including a 1-hr ad lib smoking topography session, which provided a detailed assessment of smoking behavior. Both the change in hormone levels over time and the relative ratios of ovarian hormones were associated with smoking behavior, but each to a limited extent. Decreases in estradiol (r = -.21, p = .048) and decreases in progesterone (r = -.23, p = .03) were associated with increased puff intensity. Lower ratios of progesterone to estradiol were associated with a greater number of puffs (r = -.26, p = .01) and weight of cigarettes smoked (r = -.29, p = .005). The best predictors of smoking behavior were the ratio of progesterone to estradiol (z = -2.7, p = .004) and the change in estradiol and progesterone over time (z = -2.1, p = .02). This pattern of results may help to explain inconsistent findings in previous studies and suggest potential mechanisms by which hormones influence nicotine addiction.

Isolating the role of psychological dysfunction in smoking cessation: relations of personality and psychopathology to attaining cessation milestones

Research exploring psychological dysfunction as a predictor of smoking cessation success may be limited by nonoptimal predictor variables (i.e., categorical psychodiagnostic measures vs. continuous personality-based manifestations of dysfunction) and imprecise outcomes (i.e., summative point-prevalence abstinence vs. constituent cessation milestone measures). Accordingly, this study evaluated the unique and overlapping relations of broad-spectrum personality traits (positive emotionality, negative emotionality, and constraint) and past-year psychopathology (anxiety, mood, and substance use disorder) to point-prevalence abstinence and three smoking cessation milestones: (a) initiating abstinence, (b) first lapse, and (c) transition from lapse to relapse. Participants were daily smokers (N = 1365) enrolled in a smoking cessation treatment study. In single-predictor regression models, each manifestation of internalizing dysfunction (lower positive emotionality, higher negative emotionality, and anxiety and mood disorder) predicted failure at one or more cessation milestone(s). In simultaneous predictor models, lower positive and higher negative emotionality significantly predicted failure to achieve milestones after controlling for psychopathology. Psychopathology did not predict any outcome when controlling for personality. Negative emotionality showed the most robust and consistent effects, significantly predicting failure to initiate abstinence, earlier lapse, and lower point-prevalence abstinence rates. Substance use disorder and constraint did not predict cessation outcomes, and no single variable predicted lapse-to-relapse transition. These findings suggest that personality-related manifestations of internalizing dysfunction are more accurate markers of affective sources of relapse risk than mood and anxiety disorders. Further, individuals with high trait-negative emotionality may require intensive intervention to promote the initiation and early maintenance of abstinence.

Dependence and withdrawal-induced craving predict abstinence in an incentive-based model of smoking relapse

INTRODUCTION

Understanding factors that render some individuals more vulnerable to smoking relapse during the early stages of a quit attempt is critical to tailoring treatment efforts. Development of laboratory models of relapse can provide a framework for identifying underlying mechanisms that may contribute to vulnerability. Here, we explored predictors of abstinence in a novel incentive-based model of relapse.

METHODS

Fifty-six nontreatment seeking daily smokers completed several nicotine dependence measures prior to participating in a 1-week abstinence incentive test. During the abstinence procedure, participants earned monetary reinforcement for each biochemically verified day of abstinence according to a descending schedule of reinforcement.

RESULTS

Compliance with the procedure was excellent. All but 3 participants were able to initiate abstinence; nearly 70% lapsed as incentives were reduced. Scores on the Fagerström Test for Nicotine Dependence (FTND), number of cigarettes smoked per day, and self-reported craving on the first day of abstinence each independently predicted time to lapse. The single item of time to first cigarette in the morning on the FTND significantly predicted time to lapse, even when controlling for other significant predictors just listed. The Nicotine Dependence Syndrome Scale (NDSS) and Wisconsin Inventory of Smoking Dependence Motives did not predict lapse, but the NDSS did predict reinitiation of abstinence among those experiencing an initial lapse.

CONCLUSIONS

These findings partially replicate those of previous full-scale clinical trials and support the feasibility and validity of an incentive-based model of relapse. The time-limited and laboratory-based nature of this model has the potential to further investigations of underlying mechanisms contributing to relapse.

Should all smokers use combination smoking cessation pharmacotherapy? Using novel analytic methods to detect differential treatment effects over 8 weeks of pharmacotherapy

INTRODUCTION

Combination pharmacotherapy for smoking cessation has been shown to be more effective than monotherapy in meta-analyses. We address the question of whether combination pharmacotherapy should be used routinely with smokers or if some types of smokers show little or no benefit from combination pharmacotherapy versus monotherapy.

METHODS

Two smoking cessation trials were conducted using the same assessments and medications (bupropion, nicotine lozenge, nicotine patch, bupropion + lozenge, and patch + lozenge). Participants were smokers presenting either to primary care clinics in southeastern Wisconsin for medical treatment (Effectiveness trial, N = 1,346) or volunteering for smoking cessation treatment at smoking cessation clinics in Madison and Milwaukee, WI (Efficacy trial, N = 1,504). For each trial, decision tree analyses identified variables predicting outcome from combination pharmacotherapy versus monotherapy at the end of treatment (smoking 8 weeks after the target quit day).

RESULTS

All smokers tended to benefit from combination pharmacotherapy except those low in nicotine dependence (longer latency to smoke in the morning as per item 1 of the Fagerström Test of Nicotine Dependence) who also lived with a spouse or partner who smoked.

CONCLUSIONS

Combination pharmacotherapy was generally more effective than monotherapy among smokers, but one group of smokers, those who were low in nicotine dependence and who lived with a smoking spouse, did not show greater benefit from using combination pharmacotherapy. Use of monotherapy with these smokers might be justified considering the expense and side effects of combination pharmacotherapy.

Pharmacogenetics of smoking cessation: role of nicotine target and metabolism genes

Many smokers attempt to quit smoking but few are successful in the long term. The heritability of nicotine addiction and smoking relapse have been documented, and research is focused on identifying specific genetic influences on the ability to quit smoking and response to specific medications. Research in genetically modified cell lines and mice has identified nicotine acetylcholine receptor subtypes that mediate the pharmacological and behavioral effects of nicotine sensitivity and withdrawal. Human genetic association studies have identified single nucleotide polymorphisms (SNPs) in genes encoding nicotine acetylcholine receptor subunits and nicotine metabolizing enzymes that influence smoking cessation phenotypes. There is initial promising evidence for a role in smoking cessation for SNPs in the β2 and α5/α3/β4 nAChR subunit genes; however, effects are small and not consistently replicated. There are reproducible and clinically significant associations of genotypic and phenotypic measures of CYP2A6 enzyme activity and nicotine metabolic rate with smoking cessation as well as response to nicotine replacement therapies and bupropion. Prospective clinical trials to identify associations of genetic variants and gene-gene interactions on smoking cessation are needed to generate the evidence base for both medication development and targeted therapy approaches based on genotype.