Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report

Socioeconomic deprivation and blood lipids in first-episode psychosis patients with minimal antipsychotic exposure: Implications for cardiovascular risk

BACKGROUND

The influence of socioeconomic deprivation on the cardiovascular health of patients with psychosis-spectrum disorders (PSD) has not been investigated despite the growing recognition of social factors as determinants of health, and the disproportionate rates of cardiovascular mortality observed in PSD. Discordant results have been documented when studying dyslipidemia -a core cardiovascular risk factor- in first-episode psychosis (FEP), before chronic exposure to antipsychotic medications. The objective of the present study is to determine the extent to which socioeconomic deprivation affects blood lipids in patients with FEP, and examine its implications for cardiovascular risk in PSD.

METHODS

Linear regression models, controlling for age, sex, exposure to pharmacotherapy, and physical anergia, were used to test the association between area-based measures of material and social deprivation and blood lipid levels in a sample of FEP patients (n = 208).

RESULTS

Social, but not material deprivation, was associated with lower levels of total and HDL cholesterol. This effect was statistically significant in patients with affective psychoses, but not in schizophrenia-spectrum disorders.

CONCLUSIONS

Contrary to other reports from the literature, the relationship between socioeconomic disadvantage and blood lipid levels was contingent on the social rather than the material aspects of deprivation. Furthermore, this association also depended on the main diagnostic category of psychosis, suggesting a complex interaction between the environment, psychopathology, and physical health. Future studies exploring health issues in psychosis might benefit from taking these associations into consideration. A better understanding of the biology of blood lipids in this context is necessary.

Receipt and predictors of smoking cessation pharmacotherapy among veterans with and without HIV

Smoking is highly prevalent among people living with HIV (PLWH) and increases cardiovascular risk. Pharmacotherapies such as nicotine replacement therapy (NRT), bupropion, and varenicline help to reduce smoking, though rates of receipt among PLWH compared with HIV-uninfected persons are unknown. Among 814 PLWH and 908 uninfected patients enrolled in the Veterans Aging Cohort Study (2012-2017) who reported current smoking, we used marginal multivariable log-linear regression models to estimate adjusted relative risks (ARR) of receiving pharmacotherapy by HIV status. We also assessed patient-level factors associated with pharmacotherapy receipt within each group. In multivariable analyses, receipt of NRT was less likely among PLWH relative to uninfected participants (ARR 0.77, 95% CI 0.67, 0.89). In both populations, documented mental health disorders and contemplation to quit were associated with greater likelihood of receiving pharmacotherapy. Further research is needed to explore potential treatment disparities.

Experiences of Tobacco Use among Chinese Individuals with Schizophrenia in Community-Based Residential Settings: A Qualitative Study

Although there is a high prevalence of smoking among individuals with schizophrenia, no previous attempt has been made to explore experiences of tobacco use and cessation within a Chinese sample of this population. A qualitative descriptive study was conducted to explore through the use of individual and semi-structured interviews the experiences of tobacco use and quitting in a sample Chinese population with schizophrenia. Twenty-three eligible participants with schizophrenia who currently smoke were recruited from three community residential mental health service settings. Four main themes representing the experiences of the participants were uncovered in this study: (1) smoking and illness; (2) environment and culture; (3) reasons for smoking; and (4) beliefs about cessation methods. The findings indicated that the participants considered the disease to be far more harmful than smoking, and perceived many benefits to smoking. Although some thought of quitting at times, most gave up the idea or failed to quit due to internal factors such as disease-related suffering, the use of an avoidance coping strategy, and a lack of cessation support. The most notable finding concerns the use of avoidance coping by the participants, who relied on smoking as a way to avoid the suffering brought about by the disease.

Smoking cessation treatment outcomes among people with and without mental and substance use disorders: An observational real-world study

Background:

There is a lack of studies evaluating smoking cessation treatment protocols which include people with and without mental and substance use disorders (MSUD), and which allows for individuals with MSUD undergoing their psychiatric treatment.

Methods:

We compared treatment success between participants with (n = 277) and without (n = 419) MSUD among patients in a 6-week treatment provided by a Brazilian Psychosocial Care Center (CAPS) from 2007 to 2013. Sociodemographic, medical and tobacco use characteristics were assessed at baseline. Tobacco treatment consisted of 1) group cognitive behavior therapy, which included people with and without MSUD in the same groups, and 2) pharmacotherapy, which could include either nicotine patches, nicotine gum, bupropion or nortriptyline. For participants with MSUD, tobacco treatment was integrated into their ongoing mental health treatment. The main outcome was 30-day point prevalence abstinence, measured at last day of treatment.

Results:

Abstinence rates did not differ significantly between participants with and without MSUD (31.1% and 34.4%, respectively). Variables that were significantly associated with treatment success included years smoking, the Heaviness of Smoking Index, and use of nicotine patch or bupropion.

Conclusions:

The inclusion of individuals with and without MSUD in the same protocol, allowing for individuals with MSUD undergoing their psychiatric treatment, generates at least comparable success rates between the groups. Predictors of treatment success were similar to those found in the general population. Facilities that treat patients with MSUD should treat tobacco use in order to reduce the disparities in morbidity and mortality experienced by this population.

Predictors of Smoking Cessation Attempt and Continued Abstinence among Low-Income Disabled Smokers: Evidence from the French National Smoking Cessation Cohort CDT-Net

Background: In France, daily smoking has been highly prevalent among low-income smokers.Objectives: Our aim was to search for factors associated with both continued abstinence and attempting to quit among low-income disabled smokers. Methods: From the French national smoking cessation cohort CDT-net, we included 1624 adults living with disability pension or disabled adult allowance. Our dependent variables (abstainers, attempting to quit among non-abstainers) were used in logistic regressions. Continued abstinence was defined as self-reports of no smoking for more than 28 days and attempting to quit was defined as self-reports of no smoking for less than 28 days; both validated with carbon monoxide < 10 ppm. Results: The average age was 48.5 years, with a predominance of men (55.5%). Achieved continued abstinence was 29.9% and was positively associated with age ≥ 55, history of previous attempts, low-dependence, and number of consultations during follow-up (all p < .05). Depression history, anxiety symptoms and cannabis use were negatively associated with continued abstinence (p < .05). Quit attempts were associated with lower dependence and number of consultations during follow-up. Pharmacological treatments prescribed at inception did not contribute to improve continued abstinence rates but varenicline was found to increase quit attempts unless the number of prescriptions was scarce. Conclusion: Even among low-income disabled smokers, achieving continued abstinence and attempting to quit could be promoted with similar predictors than among affluent smokers. Treatment of anxiety symptoms and specific support for smokers with a depression history could be included in the follow-up of quit attempts.

Receptivity to Tobacco Advertising among Young Adults with Internalizing Problems: Findings from the Population Assessment of Tobacco and Health Study

Background: Many risk factors for tobacco use among the general young adult population, such as tobacco advertising receptivity, have gone unexamined among those with internalizing problems, despite disproportionately high rates of tobacco use. Objective: The objective of this study was to examine the interrelationship of internalizing problems, tobacco advertising receptivity, and tobacco use among young adults using data from Wave 1 of the Population Assessment for Tobacco and Health Study. Methods: The sample included 9,110 young adults (ages 18-24). Multivariable logistic regression models examined the association between internalizing problems and advertising receptivity and tobacco use. Separate models were run for cigarettes, cigars, e-cigarettes, smokeless tobacco and any tobacco use. An interaction term (receptivity × internalizing problems) was added to each model. Results: Except for smokeless tobacco, individuals with high internalizing problems reported greater odds of product use compared to those with low internalizing problems. There was no association between internalizing problems and use of smokeless tobacco. For all products, receptivity was positively associated with tobacco use. A borderline significant interaction was detected between cigarette advertising receptivity and internalizing problems, such that the magnitude of the relationship between receptivity to cigarette advertising and cigarette use was stronger for those with high internalizing problems compared those with low internalizing problems. Conclusions/Importance: The relationship between cigarette advertising receptivity and cigarette use may differ for those with and without internalizing problems. Disproportionate receptivity to risk-promoting messages among young adults with internalizing problems could exacerbate disparities in cigarette use.

Bidirectional Associations among Nicotine and Tobacco Smoke, NeuroHIV, and Antiretroviral Therapy

People living with HIV (PLWH) in the antiretroviral therapy (ART) era may lose more life-years to tobacco use than to HIV. Yet, smoking rates are more than twice as high among PLWH than the general population, contributing not just to mortality but to other adverse health outcomes, including neurocognitive deficits (neuroHIV). There is growing evidence that synergy with chronic inflammation and immune dysregulation that persists despite ART may be one mechanism by which tobacco smoking contributes to neuroHIV. This review will summarize the differential effects of nicotine vs tobacco smoking on inflammation in addition to the effects of tobacco smoke components on HIV disease progression. We will also discuss biomarkers of inflammation via neuroimaging as well as biomarkers of nicotine dependence (e.g., nicotine metabolite ratio). Tobacco smoking and nicotine may impact ART drug metabolism and conversely, certain ARTs may impact nicotine metabolism. Thus, we will review these bidirectional relationships and how they may contribute to neuroHIV and other adverse outcomes. We will also discuss the effects of tobacco use on the interaction between peripheral organs (lungs, heart, kidney) and subsequent CNS function in the context of HIV. Lastly, given the dramatic rise in the use of electronic nicotine delivery systems, we will discuss the implications of vaping on these processes. Despite the growing recognition of the importance of addressing tobacco use among PLWH, more research is necessary at both the preclinical and clinical level to disentangle the potentially synergistic effects of tobacco use, nicotine, HIV, cognition and immune dysregulation, as well as identify optimal approaches to reduce tobacco use. Graphical Abstract Proposed model of the relationships among HIV, ART, smoking, inflammation, and neurocognition. Solid lines represent relationships supported by evidence. Dashed lines represent relationships for which there is not enough evidence to make a conclusion. (a) HIV infection produces elevated levels of inflammation even among virally suppressed individuals. (b) HIV is associated with deficits in cognition function. (c) Smoking rates are higher among PLWH, compared to the general population. (d) The nicotine metabolite ratio (NMR) is associated with smoking behavior. (e) HIV and tobacco use are both associated with higher rates of psychiatric comorbidities, such as depression, and elevated levels of chronic stress. These factors may represent other mechanisms linking HIV and tobacco use. (f) The relationship between nicotine, tobacco smoking, and inflammation is complex, but it is well-established that smoking induces inflammation; the evidence for nicotine as anti-inflammatory is supported in some studies, but not others. (g) The relationship between tobacco use and neurocognition may differ for the effects of nicotine (acute nicotine use may have beneficial effects) vs. tobacco smoking (chronic use may impair cognition). (h) Elevated levels of inflammation may be associated with deficits in cognition. (i) PLWH may metabolize nicotine faster than those without HIV; the mechanism is not yet known and the finding needs validation in larger samples. We also hypothesize that if HIV-infection increases nicotine metabolism, then we should observe an attenuation effect once ART is initiated. (j) It is possible that the increase in NMR is due to ART effects on CYP2A6. (k) We hypothesize that faster nicotine metabolism may result in higher levels of inflammation since nicotine has anti-inflammatory properties.

Effects of Financial Incentives for Smoking Cessation on Mood and Anxiety Symptoms Among Pregnant and Newly Postpartum Women

Introduction

Financial incentives for smoking cessation increase smoking abstinence and decrease Beck Depression Inventory (BDI) scores among depression-prone pregnant and postpartum women. The present study is a secondary analysis using the Brief Symptom Inventory (BSI) to examine whether this treatment impacts a broader array of mood and anxiety symptoms.

Methods

Participants (N = 253) were pregnant cigarette smokers who participated in four controlled clinical trials examining the efficacy of financial incentives for smoking cessation. Women were assigned to an intervention wherein they earned vouchers exchangeable for retail items contingent on smoking abstinence (Contingent, n = 143) or a control condition wherein they received comparable vouchers independent of smoking status (Noncontingent, n = 110). Participants were categorized as depression-prone (n = 105) or depression-negative (n = 148) based on self-reported history of depression and BDI scores at intake. A prior study demonstrated that financial incentives decreased depressive symptoms among depression-prone women in this sample. The present study examined whether those effects extended to a broader array of mood and anxiety symptoms using the BSI. Effects of treatment, time, and depression status were examined using repeated measures analyses of covariance.

Results

In addition to depressive symptoms, financial incentives reduced a multitude of BSI scores among depression-prone women, including the BSI global measure of distress and seven symptom subscales. Treatment effects were discernible by late pregnancy, peaked at 8 weeks postpartum, and dissipated by 24 weeks postpartum.

Discussion

In addition to reducing smoking, this financial incentives treatment appears to reduce a range of mood and anxiety symptoms among depression-prone pregnant and postpartum women.

Implications

This study adds evidence that providing financial incentives contingent on smoking cessation lowers a broad array of psychiatric symptoms, as measured by the BSI, among depression-prone pregnant and newly postpartum women during a time of heightened risk for peripartum mood disorders.

Tobacco-related knowledge following a comprehensive tobacco-free workplace program within behavioral health facilities: Identifying organizational moderators

OBJECTIVE

Although smoking prevalence rates among behavioral health consumers is nearly five times that of the general population, evidence-based policies and practices to address tobacco use are uncommon within behavioral health settings. This study assessed changes in non-clinical, general staff and clinician tobacco-related knowledge following brief education provided as part of a comprehensive tobacco-free workplace program implementation and explored organizational moderators of pre- to post-education knowledge change.

METHODS

Fifteen behavioral health facilities, comprising hundreds of individual clinics in Texas, participated in a one (for general staff) or two (for clinicians) hour educational session.

RESULTS

There were large effect sizes in general staff knowledge gain within each consortium, and large effect sizes in clinician knowledge gain in all but one consortium. Knowledge of the requirements for change, perceived availability of resources, and total number of client contacts moderated general staff knowledge gain. Value in the change and total number of client contacts moderated training effectiveness among clinicians.

CONCLUSIONS

We conclude that a brief tobacco-related education for behavioral health employees was effective in increase attendee knowledge.

PRACTICE IMPLICATIONS

Attention to organization-level factors moderating knowledge gain has the potential to guide and improve program implementation.

Associations Between Physical Health Limitations and Community Participation Among People With and Without Serious Mental Illnesses

OBJECTIVE

Research has suggested that individuals with serious mental illnesses are not as physically healthy as the general population and are more likely to experience physical illnesses such as diabetes, obesity, and cardiovascular and respiratory diseases. Less is known about how physical health may be related to community participation among individuals with serious mental illnesses, although research with adults in the general population has suggested strong negative associations between health impairments and engagement in a variety of activity domains.

METHODS

In this study, the authors drew from two national data sets to examine the relationship between physical health impairments and community participation among 300 participants with serious mental illnesses and 300 participants without serious mental illnesses.

RESULTS

For participants in both groups, physical health concerns and use of mobility aids were associated with lower reported rates of community participation.

CONCLUSIONS

Findings shed light on the complex association between physical health impairments and community participation while also suggesting the need to focus on other potential barriers to participation among individuals with serious mental illnesses.

The association between exposure to secondhand smoke and psychological symptoms among Chinese children

Background

The effect of secondhand smoke (SHS) exposure on child psychological problems remained inconclusive in previous studies. The aim of this study is to explore the association between SHS exposure and psychological symptoms in children.

Methods

This population-based cross-sectional survey used cluster random probability sampling and recruited children aged 6–13 years in 26 primary schools in Shanghai, China, in 2014. Duration of SHS exposure in children were categorized as none, < 1 h/day, 1–2 h/day, ≥3 h/day. Psychological symptoms were assessed by the parental version of the Strengths and Difficulties Questionnaire (SDQ). We used logistic regression to estimate the adjusted associations of SHS exposure with total SDQ and its specific domains. Multiple imputation was used for handling missing data.

Results

A total of 17,571 children completed this survey, with a response rate of 99.7%. SDQ scores were available for 15,344 participants, of whom 20.9% were not exposed to SHS, 63.0% exposed for < 1 h/day, 10.4% for 1–2 h/day, and 5.7% for ≥3 h/day. Compared to children not exposed to SHS, SHS exposure was positively associated with total SDQ score: OR 1.42, 95% confidence interval (CI) 1.22 to 1.66 for SHS exposure < 1 h/day, OR 2.14, 95% CI 1.76 to 2.62 for 1–2 h/day and OR 2.53, 95% CI 2.01 to 3.18 for ≥3 h/day after adjusting for sex, age, mode of birth, family socio-economic status and place of birth. These associations did not vary by sex.

Conclusion

SHS exposure is an independent risk factor for psychological problems among children. Nonetheless, our study is unable to distinguish between fetal and child exposure to SHS.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7006-8) contains supplementary material, which is available to authorized users.

Clozapine reduces nicotine self-administration, blunts reinstatement of nicotine-seeking but increases responding for food

People with schizophrenia display significantly higher rates of smoking than the general population, which may be due to an interaction between nicotine and antipsychotic medication. While the conventional antipsychotic drug haloperidol sometimes increases cigarette smoking in patients with schizophrenia, there is some evidence suggesting that clozapine, an atypical antipsychotic drug, may reduce nicotine use in these patients. However, the effects of antipsychotic drugs like clozapine on aspects of nicotine self-administration and reinstatement have not been systematically examined. In the current study, we assessed the effect of clozapine on nicotine self-administration under fixed ratio and progressive ratio schedules of reinforcement, as well as reinstatement of nicotine-seeking following a period of abstinence. To determine the specificity of its effect on nicotine reward, we also tested the effect of clozapine on responding for food reinforcement under fixed ratio and progressive ratio schedules. For comparison, we also examined the effects of haloperidol, a first-generation antipsychotic drug, under some of the same behavioral conditions as clozapine. We show that clozapine inhibits nicotine self-administration and reinstatement of nicotine-seeking but also increases the amount of effort that rats will exert for food reward. In contrast, haloperidol at a wide range of doses attenuated responding for nicotine and food reward, suggestive of a non-specific reduction in reinforcer efficacy. These results show the potential utility of clozapine as a smoking cessation treatment for patients with schizophrenia, in addition to its antipsychotic properties.

Comparing Treatment Acceptability and 12-Month Cessation Rates in Response to Web-Based Smoking Interventions Among Smokers Who Do and Do Not Screen Positive for Affective Disorders: Secondary Analysis

BACKGROUND

Web-based cessation programs are now common for intervening with smokers. However, it remains unclear how acceptable or effective these interventions are among people with affective disorders and symptoms (ADS; eg, depression and anxiety). Research examining this is extremely limited, with mixed results on cessation rates. Additional large studies are needed to more fully understand whether Web-based interventions are similarly used and equally effective among people with and without affective disorder symptomology. If not, more targeted Web-based interventions may be required.

OBJECTIVE

The goal of the research was to compare Web-based treatment acceptability (defined by satisfaction and use) and 12-month cessation outcomes between smokers with and without ADS.

METHODS

Participants (N=2512) were adult smokers enrolled in a randomized, comparative effectiveness trial of two Web-based smoking interventions designed for the general population of smokers. At baseline, participants reported demographic and smoking characteristics and completed measures assessing ADS. Participants were then classified into subgroups based on their self-reported ADS-either into a no ADS group or into six nonmutually exclusive subgroups: depression, posttraumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and more than one ADS. Surveys at 12 months postrandomization included subjective ratings of treatment acceptability and self-reported smoking cessation. Treatment use (ie, number of log-ins and total duration of exposure) was assessed via automated records.

RESULTS

Relative to the no ADS group, all six ADS subgroups reported significantly greater satisfaction with their assigned Web treatment program, but they spent less time logged in than those with no ADS. For number of log-ins, a treatment arm by ADS group interaction was observed across all ADS subgroups except GAD, suggesting that relative to the no ADS group, they logged in less to one website but not the other. At the 12-month follow-up, abstinence rates in the no ADS group (153/520, 29.42%) were significantly higher than for participants who screened positive for depression (306/1267, 24.15%; P=.03), PTSD (294/1215, 24.19%; P=.03), PD (229/1003, 23.83%; P=.009), and two or more ADS (323/1332, 24.25%; P=.03). Post hoc analyses suggest the lower quit rates may be associated with differences in baseline nicotine dependence and levels of commitment to resist smoking in difficult situations. Website use did not explain the differential abstinence rates.

CONCLUSIONS

Despite reporting higher levels of treatment satisfaction, most smokers with ADS used their assigned intervention less often and had lower quit rates than smokers with no ADS at treatment onset. The results support the need for developing more targeted interventions for smokers with ADS.

TRIAL REGISTRATION

Clinical Trials.gov NCT01812278; https://clinicaltrials.gov/ct2/show/NCT01812278 (Archived by WebCite at http://www.webcitation.org/78L9cNdG4).

Adaptation of a sustained care cessation intervention for smokers hospitalized for psychiatric disorders: Study protocol for a randomized controlled trial

BACKGROUND

Individuals with serious mental illness (SMI) smoke at disproportionately higher rates than those without SMI, have lifespans 25-32 years shorter, and thus bear an especially large burden of tobacco-related morbidity and mortality. Several recent studies demonstrate that smokers with SMI can successfully quit smoking with adequate support. Further evidence shows that using technology to deliver sustained care interventions to hospitalized smokers can lead to smoking cessation up to 6 months after discharge. The current comparative effectiveness trial adapts a technology-assisted sustained care intervention designed for smokers admitted to a general hospital and tests whether this approach can produce higher cessation rates compared to usual care for smokers admitted to a psychiatric inpatient unit.

METHODS

A total of 353 eligible patients hospitalized for psychiatric illness are randomized by cohort into one of two conditions, Sustained Care (SusC) or Usual Care (UC), and are followed for six months after discharge. Participants assigned to UC receive brief tobacco education delivered by a hospital nurse during or soon after admission. Those assigned to SusC receive a 40-min, in-hospital motivational counseling intervention. Upon discharge, they also receive up to 8 weeks of free nicotine patches, automated interactive voice response (IVR) telephone and text messaging, and access to cessation counseling resources lasting 3 months post discharge. Smoking cessation outcomes are measured at 1-, 3- and 6-months post hospital discharge.

CONCLUSION

Results from this comparative effectiveness trial will add to our understanding of acceptable and effective smoking cessation approaches for patients hospitalized with SMI.

Tobacco smoking and schizophrenia: re-examining the evidence

Tobacco smoking among people with mental illnesses can be explained by biological, psychological and social factors. The prevalence of smoking in people diagnosed with schizophrenia is higher than in people with other mental disorders and in the general population. This article explores three current hypotheses that explain this higher prevalence of smoking in schizophrenia. The first, the self-medication hypothesis, is increasingly countered by a growing body of evidence indicating that smokers experience more severe symptoms of schizophrenia. Numerous researchers have already identified smoking as a possible risk factor for the development of schizophrenia, which is the second hypothesis. The third hypothesis (shared genetic vulnerability) identifies certain genes that confer vulnerability for both schizophrenia and nicotine dependence. Understanding the reasons behind the higher prevalence of smoking among people with schizophrenia is vital in planning effective primary, secondary and tertiary smoking prevention for these individuals.

LEARNING OBJECTIVES

At the end of this article, readers will be able to: •

Tobacco smoking and nicotine dependence in first episode and established psychosis

AIM

People with psychotic disorders have increased premature mortality in comparison with the general population, with high rates of cigarette use a contributing factor. We aimed to describe the prevalence of cigarette use and nicotine dependence (ND) in first episode psychosis (FEP), and established psychosis; and to investigate associations between clinical symptoms and ND.

METHODOLOGY

Smoking and clinical data were collected from two cohorts: 181 people with FEP recruited as part of the Physical Health and Substance Use Measures in First Onset Psychosis (PUMP) study and from 432 people with established psychosis recruited as part of the Improving physical health and reducing substance use in psychosis randomised controlled trial (IMPaCT RCT).

RESULTS

The prevalence of cigarette smoking was 78% in FEP and 62% in established psychosis. Forty nine percent (n = 60) of smokers in the FEP cohort and 69% (n = 183) of smokers with established psychosis were highly nicotine dependent. Being a highly nicotine dependent smoker was significantly associated with higher PANSS positive symptom scores (F = 5.480 p = 0.004), and with decreased scores on the Rosenberg self-esteem scale (F = 3.261, p = 0.039) in established psychosis. There was no diagnostic specificity identified in relation to smoking or ND in both groups.

CONCLUSION

High rates of cigarette usage and nicotine dependence are problems from the early stages of psychosis. ND is higher in people with established psychosis. Smoking cessation strategies as part of comprehensive management of psychotic disorders at every stage require further development and evaluation.

Genome-Wide Variants Shared Between Smoking Quantity and Schizophrenia on 15q25 Are Associated With CHRNA5 Expression in the Brain

Cigarette smokers with schizophrenia consume more cigarettes than smokers in the general population. Schizophrenia and smoking quantity may have shared genetic liability. Genome-wide association studies (GWASs) of schizophrenia and smoking quantity have highlighted a biological pleiotropy in which a robust 15q25 locus affects both traits. To identify the genetic variants shared between these traits on 15q25, we used summary statistics from large-scale GWAS meta-analyses of schizophrenia in the Psychiatric Genomics Consortium 2 and smoking quantity assessed by cigarettes smoked per day in the Tobacco and Genetics Consortium. To evaluate the regulatory potential of the shared genetic variants, expression quantitative trait loci analysis in 10 postmortem brain regions was performed using the BRAINEAC dataset in 134 neuropathologically normal individuals. Twenty-two genetic variants on 15q25 were associated with both smoking quantity and schizophrenia at the genome-wide significance level (P < 5.00 × 10-8). Major alleles of all variants were associated with higher smoking quantity and risk of schizophrenia. These genetic variants were associated with PSMA4, CHRNA3, and CHRNB4 expression in specific brain regions (lowest P = 4.81 × 10-4) and with CHRNA5 expression in multiple brain regions (lowest P = 8.70 × 10-6). Risk-associated major alleles of these variants were commonly associated with higher expression in several brain regions, excluding the medulla, at the transcript level. In addition, the risk-associated major allele at rs637137 was associated with higher CHRNA5 expression at the specific exon level in multiple brain regions (lowest P = 2.37 × 10-5). Our findings suggest that genome-wide variants shared between smoking quantity and schizophrenia contribute to a common pathophysiology underlying these traits involving altered CHRNA5 expression in the brain.

The Role of Cognitive Control in the Self-Regulation and Reinforcement of Smoking Behavior

Cognitive control (CC)-the ability to regulate attention and memory-plays an important role in a variety of health behaviors, including smoking behavior. In this theoretical review of the literature, we propose a CC and smoking behavior framework that includes (1) the positive influence of CC on the self-regulation of smoking, (2) nicotine-induced improvements in CC that may indirectly reinforce smoking (including withdrawal reversal effects), and (3) the long-term effects of smoking on the brain that may result in reduced CC. Integration of these literatures suggests that CC contributes to both self-regulation (ie, brake pedal) and nicotine-related reinforcement (ie, gas pedal) amid the catastrophic effects of long-term smoking, which may reduce self-regulatory control over smoking while also enhancing indirect reinforcement. Supportive evidence and limitations of this approach will be presented, as well as ideas for future research directions that may fully examine this multifaceted modeling of CC in relation to smoking behavior.

IMPLICATIONS

There is substantial evidence that CC contributes to self-regulation (ie, brake pedal) and reinforcement (ie, gas pedal) of smoking behavior as well as evidence that long-term smoking may cause reduced CC. The proposed model delineates how these opposing influences of CC may mask the unique contribution of self-regulation and reinforcement in maintaining smoking behavior. Targeting CC for treating nicotine dependence will require more nuanced approaches that consider the independent and combined effects of self-regulation and reinforcement to improve smoking cessation success rates.

A qualitative study of the feasibility and acceptability of a smoking cessation program for people living with HIV and emotional dysregulation

Despite high rates of co-occurring tobacco use and anxiety among persons living with HIV, evidence-based interventions for these individuals are limited. An existing cognitive-behavioral treatment protocol for smoking cessation and anxiety (Norton, P. J., & Barrera, T. L. (2012). Transdiagnostic versus diagnosis-specific CBT for anxiety disorders: A preliminary randomized controlled noninferiority trial. Depression and Anxiety, 29(10), 874-882. https://doi.org/10.1002/da.21974) was modified to address transdiagnostic constructs, such as anxiety sensitivity, distress tolerance, and depressive symptomatology (Labbe, A. K., Wilner, J. G., Kosiba, J. D., Gonzalez, A., Smits, J. A., Zvolensky, M. J., … O'Cleirigh, C. (2017). Demonstration of an Integrated Treatment for Smoking Cessation and Anxiety Symptoms in People with HIV: A Clinical Case Study. Cognitive and Behavioral Practice, 24(2), 200-214. https://doi.org/10.1016/j.cbpra.2016.03.009). This study examines the feasibility and acceptability of the intervention as determined from qualitative data from structured exit interviews from 10 participants who completed treatment. Results demonstrated that participants were very motivated to quit smoking and enrolled in the program for health-related reasons and to be able to quit. Participants found nearly all the treatment components to be useful for reaching their smoking cessation goal and in managing emotional dysregulation. Last, all participants stated that they would strongly recommend the treatment program. This qualitative study provides initial evidence for the feasibility and acceptability of a modified smoking cessation treatment protocol for HIV+ individuals with anxiety and emotional dysregulation. Future research will focus on evaluating the efficacy of the protocol in a full-scale randomized controlled trial, as well as working to collect qualitative data from participants who discontinue treatment to better understand reasons for treatment attrition.

The phenolic interactome and gut microbiota: opportunities and challenges in developing applications for schizophrenia and autism

Schizophrenia and autism spectrum disorder have long been associated with elevated levels of various small phenolic molecules (SPMs). In turn, the gut microbiota (GMB) has been implicated in the kinetics of many of these analytes. Unfortunately, research into the possible relevance of GMB-mediated SPMs to neuropsychiatry continues to be limited by heterogeneous study design, numerous sources of variance and technical challenges. Some SPMs have multiple structural isomers and most have conjugates. Without specialized approaches, SPMs can be incorrectly assigned or inaccurately quantified. In addition, SPM levels can be affected by dietary polyphenol or protein consumption and by various medications and diseases. Nonetheless, heterotypical excretion of various SPMs in association with schizophrenia or autism continues to be reported in independent samples. Recent studies in human cerebrospinal fluid demonstrate the presence of many SPMs A large number of these are bioactive in experimental models. Whether such mechanisms are relevant to the human brain in health or disease is not known. Systematic metabolomic and microbiome studies of well-characterized populations, an appreciation of multiple confounds, and implementation of standardized approaches across platforms and sites are needed to delineate the potential utility of the phenolic interactome in neuropsychiatry.

A Cluster-Randomized Clinical Trial Testing the Effectiveness of the Addressing Tobacco Through Organizational Change Model for Improving the Treatment of Tobacco Use in Community Mental Health Care: Preliminary Study Feasibility and Baseline Findings

INTRODUCTION

People with mental illness are more likely to smoke and less likely to receive tobacco treatment than the general population. The Addressing Tobacco Through Organizational Change (ATTOC) approach supports organizational change to increase tobacco treatment in this population. We describe preliminary study feasibility and baseline behaviors and attitudes among clients and staff regarding tobacco treatment, and assesse correlates of treatment of smoking.

METHODS

Preliminary accrual, engagement, and baseline data are reported from a cluster-randomized trial comparing ATTOC to usual care. Feasibility, thus far, was the rate of site and participant accrual and engagement (eg, participants remaining in the trial). Correlates of assessing smoking, advising cessation, and providing treatment were assessed.

RESULTS

Site and participant accrual is 80% (8/10) and 86% (456/533), and engagement is 100% and 82%. "Staff asking about smoking" was reported by 63% of clients and 38% of staff; "staff advising cessation" was reported by 57% of clients and 46% of staff; staff report "assisting clients with any medication" at most 22% of the time, whereas at most 18% of clients report receiving a cessation medication; 59% of clients want tobacco treatment, but 36% of staff think that it is part of their job. "Staff assisting with medications" is related to more training, believing treating smoking is part of their job, and believing patients are concerned about smoking (ps < .05).

CONCLUSIONS

This trial of training in tobacco treatment within mental health care is feasible thus far; self-reported rates of tobacco treatment are low and associated with clinician attitudes and barriers.

IMPLICATIONS

Evaluation of ways to help address tobacco use treatment in community mental health care is feasible and needed, including the use of technical assistance and training guided by an organizational change approach.

Smokefree mental health inpatient settings – a matter of debate?

Abstract. Background: The prevalence of tobacco smoking among people with severe mental illness (SMI) substantially exceeds smoking rates in the general population and has been identified as the largest contributor to health inequalities in this group. Historically deeply embedded in the culture of mental health treatment environments, smoking until very recently was the norm in inpatient settings and still prevails in many settings internationally. In England however, mental health Trusts are currently implementing recent national guidance, according to which mental health settings will become entirely smokefree, with no exemptions, providing comprehensive evidence-based support to patients for smoking cessation and smoking abstinence during the inpatient stay. Aim: The aim of this article is to summarise the rationale for and the debate surrounding smokefree mental health inpatient settings, and to review and discuss the evidence on challenges, opportunities and impact of smokefree policy implementation in these settings, with a focus on the English debate and experience to date.

Psychological distress and responses to comparative risk messages about electronic and combusted cigarettes

BACKGROUND

People with mental illness suffer disproportionately high health burdens of smoking. Communicating to these smokers that electronic cigarettes (e-cigarettes) are a less harmful alternative to combusted cigarettes might help them reduce their health risks by encouraging complete switching to e-cigarettes. However, such messages might also cause unintended consequences (e.g., dual use of both combusted and e-cigarettes). Our study examined how smokers with vs. without serious psychological distress (SPD) responded to messages communicating reduced harm of e-cigarettes in relation to cigarettes.

METHOD

In an online experiment, 1400 U.S. adult smokers with and without SPD viewed 1 of 6 messages about reduced harm of e-cigarettes compared to cigarettes or a control message. Then participants reported e-cigarette- and cigarette-related beliefs, and behavioral intentions.

RESULTS

Message type (comparative risk messages vs. control) did not interact with SPD status to produce differential impacts on smokers with and without SPD. Regardless of being exposed to a comparative risk message or a control message, smokers with SPD reported greater perceived absolute risk of e-cigarettes and cigarettes, greater support for tobacco control, greater intentions to switch to e-cigarettes completely and seek help with quitting, and were less likely to report e-cigarettes were less harmful than cigarettes compared to smokers without SPD.

DISCUSSION

Smokers with SPD had greater intentions to switch to e-cigarettes completely and seek help quitting compared to smokers without SPD, which indicates that smokers with SPD may be optimistic about e-cigarettes to help them quit smoking.

The Role of Mental Health and Substance Use in Homeless Adults' Tobacco Use and Cessation Attempts

Objective: Although tobacco use is prevalent among adults experiencing homelessness, research deficits exist regarding the mental health, substance use, and demographic correlates of tobacco use behaviors in this population. This study examined whether correlates of tobacco use among housed adults identified by the Center for Disease Control (CDC) were significant correlates of tobacco use and cessation attempts among a sample of homeless adults. Methods: Participants (N = 421) were adults experiencing homelessness entering permanent supportive housing programs in Los Angeles. Multivariate logistic regression determined associations of lifetime mental health diagnoses, recent substance use, demographic characteristics, and lifetime literal homelessness with daily tobacco use and cessation attempts. Results: Lifetime diagnoses of schizophrenia, posttraumatic stress disorder, depression, bipolar disorder, and illicit substance use were associated with increased odds of daily tobacco use. A lifetime diagnosis of depression was associated with an increased likelihood of a past 3-month tobacco cessation attempt, while illicit substance use was associated with a lower likelihood of a cessation attempt. Conclusions: Findings suggest that demographic and clinical characteristics associated with tobacco use differ among this sample of homeless adults and those identified by the CDC among housed adults. Mental health conditions and substance use appear to be the primary correlates of tobacco use among adults experiencing homelessness and may be critical in efforts aimed at improving cessation.

Patient-Informed Treatment Development of Behavioral Smoking Cessation for People With Schizophrenia

The objective of this study was to use qualitative methodology to tailor and refine an existing smoking cessation intervention for the population of people who use cigarettes and are diagnosed with schizophrenia, schizoaffective, or psychotic disorder. Successive cohort design methodology was used to iteratively modify the treatment in response to qualitative participant, therapist, and consultant feedback on the intervention. Qualitative methodology for participant feedback included analysis of semistructured interviews with participants, visualization of app utilization data, and stakeholder feedback from study therapists and consultants. Using the successive cohort design, a tailored multicomponent mobile health smoking cessation intervention was developed. The intervention included mobile contingency management (i.e., financial compensation for confirmed abstinence from smoking), pharmacotherapy for smoking cessation, cognitive-behavioral counseling sessions, and the Stay Quit app for relapse prevention. Two cohorts (N = 13) were completed in the study; after each cohort, the treatment protocol was revised. The intervention is described, as well as the qualitative findings from each cohort and subsequent changes made to the intervention based upon patient and provider feedback. Metrics of patient engagement included treatment adherence (40% in Cohort 1 and 63% in Cohort 2). Both participants and therapists reported that the intervention was helpful. Over one third of participants self-reported abstinence at posttreatment. Since qualitative methodology is often underutilized in mental health treatment development, this study demonstrates the utility of the successive cohort design for treatment development of behavior change interventions for at-risk, vulnerable populations.

A pilot study of Counsel to Quit®: Evaluating an Ask Advise Refer (AAR)-based tobacco cessation training for medical and mental healthcare providers

INTRODUCTION

Despite tobacco use as the largest preventable cause of premature death in the US, many healthcare providers continue to lack the knowledge and confidence in employing the Ask, Advise, Refer (AAR) model in tobacco cessation treatment delivery. This pilot study evaluated the feasibility and effectiveness of a novel AAR-styled training program, Counsel to Quit®, across a range of healthcare providers and disciplines (i.e., medical, mental health, other). The Counsel to Quit® training program primarily targeted publically-funded settings that serve communities with high smoking rates.

METHODS

Pre- and post-training surveys were administered to medical, mental health, and other professionals (N = 297) to evaluate the effectiveness of the 60-90 minute Counsel to Quit® counselor training program for improving confidence in the ability to discuss approved tobacco cessation interventions and address the current state of knowledge about the role of electronic cigarettes in tobacco cessation. The trainings were held across 14 different non-profit institutional settings in Chicago, IL.

RESULTS

The Counsel to Quit® program improved AAR beliefs, the confidence and ability to discuss smoking cessation, and knowledge on the role of electronic cigarettes in tobacco cessation among medical, mental health, and other providers (ps < .001). Interactions showed that Counsel to Quit® improved medical provider confidence in referring patients for smoking cessation the most (p < .001), and also improved mental health providers belief in the importance of tobacco cessation for preventative care the most (ps < .05).

CONCLUSIONS

Counsel to Quit® is a feasible and effective training for improving AAR beliefs across multiple healthcare provider domains and at different types of publicly-funded healthcare institutions. Further, this training increased provider preparedness to discuss the lack of evidence for e-cigarette use as a form of tobacco cessation.

Electronic nicotine delivery system (ENDS) use in relation to mental health conditions, past-month serious psychological distress and cigarette smoking status, 2017

BACKGROUND AND AIMS

Adults with mental health conditions (MHC) exhibit disproportionately high smoking prevalence and experience profound tobacco-related disparities. US nationally representative surveys from 2012 to 2015 found relatively high usage of electronic nicotine delivery systems (ENDS; e.g. e-cigarettes) among adults with MHC. However, research has not examined these associations specifically among never smokers. Aims were to examine associations among MHC diagnosis, serious psychological distress (SPD) and ENDS use and to test whether associations varied by cigarette smoking status.

DESIGN

Cross-sectional US nationally representative survey.

SETTING

United States, 2017.

PARTICIPANTS

A total of 5762 adults (52.0% female; 64.8% non-Hispanic white, 11.4% non-Hispanic black, 15.9% Hispanic, 7.9% non-Hispanic other).

MEASUREMENTS

Outcomes were lifetime, current and current daily ENDS use. Predictors were lifetime MHC, past-month SPD and cigarette smoking status, and covariates were gender, age, race/ethnicity, education and annual household income.

FINDINGS

lifetime MHC and past-month SPD were each associated with higher likelihood of having ever used ENDS (P ≤ 0.001), currently using ENDS (P ≤ 0.001) and currently using ENDS daily (P < 0.05). There were interactions between MHC and smoking status in predicting ENDS use, such that MHC status predicted higher lifetime and current ENDS use specifically among never and current smokers. Never smokers with MHC had 2.62 higher odds [95% confidence interval, (CI) = 1.54, 4.45] of current ENDS use than those without MHC. Among never smokers, those with MHC indicated higher expectations that ENDS would improve relaxation and concentration (P < 0.05).

CONCLUSIONS

In 2017, US adults with versus without mental health conditions (MHC) were more likely to use electronic nicotine delivery systems (ENDS). In particular, both never and current smokers with MHC reported disproportionately high rates of current ENDS use.

Elevated Familial Cardiovascular Burden Among Adolescents With Familial Bipolar Disorder

Background: Bipolar disorder (BD) is one of the most heritable medical conditions, and certain phenotypic characteristics are especially familial in BD. BD is also strongly associated with elevated and premature cardiovascular disease (CVD) morbidity and mortality. Thus, far, little is known regarding the familiality of cardiovascular risk in BD. We therefore examined the extent of CVD-related conditions among relatives of: adolescents with BD with a family history of BD (familial BD), adolescents with BD without a family history of BD (non-familial BD) and healthy controls (HC). Materials and Methods: The sample included 372 adolescents; 75 with familial BD, 96 with non-familial BD, and 201 HC. Parents of the adolescents completed the CARDIA Family Medical History interview regarding the adolescents' first- and second- degree adult relatives. We computed a "cardiovascular risk score" (CRS) for each relative, based on the sum of the presence of diabetes, hypertension, obesity, dyslipidemia, stroke, angina, and myocardial infarction (range 0-7). Primary analyses examined for group differences in mean overall CRS scores among first and second- degree relatives combined, controlling for age, sex, and race. Secondary analyses examined first- and second-degree relatives separately, controlling for age, sex, and race. Results: There were significant between-group differences in CRS in first- and second- degree relatives combined, following the hypothesized ordering: CRS was highest among adolescents with familial BD (1.14 ± 0.78), intermediate among adolescents with non-familial BD (0.92 ± 0.79) and lowest in HC (0.76 ± 0.79; F = 6.23, df = 2, p = 0.002, ηp 2 = 0.03). There was a significant pairwise difference between adolescents with familial BD and HC (p = 0.002, Cohen's d = 0.49). A similar pattern of between-group differences was identified when first-degree and second-degree relatives were examined separately. Limitations: familial cardiovascular burden was determined based on parent interview, not evaluated directly. Conclusions: Adolescents with BD with a family history of BD have elevated rates of CVD-related conditions among their relatives. This may be related to genetic overlap between BD and CVD-related conditions, shared environmental factors that contribute to both BD and CVD-related conditions, or a combination of these factors. More research is warranted to better understand the interaction between familial risk for BD and CVD, and to address this risk using family-wide preventive approaches.

Risk factors for possible REM sleep behavior disorder: A CLSA population-based cohort study

OBJECTIVE

To assess sociodemographic, socioeconomic, and clinical correlates of idiopathic REM sleep behavior disorder (RBD) in a 30,097-person national cohort.

METHODS

Participants 45 to 85 years of age in Canada were collected as part of the Canadian Longitudinal Study on Aging. Possible RBD (pRBD) was screened with the REM Sleep Behavior Disorder Single-Question Screen, a questionnaire with 94% specificity and 87% sensitivity. To improve diagnostic accuracy, those screening positive for apnea or non-REM parasomnia (young-onset pRBD) and those self-reporting dementia or Parkinson disease were excluded. A series of sociodemographic, lifestyle, and mental health variables were analyzed cross-sectionally. Potential correlates were assessed via multivariable logistic regression.

RESULTS

Of 30,097 participants, 958 (3.2%) were identified as having pRBD. Male sex (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.78-2.44) and lower education (OR 0.95, 95% CI 0.92-0.98) were associated with pRBD. Participants with pRBD had smoked more (pack-years OR 1.01, 95% CI 1.00-1.01) and were more likely to be moderate to heavy drinkers (OR 1.25, 95% CI 1.04-1.51). There was a strong association between pRBD and self-reported antidepressant treatment for depression (OR 2.77, 95% CI 2.23-3.45), psychological distress (OR 1.61, 95% CI 1.44-1.80), mental illness (OR 2.09, 95% CI 1.75-2.49), and posttraumatic stress disorder (OR 2.68, 95% CI 1.97-3.65).

CONCLUSIONS

Our study replicated previous reported associations between pRBD and smoking, low education, and male sex and found previously unreported links with alcohol use and psychological distress. Risk factors for pRBD differ from those previously defined for neurodegenerative synucleinopathies.

Neurobiological Determinants of Tobacco Smoking in Schizophrenia

Purpose of review: To provide an overview of the underlying neurobiology of tobacco smoking in schizophrenia, and implications for treatment of this comorbidity. Recent findings: Explanations for heavy tobacco smoking in schizophrenia include pro-cognitive effects of nicotine, and remediation of the underlying pathophysiology of schizophrenia. Nicotine may ameliorate neurochemical deficits through nicotine acetylcholine receptors (nAChRs) located on the dopamine, glutamate, and GABA neurons. Neurophysiological indices including electroencephalography, electromyography, and smooth pursuit eye movement (SPEM) paradigms may be biomarkers for underlying neuronal imbalances that contribute to the specific risk of tobacco smoking initiation, maintenance, and difficulty quitting within schizophrenia. Moreover, several social factors including socioeconomic factors and permissive smoking culture in mental health facilities, may contribute to the smoking behaviors (initiation, maintenance, and inability to quit smoking) within this disorder. Summary: Tobacco smoking may alleviate specific symptoms associated with schizophrenia. Understanding the neurobiological underpinnings and psychosocial determinants of this comorbidity may better explain these potential beneficial effects, while also providing important insights into effective treatments for smoking cessation.

Smokers with bipolar disorder, other affective disorders, and no mental health conditions: Comparison of baseline characteristics and success at quitting in a large 12-month behavioral intervention randomized trial

BACKGROUND

The extent to which smokers with bipolar disorder (BD) differ from other smokers on cessation-related characteristics and outcomes is unknown and could improve knowledge of treatment needs for this group. These analyses compared smokers with BD versus smokers with other affective disorders (ADs; anxiety and unipolar depression) and smokers with no mental health conditions (MHCs).

METHOD

Participants (n = 2570) were a subsample of those enrolled in a smoking cessation trial comparing two web-delivered intervention approaches: acceptance and commitment therapy (ACT) and cognitive behavioral therapy. Those included in this analysis self-reported having BD (n = 221), other ADs (n = 783) or no major MHCs (n = 1566). Surveys assessed baseline characteristics and self-reported abstinence at 3, 6, and 12-months post-randomization. Treatment utilization was tracked via page views.

RESULTS

Smokers with BD were distinct from both AD and no MHC smokers on the majority of baseline characteristics. At 12-months, quit rates were lower for smokers with BD (20%) than no MHCs (29%; p = 0.01), but no different than other ADs (20%; p =  .467). Interactions between treatment assignment and diagnostic group were non-significant for cessation outcome. The number of logins was higher for smokers with BD than AD in the ACT arm only (p = .001), but this finding was not replicated across other utilization indicators.

CONCLUSIONS

Smokers with BD and other ADs had similar long-term quit rates despite numerous differences in baseline characteristics. Despite being lower than for smokers without MHCs, long-term quit rates from web-based treatment are promising for smokers with BD as well as other ADs.

Modeling nicotine regulation: A review of studies in smokers with mental health conditions

Smokers with mental health conditions (MHCs) lose approximately 15 years of life relative to non-smokers without MHCs, of which two-thirds are attributable to smoking. The Food and Drug Administration (FDA) recently announced a new regulatory strategy for tobacco that includes a reduction in the nicotine content of cigarettes sold in the US to a minimally-addictive level. This action could improve cessation rates in smokers with MHCs by reducing their dependence on nicotine. However, nicotine reduction also could have unintended negative consequences in smokers with MHCs. Thus, it is important to conduct randomized controlled trials to investigate the potential effects of nicotine reduction in smokers with MHCs. Several studies of the acute or extended effects of nicotine reduction in smokers with emotional disorders or serious mental illness have been recently completed or are underway. Studies to date indicate that when smokers with MHCs are switched, under randomized, double-blind conditions, to cigarettes with very low nicotine content, they reduce their cigarette intake, with minimal or no effects on withdrawal, psychiatric symptoms, or compensatory smoking. However, some deleterious effects of nicotine reduction on cognitive performance measures in smokers with schizophrenia have been observed, which are offset by providing concurrent nicotine replacement. We review these studies and provide suggestions for potentially increasing the effectiveness of a nicotine reduction strategy for reducing smoking in people with MHCs. The research described was conducted in the United States in 2010-2018.

Preinjury employment status as a risk factor for symptomatology and disability in mild traumatic brain injury: A TRACK-TBI analysis

BACKGROUND

Preinjury employment status may contribute to disparity, injury risk, and recovery patterns following mild traumatic brain injury (MTBI).

OBJECTIVE

To characterize associations between preinjury unemployment, prior comorbidities, and outcomes following MTBI.

METHODS

MTBI patients from TRACK-TBI Pilot with complete six-month outcomes were extracted. Preinjury unemployment, comorbidities, injury factors, and intracranial pathology were considered. Multivariable regression was performed for employment and outcomes, correcting for demographic and injury factors. Mean-differences (B) and 95% CIs are reported. Statistical significance was assessed at p < 0.05.

RESULTS

162 MTBI patients were aged 39.8±15.4-years and 24.6% -unemployed. Unemployed patients demonstrated increased psychiatric comorbidities (45.0% -vs.- 23.8%; p = 0.010), drug use (52.5% -vs.- 21.3%; p < 0.001), smoking (62.5% -vs.- 27.0%; p < 0.001), prior TBI (78.4% -vs.- 55.0%; p = 0.012), and lower education (15.0% -vs.- 45.1% college degree; p = 0.003). On multivariable analysis, unemployment associated with decreased six-month functional outcome (Glasgow Outcome Scale-Extended: B = - 0.50, 95% CI [- 0.88, - 0.11]), increased psychiatric disturbance (Brief Symptom Inventory-18: B = 6.22 [2.33, 10.10]), postconcussional symptoms (Rivermead Questionnaire: B = 4.91 [0.38, 9.44]), and post-traumatic stress disorder (PTSD Checklist-Civilian: B = 5.99 [0.76, 11.22]). No differences were observed for cognitive measures or satisfaction with life.

CONCLUSIONS

Unemployed patients are at risk for preinjury psychosocial comorbidities, poorer six-month functional recovery and increased psychiatric/postconcussional/PTSD symptoms. Resource allocation and return precautions should be implemented to mitigate and/or prevent the decline of at-risk patients.

Worry, anxiety sensitivity, and electronic cigarettes among adults

Although electronic cigarette (e-cigarette) use is now a common substance use behavior, there is little understanding of the individual difference factors related to e-cigarette use beliefs and dependence. The present investigation sought to test a theoretically-driven model of anxiety sensitivity as an explanatory element in a worry-e-cigarette beliefs and dependence model. Participants included 558 adult e-cigarette users (51.4% female; 35.2 years, SD = 10.1) who were nationally recruited via an online survey system. Participants completed a single survey that assessed their mood and e-cigarette behavior and beliefs. Results supported a statistically significant indirect pathway for worry in relation to perceived benefits of e-cigarettes, e-cigarette positive outcome expectancies, and e-cigarette dependence via anxiety sensitivity; effect sizes were small. The indirect effects were evident when accounting for several theoretically relevant covariates (sex, income, education, concurrent cigarette use, and neuroticism). This study provides the first empirical evidence of the role of anxiety sensitivity in the relation between worry and e-cigarette use beliefs and behavior, which may represent a novel intervention target.

A tele-mentoring tobacco cessation case consultation and education model for healthcare providers in community mental health centers

Smoking prevalence among individuals with mental and behavioral health needs is considerably higher compared to the general population, but evidence-based smoking cessation therapies are underutilized in mental and behavioral healthcare settings, despite the fact that these treatments are both safe and effective. The goal of this paper is to present the background, design and pilot of Project TEACH (Tobacco Education and Cessation in the Health System) developed to improve clinical practice by offering specialized training in the provision of smoking cessation interventions to care providers in community mental health centers in Texas. This is achieved through engaging the expertise of clinicians at the MD Anderson Cancer Center’s Tobacco Treatment Program and disseminating this expertise to care providers by means of a novel tele-mentoring approach called Project ECHO (Extension for Community Healthcare Outcomes). Evaluation of our pilot ECHO training project demonstrated that the training was very well received and resulted in self-reported enhancement of the providers’ professional practice. This is the first project to extend the collaborative ECHO model to train healthcare providers in smoking cessation. This approach has potential to reduce smoking rates among smokers with mental and behavioral health needs, and consequently contribute to the prevention of cancer and other chronic diseases in this vulnerable population.

Electronic, heat-not-burn, and combustible cigarette use among chronic disease patients in Japan: A cross-sectional study

INTRODUCTION

Although tobacco smoking adversely affects health, many people continue to smoke while suffering from chronic disease. Few studies have examined electronic and heat-not-burn cigarette use among chronic disease patients. Our objective was to investigate electronic, heat-not-burn and combustible cigarette use among chronic disease patients with hypertension, diabetes, cerebrovascular disease, COPD (chronic obstructive pulmonary disease), asthma, atopic dermatitis, cancer, or mental disorders.

METHODS

We analyzed 4432 eligible respondents aged 40–69 years from a 2015 internet survey (randomly sampled research agency panelists) with a propensity score weighting adjustment for ‘being a respondent in an internet survey’ in Japan. The outcome measure was the prevalence of electronic, heat-not-burn, and combustible cigarette use. Intention to quit was also calculated.

RESULTS

In all, 32.1% (n=80) of male patients with more than two diseases and 10.3% (n=16) of female patients were current smokers. Of the patients who had no intention to quit smoking, 15.5% were male patients with atopic dermatitis and 63.7% with mental disorders. Of the men, 7.7% without any diseases had ever used e-cigarettes, while 7.7% and 6.4% of men with one disease or more than two diseases, respectively, had ever used e-cigarettes. Of the women, 3.5% without any diseases had ever used e-cigarettes, while 2.1% and 2.9% of women with one disease or more than two diseases, respectively, had ever used e-cigarettes. Percentage of heat-not-burn tobacco current or ever use was low (<0.1%) among both men and women.

CONCLUSIONS

Differences in the use of electronic and combustible cigarettes according to the number of diseases were not obvious. However, sex differences for smoking among chronic disease patients, especially in atopic dermatitis and mental disorders, were found.

Brief Web-Based Interventions for Young Adult Smokers With Severe Mental Illnesses: A Randomized, Controlled Pilot Study

Significance

About 50% of young adults with schizophrenia, bipolar disorder, and other severe mental illnesses smoke tobacco, but few studies have evaluated interventions for this group.

Methods

We conducted a randomized pilot study among 58 young adult smokers with severe mental illnesses comparing a brief interactive web-based motivational tool, Let's Talk About Smoking, to computerized standard education from the National Cancer Institute. An additional 23 subjects received minimal tobacco assessment at baseline and no intervention, providing a comparison condition for naturalistic cessation behavior. All participants (total n = 81) were assessed for smoking and breath carbon monoxide at baseline and 14 weeks and had access to standard cessation treatments.

Results

The 81 participants were stable outpatients ages 18-30 (mean 24.8 years): 43.2% were diagnosed with schizophrenia-spectrum disorders, the remainder with severe mood and anxiety disorders. They smoked 14.6 ± 10.2 cigarettes per day. All participants completed their assigned intervention; 83.4% of Let's Talk About Smoking users and 71.4% of standard education users rated their intervention "good" or "very good." At 14 weeks, less than 15% of participants in all conditions had used additional cessation treatment. Let's Talk About Smoking users were more likely to have biologically verified abstinence at 14 weeks than standard education users (14.8% vs. 0%; X2 = 3.7, p = .05). None of the participants in the naturalistic comparison condition were abstinent at 14 weeks.

Conclusions

Interactive, web-based motivational interventions are feasible and promising for smoking cessation among young smokers with severe mental illnesses. Such interventions warrant further study among this group of smokers.

Implications

Young adult smokers with severe mental illnesses are a vulnerable population that, without intervention, goes on to experience disparate morbidity and mortality. Brief, easily disseminable interventions are needed to facilitate cessation in this group. This pilot research indicates that brief, technology-delivered, motivational interventions that are tailored for this group may be able to activate a significant number to quit without additional cessation intervention.

Sex differences in nicotine dependency and depressive tendency among smokers

Depressive tendency and nicotine dependency are factors related to the failure of smoking cessation. Women generally have a higher depressive tendency and difficulty in smoking cessation than men. However, the impact of sex differences on the relationship between nicotine dependency and depressive tendency remains unclear. We evaluated 727 patients (496 men and 231 women) who visited our outpatient clinic for smoking cessation therapy and compared various parameters measured between sexes during consultation. Age, duration of smoking, and daily cigarette consumption were significantly higher in men during the first visit. Women had significantly higher self-rating depression scale (SDS) scores and took significantly more antidepressant drugs than men. The SDS score significantly correlated with the Fagerström test for the nicotine dependence score and with daily cigarette consumption in women, but not in men. Thus, the present study demonstrates the differential relationship of depressive tendency with tobacco use or nicotine dependency in men and women, which might reflect sex differences in response to psychological stress.

Neuroprotective Effects of Nicotine on Hippocampal Long-Term Potentiation in Brain Disorders

Long-term potentiation (LTP) is commonly considered the cellular correlate of learning and memory. In learning and memory impairments, LTP is invariably diminished in the hippocampus, the brain region responsible for memory formation. LTP is measured electrophysiologically in various areas of the hippocampus. Two mechanistically distinct phases of LTP have been identified: early phase LTP, related to short-term memory; and late-phase LTP, related to long-term memory. These two forms can be severely reduced in a variety of conditions but can be rescued by treatment with nicotine. This report reviews the literature on the beneficial effect of nicotine on LTP in conditions that compromise learning and memory.

Mirtazapine attenuates nicotine-seeking behavior in rats

BACKGROUND

Nicotine is the major psychoactive component of tobacco. A number of pharmacological therapies have been evaluated, with poor results. Given the lack of success of these therapies, several authors have proposed alternative therapeutic strategies. One of these is the use of antidepressant drugs that may have a specific effect on the neural pathways or receptors underlying nicotine addiction. Mirtazapine is an antagonist of α₂ NE receptors (noradrenergic receptor), 5-HT_2A/C and 5-HT₃ receptors and has demonstrated efficacy in reducing behavioral effects induced by drugs of abuse in human and animal models.

AIMS

In this study, we evaluated the effect of chronic dosing of mirtazapine during extinction on the re-acquisition of nicotine-seeking in rodents.

METHODS

We used the nicotine self-administration paradigm to assess the effects of mirtazapine on rats trained to self-administer nicotine under a pharmacological fixed-ratio schedule. Mirtazapine (30 mg/kg, i.p.) was administered during extinction.

RESULTS

In this work, we found that mirtazapine attenuates the re-acquisition of nicotine-seeking responses.

CONCLUSIONS

These results support the use of mirtazapine in clinical controlled trials as a useful therapy that prolongs and increases rates of preventing relapse into nicotine intake in humans.

Nicotine metabolite ratio and smoking outcomes using nicotine replacement therapy and varenicline among smokers with and without psychiatric illness

INTRODUCTION

It has been suggested that the effectiveness of nicotine replacement smoking cessation pharmacotherapy may be enhanced by assessing rates of nicotine metabolism using the nicotine metabolite ratio - which reflects differences in the activity of the CYP2A6 hepatic enzyme - and titrating doses appropriately. To date, supporting evidence is equivocal, with little information regarding the assessment and effectiveness of the nicotine metabolite ratio among smokers with psychiatric conditions.

METHODS

The nicotine metabolite ratio of 499 smokers from the FLEX trial was determined using urine samples obtained at baseline. They were randomized to receive either: standard transdermal nicotine (nicotine replacement therapy); extended nicotine replacement therapy + adjunct nicotine agent; or varenicline. Primary cessation outcomes were seven-day point prevalence at 5, 10, 22, and 52 weeks post-target quit date, comparing across treatment and psychiatric status. Our principal analysis employed logistic regression (outcome: abstinence), using slow metabolizers as the reference category.

RESULTS

No differences were observed by nicotine metabolite ratio classification (slow, moderate, fast) with respect to any demographic or smoking-related variables. Nicotine metabolite ratio class did not predict smoking cessation in either the overall sample, or by treatment condition at any time-point (week 52 moderate metabolizers: odds ratio 1.34, 95% confidence interval (0.68-2.63), p=0.394; fast metabolizers: odds ratio 1.04 (0.56-1.91), p=0. 906).

CONCLUSION

Our results did not find any associations between nicotine metabolite ratio and cessation outcomes among smokers using nicotine replacement therapy or varenicline with and without lifetime psychiatric conditions.

Nicotine modulates contextual fear extinction through changes in ventral hippocampal GABAergic function

Numerous studies have attributed the psychopathology of anxiety and stress disorders to maladaptive behavioral responses such as an inability to extinguish fear. Therefore, understanding neural substrates of fear extinction is imperative for developing more effective therapies for anxiety and stress disorders. Although several studies indicated a role for cholinergic transmission and nicotinic acetylcholine receptors (nAChRs) in anxiety and stress disorder symptomatology, very little is known about the specific contribution of nAChRs in the fear extinction process. In the present study, we first examined the involvement of several brain regions essential for fear extinction (i.e., dorsal and ventral hippocampus, dHPC and vHPC; infralimbic, IL, and prelimbic, PL of the medial prefrontal cortex, mPFC; basolateral nucleus of the amygdala, BLA) in the impairing effects of a nAChR agonist, nicotine, on contextual fear extinction in mice. Our results showed that systemic administration of nicotine during contextual fear extinction increased c-fos expression in the vHPC and BLA while not affecting dHPC, IL or PL. In line with these results, local nicotine infusions into the vHPC, but not dHPC, resulted in impaired contextual fear extinction. Interestingly, we found that local nicotine infusions into the PL also resulted in impairment of contextual fear extinction. Second, we measured the protein levels of the GABA synthesizing enzymes GAD65 and GAD67 in the dHPC and vHPC during contextual fear extinction. Our results showed that in the group that received acute nicotine, both GAD65 and GAD67 protein levels were downregulated in the vHPC, but not in dHPC. This effect was negatively correlated with the level of freezing response during fear extinction suggesting that the downregulated GAD65/67 levels were associated with disrupted fear extinction. Finally, using c-fos/GAD65/67 double immunofluorescence, we showed that nicotine mainly increased c-fos expression in non-GABAergic ventral hippocampal cells, indicating that acute nicotine increases vHPC excitability. Overall, our results suggest that acute nicotine's impairing effects on fear extinction are associated with ventral hippocampal disinhibition. Therefore, these results further our understanding of the interaction between nicotine addiction and anxiety and stress disorders by describing novel neural mechanisms mediating fear extinction.

Anhedonia and smoking cessation among Spanish-speaking Mexican-Americans

OBJECTIVE

Smoking cessation is associated with improved health and reduced risk of disease. Understanding specific factors that are associated with smoking cessation is important both for identifying those who may have the greatest difficulty quitting smoking and tailoring smoking cessation interventions accordingly. Low positive affect/anhedonia, a key transdiagnostic symptom of several psychiatric disorders, is associated with lower levels of smoking cessation in the general population, but to date, few studies have examined factors influencing smoking cessation among Spanish-speaking Mexican-American smokers.

METHODS

The current study examined whether low positive affect/anhedonia was inversely related to cessation status across 3 time points among Spanish-speaking Mexican-American smokers (N = 199) who were making a smoking quit attempt.

RESULTS

Using multilevel modeling, the between-person low positive affect/anhedonia score was found to be inversely associated with smoking at quit day, 3 and 26 weeks after quit while controlling for relevant covariates (i.e., age, gender, education, income, relationship status, heaviness of smoking index) but not when controlling for other symptoms of depression.

CONCLUSIONS

Contrary to prior research, the results of this study did not confirm the unique predictive role of low positive affect/anhedonia among Mexican Americans, suggesting that risk factors for this group may be different from other populations and cessation approaches may also need to differ. (PsycINFO Database Record

Comorbid Cannabis and Tobacco Use Disorders in Hospitalized Patients with Psychotic-Spectrum Disorders

OBJECTIVE

Individuals with psychotic-spectrum disorders use tobacco and cannabis at higher rates than the general population and individuals with other psychiatric disorders, which may contribute to increased rates of medical problems and mortality. The present study examined whether individuals with psychosis and comorbid tobacco and/or cannabis use disorders exhibit differing clinical characteristics in terms of their sociodemographic, mental health, substance use, physical health, and medication use patterns. Elucidation of these profiles, and determining their relative severity, has important implications for treatment, including offering more targeted interventions based on type of comorbidity pattern.

METHODS

We examined the electronic medical records of 829 patients with psychotic-spectrum disorders admitted to a psychiatric hospital and categorized them as having: (1) cannabis use disorder (CUD); (2) tobacco use disorder (TUD); (3) comorbid cannabis and tobacco use disorders (CUD + TUD); or (4) neither disorder (no CUD/TUD). Multinomial logistic regression was used to compare the aforementioned groups on multiple variables controlling for age and sex.

RESULTS

Alcohol and stimulant use disorder diagnoses were each related to higher odds of having a CUD and CUD + TUD, relative to no CUD/TUD. Stimulant and polysubstance use disorder diagnoses were each related to higher odds of having a TUD compared to no CUD/TUD. Greater number of prescribed psychotropic medications was related to higher odds of a TUD compared to no CUD/TUD.

CONCLUSIONS

Although several differences between groups were accounted for by age of cannabis versus tobacco users, findings point to the importance of considering comorbid alcohol and substance use disorders among those with psychosis and CUD/TUD, as these comorbidities have important implications for screening and treatment selection during and following acute hospitalization.