Nicotine dependence phenotype and lung cancer risk

Smoking, Lung Cancer Stage, and Prognostic Factors-Findings from the National Lung Screening Trial

BACKGROUND

Low-dose computed tomography (LDCT) increases the early detection of lung cancer. Identifying modifiable behaviors that may affect tumor progression in LDCT-detected patients increases the likelihood of long-term survival and a good quality of life.

METHODS

We examined cigarette smoking behaviors on lung cancer stage, progression, and survival in 299 ever-smoking patients with low-dose CT-detected tumors from the National Lung Screening Trial. Univariate and multivariate Cox models were used to estimate the hazard ratio (HR) for smoking variables on survival time.

RESULTS

Current vs. former smokers and early morning smokers (≤5 min after waking, i.e., time to first cigarette (TTFC) ≤ 5 min) had more advanced-stage lung cancer. The adjusted HR for current vs. former smokers was 1.3 (95% confidence interval [CI] 0.911-1.98, p = 0.136) for overall survival (OS) and 1.3 (0.893-1.87, p = 0.1736) for progression-free survival (PFS). The univariate hazard ratios for TTFC ≤ 5 min vs. >5 min were 1.56 (1.1-2.2, p = 0.013) for OS and 1.53 (1.1-2.12, p = 0.01) for PFS. Among current smokers, the corresponding HRs for early TTFC were 1.78 (1.16-2.74, p = 0.0088) and 1.95 (1.29-2.95, p = 0.0016) for OS and PFS, respectively. In causal mediation analysis, the TTFC effect on survival time was mediated entirely through lung cancer stage.

CONCLUSION

The current findings indicate smoking behaviors at diagnosis may affect lung cancer stage and prognosis.

Acceptance and Commitment Therapy-Based Smartphone Applications for Cessation of Tobacco Use among Adults with High Nicotine Dependence: Results from the iCanQuit Randomized Trial

Background: With 1 in 2 adult tobacco users being highly dependent on nicotine, population-based interventions specifically designed for this group are urgently needed. This study used data from a randomized trial to evaluate whether (1) Acceptance and Commitment Therapy (ACT) delivered via a smartphone application (iCanQuit) would be more efficacious for cessation of nicotine-containing tobacco products than the US Clinical Practice Guidelines (USCPG)-based application (QuitGuide) among highly nicotine-dependent adults, (2) the effect of treatment on cessation was mediated by increases in acceptance of cravings to smoke, and (3) treatment utilization and satisfaction differed by arm. Methods: A total of 1452 highly nicotine-dependent adults received the iCanQuit or QuitGuide application for 12-months. Cessation outcomes were self-reported complete-case 30-day abstinence of nicotine-containing tobacco products (e.g., combustible cigarettes, e-cigarettes, chewing tobacco, snus, hookahs, cigars, cigarillos, tobacco pipes, and kreteks) at 3, 6, and 12-month post-randomization timepoints, missing-as-smoking, and multiple imputation analyses. Acceptance of cues to smoke and satisfaction with the applications was also reported. Results: Participants who received iCanQuit were significantly more likely to report 30-day abstinence of nicotine-containing tobacco products than those who received QuitGuide at 12-months (24% vs. 17%; OR = 1.47 95% CI: 1.11, 1.95). iCanQuit participants utilized their application more frequently and reported greater satisfaction than those who received QuitGuide. Increases in participants' acceptance of cues to smoke mediated the intervention effect on cessation of nicotine-containing tobacco products. Conclusions: Among nicotine-dependent adults, an application-delivered ACT-based intervention was more engaging and efficacious than a USCPG-based intervention for cessation of nicotine-containing tobacco products.

A measure of illness awareness in individuals with nicotine dependence - Nicotine Use Awareness and Insight Scale (NAS)

INTRODUCTION

Impaired illness awareness or the inability to recognize that one has a dependence on nicotine may be a major barrier to seeking cessation treatment. To better understand the role of impaired illness awareness on treatment seeking behavior and clinical outcomes in individuals with nicotine dependence, we developed and examined the psychometric properties of a novel scale measuring illness awareness.

METHODS

We developed the Nicotine Use Awareness and Insight Scale (NAS), a 7-item self-report measure to assess the theoretical construct of illness awareness in individuals with dependence on nicotine. Data from participants 18 years of age or older were collected via a web-based survey company, Dynata. Participants with moderate dependence on nicotine were included, defined by a score of 4 or more on the Fagerström Test for Cigarette Dependence (FTCD) or the FTCD adapted for electronic cigarettes (eFTCD).

RESULTS

A total of 100 participants (mean (SD) age=49.1 (16.1), 52% women) that met the inclusion criteria for either FTCD (n=50) or eFTCD (n=50) were studied. The NAS demonstrated good convergent (r=.74, p<0.001) and discriminant validity (r=.03, p=0.786). It also demonstrated good internal consistency (Cronbach's alpha=0.78) and one-month test-retest reliability (intra-class correlation=0.86). An exploratory factor analysis yielded retention of two components.

CONCLUSIONS

This study provides initial support for the validity and reliability of the NAS, a scale measuring impaired illness awareness in individuals with dependence on nicotine. The NAS can be used in research and clinical practice to evaluate the impact of impaired illness awareness in seeking nicotine cessation treatment.

IMPLICATIONS

Impaired illness awareness or the inability to recognize that one is dependent on nicotine may be a barrier to seeking cessation treatment. The Nicotine Use Awareness and Insight Scale (NAS) is a novel scale to assesses subjective illness awareness in individuals with dependence on nicotine. This study provides initial support for the psychometric validity and reliability of the NAS. NAS demonstrated good convergent and discriminant validity with measures of illness recognition and affect states, respectively, internal consistency, and test-retest reliability. The NAS can be used in research and clinical practice to evaluate the impact of impaired illness awareness on treatment and clinical outcomes.

Dependence on nicotine in US high school students in the context of changing patterns of tobacco product use

BACKGROUND AND AIM

There have been substantial recent changes in youth tobacco product use in the United States-including, notably, a rapid increase in use of e-cigarettes. It is not known whether, and if so how far, these changes are reflected in levels of nicotine dependence. This study used data from a large, nationally representative sample of US adolescents to (i) estimate the annual prevalence of nicotine dependence in relation to current use of tobacco products, (ii) describe trends in dependence over time and (iii) evaluate whether the increase in youth use of tobacco products has been paralleled by a similar increase in the population burden of nicotine dependence.

DESIGN

Secondary analysis of National Youth Tobacco Surveys conducted annually, 2012-19.

SETTING

United States.

PARTICIPANTS

A total of 86 902 high school students.

MEASUREMENTS

Prevalence of (i) strong cravings to use tobacco in the past 30 days and (ii) wanting to use nicotine products within 30 minutes of waking, in relation to type of product used (cigarettes, other combustible tobacco, smokeless tobacco, e-cigarettes).

FINDINGS

Between 2012 and 2019 there was a marked decline in past 30-day cigarette smoking and a surge in use of e-cigarettes. Different products were associated with differing levels of nicotine dependence, with cigarettes characterized by highest dependence (strong craving 42.3%; wanting to use within 30 minutes 16.8% among exclusive users in 2019) and e-cigarettes in otherwise tobacco-naive students by low dependence (16.1 and 8.8% respectively in 2019). The overall 33.8% increase in population use of nicotine products between 2012 and 2019 (from 23.2 to 31.2%) was not accompanied by an equivalent increase in overall population burden of dependence {percentage reporting craving 10.9% [95% confidence interval (CI) = 9.8-12.2%] in 2012 and 9.5% (95% CI = 7.5-12.0%) in 2019; wanting to use within 30 minutes 4.7% (95% CI = 4.0-5.5%) in 2012, 5.4% (95% CI = 4.0-7.2%) in 2019}.

CONCLUSIONS

Among US high school students, increases in the prevalence of nicotine product use from 2012 to 2019 do not appear to have been accompanied by a similar increase in the population burden of nicotine dependence. This may be at least partly attributable to a shift in the most common product of choice from cigarettes (on which users are most dependent) to e-cigarettes (on which users are least dependent).

Efficacy and safety of acupuncture combined with analgesics on lung cancer pain: A protocol for systematic review and meta-analysis

BACKGROUND

Lung cancer (LC) is the malignant tumor with the highest incidence in the world, and treatment methods include surgery, radiotherapy, chemotherapy, and immunotherapy. Cancer pain is a common symptom in patients with LC, and the clinical treatment is to relieve it with analgesics. Acupuncture can relieve cancer pain. This study aims to systematically study the efficacy and safety of acupuncture combined with analgesics on cancer pain in patients with LC.

METHODS

From the beginning to April 2021, search Medline, Embase, Cochrane Central Controlled Trials Register (Central), China National Knowledge Infrastructure (CNKI), Wanfang Database, China Biomedical Literature Database (CBM), and Chinese Science Journal Database (VIP database). Search the international clinical trial registration platform and the Chinese clinical trial registration platform to find ongoing or unpublished trials. The main outcome indicator is the total effective rate of analgesia, and the secondary outcome indicator is pain intensity score and adverse reactions. The RevMan 5.4 software will be used for statistical analysis.

RESULTS

This study will provide the latest evidence for acupuncture combined with analgesics to relieve LC pain.

CONCLUSION

The conclusion of this study is to evaluate the effectiveness and safety of acupuncture combined with analgesics in alleviating LC pain.

INPLASY REGISTRATION NUMBER

INPLASY202150051.

A key indicator of nicotine dependence is associated with greater depression symptoms, after accounting for smoking behavior

INTRODUCTION

Depression is a global burden that is exacerbated by smoking. The association between depression and chronic smoking is well-known; however, existing findings contain possible confounding between nicotine dependence (ND), a latent construct measuring addiction, and objective smoking behavior. The current study examines the possible unique role of ND in explaining depression, independently of smoking behavior.

METHODS

A nationally-representative sample of current adult daily smokers was drawn by pooling three independent, cross-sectional, biennial waves (spanning 2011-16) of the National Health and Nutrition Examination Survey (NHANES). The association between ND (operationally defined as time to first cigarette (TTFC) after waking) and the amount of depression symptoms was examined after adjusting for both current and lifetime smoking behaviors (cigarettes per day and years of smoking duration) and sociodemographic factors (gender, age, race, education and income to poverty ratio).

RESULTS

Earlier TTFC was associated with more depression symptoms, such that those smoking within 5 minutes of waking had an approximately 1.6-fold higher depression score (PRR = 1.576, 95% CI = 1.324-1.687) relative to those who smoke more than 1 hour after waking. This relationship remained significant after adjusting for current and lifetime smoking behavior as well as sociodemographic factors (PRR = 1.370, 95% CI = 1.113, 1.687).

CONCLUSIONS

The latent construct of ND, as assessed by TTFC, may be associated with an additional risk for depression symptoms, beyond that conveyed by smoking behavior alone. This finding can be used for more refined risk prediction for depression among smokers.

Ocular Surface, Meibomian Gland Alterations, and In Vivo Confocal Microscopy Characteristics of Corneas in Chronic Cigarette Smokers

PURPOSE

To evaluate the ocular surface, meibomian gland alterations, and in vivo confocal microscopy (IVCM) parameters through correlation with nicotine dependency level (NDL) and duration of smoking (DS) in chronic smokers.

METHODS

This cross-sectional study included 50 eyes of 50 chronic smokers, and 50 eyes of 50 age- and gender-matched healthy nonsmokers. To examine the ocular surface and tear film, corneal sensitivity (CS) measurement with Cochet-Bonnet esthesiometer, tear film break-up time (TBUT), lissamine green (LG) staining, Schirmer I test with anesthesia, and Ocular Surface Disease Index (OSDI) questionnaire were performed consecutively. Basal epithelial cell, keratocyte, and endothelial cell density, the percentage of endothelial polymegethism/pleomorphism, and subbasal nerve plexus were evaluated using IVCM. Meibomian gland density was evaluated with a meibography unit. The Fagerström test was used to measure NDL, and DS was recorded.

RESULTS

In the chronic smokers group, the basal epithelial cell density, anterior and posterior keratocytes, endothelial cell density, and long and total subbasal nerve numbers were lower, and LG staining, meiboscore, and OSDI scores were higher, compared with the control group, whereas other parameters were similar. The percentage of polymegethism was higher and the percentage of pleomorphism was lower in the chronic smokers group. In the correlation analysis, no significant relationship was found between the DS, NDL and ocular surface, and IVCM findings.

CONCLUSION

Decreased corneal basal epithelium, anterior and posterior keratocytes, endothelial cell density, meibomian gland density, and subbasal nerve numbers were found in chronic smokers. The results of the study show that smoking has an adverse effect on ocular surface parameters.

Nicotine dependence as an independent risk factor for atherosclerosis in the National Lung Screening Trial

Background

Atherosclerosis and COPD are systemic inflammatory diseases that share common risk factors including cigarette smoking. A high level of nicotine dependence is emerging as a recently identified risk factor for pulmonary impairment, chronic obstructive pulmonary disease and tobacco-related cancers. We hypothesized that nicotine dependence is associated with the risk of atherosclerosis in long-term cigarette smokers.

Methods

A nested case-control study was conducted within the National Lung Cancer Screening Trial- American College of Radiology Imaging Network. Cases were defined as having a new diagnosis of any type of atherosclerosis. Controls were matched on a 2:1 basis by age, sex, race, study center, smoking status, years of smoking, and frequency of smoking. Dependence was measured by the time to first cigarette after awakening (TTFC).

Results

The study included 166 cases and 286 controls. Compared to participants who smoked within 5 min after waking, the risk of atherosclerosis for participants who smoked an hour or more after waking was borderline non-significant (odds ratio = 0.49, 95% confidence intervals [CI] 0.23, 1.00). Findings were similar for men and women. For aortic atherosclerosis, the corresponding odds ratio was 0.24 (95% CI 0.08, 0.69). Hypertension was associated with an increased risk and body mass index was associated with a decreased risk of aortic atherosclerosis. The TTFC was unrelated to coronary atherosclerosis.

Conclusions

Compared to smoking immediately after waking, delaying an hour or more reduces the risk of aortic atherosclerosis even among long-term heavy smokers. Possible mechanisms that explain this association are intensity of smoking, inflammation and oxidative stress, and elevated lipid levels.

Earlier smoking after waking and the risk of asthma: a cross-sectional study using NHANES data

Background

Recent research shows that nicotine dependence conveys additional health risks above and beyond smoking behavior. The current study examines whether smoking within 5 min of waking, an indicator of nicotine dependence, is independently associated with asthma outcomes.

Methods

Data were drawn from five pooled cross-sectional waves (2005–14) of NHANES, and the final sample consisted of N = 4081 current adult smokers. Weighted logistic regressions were run examining the relationship between smoking within 5 min of waking and outcomes of lifetime asthma, past-year asthma, and having had an asthma attack in the past year. Control variables included demographics, smoking behavior, family history of asthma, depression, obesity, and secondhand smoking exposure.

Results

After adjusting for smoking behavior, smoking within 5 min was associated with an approximately 50% increase in the odds of lifetime asthma (OR = 1.46, p = .008) and past-year asthma (OR = 1.47, p = .024), respectively. After additionally adjusting for demographics and other asthma risk factors, smoking within 5 min of waking was associated with a four-fold increase in the odds of lifetime asthma (OR = 4.05, p = .015).

Conclusions

Smoking within 5 min of waking, an indicator of nicotine dependence, is associated with a significantly increased risk of lifetime asthma in smokers. These findings could be utilized in refining risk assessment of asthma among smokers.

Electronic supplementary material

The online version of this article (10.1186/s12890-018-0672-y) contains supplementary material, which is available to authorized users.

Tobacco Dependence Predicts Higher Lung Cancer and Mortality Rates and Lower Rates of Smoking Cessation in the National Lung Screening Trial

BACKGROUND

Incorporating tobacco treatment within lung cancer screening programs has the potential to influence cessation in high-risk smokers. We aimed to better understand the characteristics of smokers within a screening cohort, correlate those variables with downstream outcomes, and identify predictors of continued smoking.

METHODS

This study is a secondary analysis of the National Lung Screening Trial randomized clinical study. Tobacco dependence was evaluated by using the Fagerstrӧm Test for Nicotine Dependence, the Heaviness of Smoking Index, and time to first cigarette (TTFC); descriptive statistics were performed. Clinical outcomes (smoking cessation, lung cancer, and mortality) were assessed with descriptive statistics and χ² tests stratified according to nicotine dependence. Logistic and Cox regression models were used to study the influence of dependence on smoking cessation and mortality, respectively.

RESULTS

Patients with high dependence scores were less likely to quit smoking compared with low dependence smokers (TTFC OR, 0.50 [95% CI, 0.42-0.60]). Indicators of high dependence, as measured according to all three metrics, were associated with worsening clinical outcomes. TTFC showed that patients who smoked within 5 min of waking (indicating higher dependence) had higher rates of lung cancer (2.07% for > 60 min after waking vs 5.92% ≤ 5 min after waking; hazard ratio [HR], 2.56 [95% CI, 1.49-4.41]), all-cause mortality (5.38% for > 60 min vs 11.21% ≤ 5 min; HR, 2.19 [95% CI, 1.55-3.09]), and lung cancer-specific mortality (0.55% for > 60 min vs 2.92% for ≤ 5 min; HR, 4.46 [95% CI, 1.63-12.21]).

CONCLUSIONS

Using TTFC, a one-question assessment of tobacco dependence, at the time of lung cancer screening has implications for personalizing tobacco treatment and improving risk assessment.

Item Response Theory analysis of Fagerström Test for Cigarette Dependence

INTRODUCTION

The Fagerström Test for Cigarette Dependence (FTCD) and the Heaviness of Smoking Index (HSI) are the gold standard measures to assess cigarette dependence. However, FTCD reliability and factor structure have been questioned and HSI psychometric properties are in need of further investigations. The present study examined the psychometrics properties of the FTCD and the HSI via the Item Response Theory.

METHODS

The study was a secondary analysis of data collected in 862 Italian daily smokers. Confirmatory factor analysis was run to evaluate the dimensionality of FTCD. A Grade Response Model was applied to FTCD and HSI to verify the fit to the data. Both item and test functioning were analyzed and item statistics, Test Information Function, and scale reliabilities were calculated. Mokken Scale Analysis was applied to estimate homogeneity and Loevinger's coefficients were calculated.

RESULTS

The FTCD showed unidimensionality and homogeneity for most of the items and for the total score. It also showed high sensitivity and good reliability from medium to high levels of cigarette dependence, although problems related to some items (i.e., items 3 and 5) were evident. HSI had good homogeneity, adequate item functioning, and high reliability from medium to high levels of cigarette dependence. Significant Differential Item Functioning was found for items 1, 4, 5 of the FTCD and for both items of HSI.

CONCLUSIONS

HSI seems highly recommended in clinical settings addressed to heavy smokers while FTCD would be better used in smokers with a level of cigarette dependence ranging between low and high.

Potential Impact of Including Time to First Cigarette in Risk Models for Selecting Ever-Smokers for Lung Cancer Screening

INTRODUCTION

Selecting individuals on the basis of model-predicted risks has been reported to improve lung cancer screening efficiency. On the basis of case-control studies, time to first cigarette (TTFC), a nicotine dependency measurement, has been a strong independent predictor of lung cancer risk. Our objective was to verify the TTFC-lung cancer association in the prospective National Lung Screening Trial and evaluate whether adding TTFC can improve lung cancer risk-prediction models.

METHODS

Using Cox models, we examined associations between TTFC (≤5, 6-14, 15-29, 30-59, and ≥60 minutes) and lung cancer incidence and death in 18,729 National Lung Screening Trial participants, adjusting for smoking and other lung cancer risk factors comprehensively. We estimated 5-year individual lung cancer incidence by using models without and with TTFC and dichotomized into screening or no-screening groups based on risk thresholds of 1% and 2%. Area under the receiver operating curve values were calculated for models without and with TTFC.

RESULTS

Smokers with a TTFC of 60 minutes or more had a much lower standardized 5-year lung cancer incidence risk-1.54% (1.52%-1.56%) for TTFC 60 minutes or more versus 4.07% (4.04%-4.09%) for TTFC 5 minutes or less-and lung cancer death risk-0.59% (0.57%-0.61%) for TTFC 60 minutes or more versus 2.26% (2.23%-2.28%) for TTFC 5 minutes or less (p trend < 0.001). Adding TTFC to the lung cancer incidence model improved the area under the receiver operating curve by 0.0079 (95% confidence interval = 0.0019-0.0138 [p = 0.0085]). Among 8994 smokers without a lung cancer diagnosis, 180 (2.00%) and 155 (1.67%) more people would be assigned to the no-screening group by adding TTFC to the model (p values for percent changes <0.001) at the 1% and 2% risk thresholds, respectively.

CONCLUSION

Including TTFC, which can be elicited by a single question at very low cost and noninvasively question, into risk models might better identify smokers with lower risk and could therefore be a safe, convenient tool to improve identification of those who benefit less from lung cancer screening.

Household Smoking Restrictions Relate To Time To First Cigarette Smoked In The Morning

Introduction

The time a smoker waits until the first cigarette of the morning is often used as a measure of dependence with the rationale that more dependent smokers will smoke sooner upon waking than will less dependent smokers after going several hours without a cigarette overnight.

Aims

We sought to examine the relationship between time-to-first-cigarette (TTFC) and household smoking restrictions in two independent samples.

Methods

Two samples of smokers, one treatment-seeking community sample (N = 433) and one non-treatment-seeking sample of smokers with serious mental illness (i.e., Schizophrenia, Schizoaffective Disorder, or Bipolar I Disorder) (N = 94), provided information on cigarette dependence with the Fagerström Test for Nicotine Dependence and on household smoking restrictions.

Results

Half (50%) of smokers with serious mental illness and 36.7% of smokers from the general population reported that there were no limitations to smoking in their home. Household smoking restrictions were significantly and positively related to TTFC in both samples.

Conclusions

These data indicate that greater attention to TTFC may be warranted. The TTFC item is intended to measure dependence based on the premise that greater dependence should be associated with shorter TTFC. If TTFC is related to a household smoking ban, however, this item may not be assessing dependence as intended in some cases.

Genetic susceptibility variants for lung cancer: replication study and assessment as expression quantitative trait loci

Many single nucleotide polymorphisms (SNPs) have been associated with lung cancer but lack confirmation and functional characterization. We retested the association of 56 candidate SNPs with lung adenocarcinoma risk and overall survival in a cohort of 823 Italian patients and 779 healthy controls, and assessed their function as expression quantitative trait loci (eQTLs). In the replication study, eight SNPs (rs401681, rs3019885, rs732765, rs2568494, rs16969968, rs6495309, rs11634351, and rs4105144) associated with lung adenocarcinoma risk and three (rs9557635, rs4105144, and rs735482) associated with survival. Five of these SNPs acted as cis-eQTLs, being associated with the transcription of IREB2 (rs2568494, rs16969968, rs11634351, rs6495309), PSMA4 (rs6495309) and ERCC1 (rs735482), out of 10,821 genes analyzed in lung. For these three genes, we obtained experimental evidence of differential allelic expression in lung tissue, pointing to the existence of in-cis genomic variants that regulate their transcription. These results suggest that these SNPs exert their effects on cancer risk/outcome through the modulation of mRNA levels of their target genes.

Time to first cigarette and serum cholesterol levels

RATIONALE

Cigarette smoking is a primary cause of cardiovascular disease (CVD); however, prior research has rarely distinguished smoking behavior from nicotine dependence.

OBJECTIVE

The current study presents a novel investigation into whether time to first cigarette (TTFC), a reliable proxy for nicotine dependence, is associated with lipid cholesterol, a biomarker for CVD, after controlling for smoking behavior and other risk factors.

METHODS

In total, 3903 current adult smokers were drawn from four consecutive cross-sectional waves (2005-06, 2007-08, 2009-10, and 2011-12) of the National Health and Nutrition Survey (NHANES). Weighted regressions were used to examine whether earlier TTFC is associated with differences in a) numeric values; b) guideline-based binary outcomes of total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and the LDL/HDL ratio; and c) 10-year risk scores for CVD.

RESULTS

Earlier TTFC (within 5, 30, or 60 min vs. >60 min) was significantly (p < 0.05) associated with lower HDL (2-3 mg/dL) and a lower odds ratio (OR = 0.70) of having optimal HDL levels, and a lower LDL/HDL ratio (0.14-0.32); these results were consistent across three models (unadjusted, adjusted for smoking behavior, and also adjusted for demographics and other CVD risk factors). Earlier TTFC was also associated (p < 0.05) with higher odds of having sub-optimal total cholesterol levels (OR = 1.55) and higher LDL values (8 mg/dL), but only in the models adjusting for smoking behavior. However, the association of TTFC with 10-year CVD risk scores did not reach significance (p > 0.05).

CONCLUSION

More "addicted" smokers, as indicated by earlier TTFC, have less favorable lipid profiles, even after accounting for current and lifetime smoking history and other CVD risk factors. Future research should further explore whether TTFC could be a useful tool for refining clinically significant CVD risk among smokers.

Time to First Cigarette, a Proxy of Nicotine Dependence, Increases the Risk of Pulmonary Impairment, Independently of Current and Lifetime Smoking Behavior

INTRODUCTION

Cigarette smoking is the largest known risk factor for chronic obstructive pulmonary disease (COPD), but little is known about the role of time to first cigarette (TTFC), an indicator of nicotine dependence (ND). This study examines whether daily TTFC is associated with pulmonary outcomes, independently of smoking behavior.

METHODS

A cross-sectional sample of 1461 current adult smokers were drawn from the National Health and Nutrition Examination Survey (NHANES), 2007-2010. The relationships of daily TTFC with outcomes of spirometry-defined pulmonary impairment and self-reported respiratory symptoms (coughing, bringing up phlegm, and wheezing) were examined (1) at the unadjusted level, (2) after adjusting for smoking heaviness and duration, and (3) after also adjusting for environmental exposure and demographics.

RESULTS

In fully-adjusted weighted regressions, those reporting TTFC ≤ 5 minutes were three times as likely to have COPD (confidence interval [CI] = 1.30-8.77), had a 3% lower forced vital capacity expired in the first second (FEV1/FVC) (CI = -0.051 to -0.009), were seven times as likely to report coughing (CI = 1.96-26.41), and 16 times as likely to report bringing up phlegm (CI = 3.43-74.82), relative to those reporting TTFC > 60 minutes. Similar associations were often found when comparing TTFC between 5 to 30 minutes and TTFC between 30 to 60 minutes with TTFC > 60 minutes.

CONCLUSIONS

"Addicted" smoking, as measured by earlier TTFC, is associated with a markedly increased risk of spirometry-measured obstructive pulmonary impairment, and of reporting symptoms of coughing and phlegm, even after controlling for smoking behavior and other risk factors for COPD. TTFC may prove valuable in more precisely assessing smokers' risk of pulmonary impairment.

IMPLICATIONS

This study shows that smoking sooner after waking, a reliable indicator of ND, substantially increases the risk of spirometry-defined pulmonary impairment and self-reported symptoms, independently of lifetime and current smoking behavior. This study adds to a small body of literature examining health outcomes associated with higher ND, including outcomes of COPD. The current study overcomes important shortcomings of these existing studies in at least two ways: controlling for other known risk factors for COPD, and using empirical, spirometry-defined outcomes pulmonary function rather than self-reported COPD outcomes.

Time to First Morning Cigarette and Risk of Chronic Obstructive Pulmonary Disease: Smokers in the PLCO Cancer Screening Trial

BACKGROUND

Time to first cigarette (TTFC) after waking is an indicator of nicotine dependence. The association between TTFC and chronic obstructive pulmonary disease (COPD), the third leading cause of death in the United States, has not yet been reported.

METHODS

We investigated the cross-sectional association between TTFC and prevalent COPD among 6,108 current smokers in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. COPD was defined as a self-reported diagnosis of emphysema, chronic bronchitis, or both. Current smokers in PLCO reported TTFC, the amount of time they typically waited before smoking their first cigarette of the day after waking, in four categories: ≤ 5, 6-30, 31-60, or > 60 minutes. We used logistic regression models to investigate the association between TTFC and prevalent COPD with adjustments for age, gender, race, education, and smoking (cigarettes/day, years smoked during lifetime, pack-years, age at smoking initiation), and prior lung cancer diagnosis.

RESULTS

COPD was reported by 19% of these 6,108 smokers. Individuals with the shortest TTFC had the greatest risk of COPD; compared to those with the longest TTFC (> 60 minutes) the adjusted odds ratios (OR) and 95% confidence intervals (CI) for COPD were 1.48 (95% CI, 1.15-1.91), 1.64 (95% CI, 1.29-2.08), 2.18 (95% CI, 1.65-2.87) for those with TTFC 31-60 minutes, 6-30 minutes, and ≤ 5 minutes, respectively (P-trend < 0.0001). The association between TTFC and emphysema was similar to that for bronchitis, albeit the ORs were slightly stronger for chronic bronchitis; comparing TTFC ≤5 minutes to > 60 minutes, the adjusted OR (95% CI) was 2.29 (1.69-3.12) for emphysema and 2.99 (1.95-4.59) for chronic bronchitis.

CONCLUSIONS

Current smokers with shorter TTFC have increased risk of COPD compared to those with longer TTFC, even after comprehensive adjustment for established smoking covariates. Future epidemiologic studies, including prospective designs, should incorporate TTFC to better assess disease risk and evaluate the potential utility of TTFC as a COPD screening tool for smokers in the clinical setting.

Predictors of the Nicotine Dependence Behavior Time to the First Cigarette in a Multiracial Cohort

BACKGROUND

The time to first cigarette of the day (TTFC) is a strong indicator of nicotine dependence behaviors such as nicotine uptake and quit success in young and older smokers. There are substantial differences in levels of nicotine dependence by race and ethnic group.

METHODS

Data from Wave III of the multiracial National Longitudinal Study of Adolescent Health were analyzed for young smokers between the ages of 21 and 28 (N = 1,425). Time to first cigarette data was compared between Hispanic, White, Black, Native American, and Asian smokers.

RESULTS

Black smokers were significantly more likely to smoke within 5min of waking than White, Hispanic, and Asian smokers. Lower personal income predicted smoking within 5min of waking for both White and Black smokers. For White smokers, increased number of cigarettes per day and increased years of smoking also predicted smoking within 5min of waking. The number of days smoked or number of cigarettes per day did not predict smoking within 5min of waking among smokers.

CONCLUSIONS

The higher prevalence of early TTFC among Blacks indicates increased nicotine and carcinogen exposure, and may help explain the increased lung cancer rates and failed cessation attempts among Black smokers. TTFC may be an important screening item, independent of cigarettes per day, for clinicians and interventions to identify those at highest risk for cessation failure and disease risk.

[Smoking cessation in smokers with chronic obstructive pulmonary disease]

One out of two smokers who smoke throughout their lifetime will die from a disease related to smoking. Tobacco smoking therefore represents a major global public health issue. Smoking is the leading cause of chronic obstructive pulmonary disease (COPD). Projections for 2020 indicate that by then, COPD will have become the third cause of death and the fifth cause of disability worldwide. Stopping smoking reduces the risk of developing COPD and is an essential treatment for this inflammatory disease. Smoking cessation decreases the prevalence of respiratory symptoms, number of hospitalizations, and decline in FEV1, as well as exacerbation frequency and overall mortality. Among the patients, 38-77% with COPD are smokers. Their daily cigarette consumption and level of nicotine dependence are often high. The combination of high intensity behavioral interventions and medication treatments (nicotine replacement therapy, varenicline, bupropion) is the most effective strategy for smokers with COPD. In contrast, behavioral interventions without medication are not more effective than simple advice to stop. Two factors seem to predict the success of the attempt to quit in smokers with COPD: a strong motivation to quit and the use of smoking cessation medications.

Time to smoke first morning cigarette and lung cancer in a case-control study

BACKGROUND

Targeting smokers at higher lung cancer risk can improve efficiency and reduce false-positive detection in lung cancer screening. We evaluated whether time to first cigarette after waking (TTFC), a single-item measure of nicotine dependency, could improve stratification of lung cancer risk beyond standard smoking metrics (intensity, duration, and pack-years).

METHODS

In 3249 ever-smokers (n = 1812 case subjects; n = 1437 control subjects) from a population-based case-control study in Italy, we examined the association between TTFC and lung cancer using logistic regression and estimated lung cancer incidence by levels of TTFC, and intensity, duration, and pack-years using absolute risk regression. Significance tests were two-sided.

RESULTS

Compared with smokers with TTFC greater than 60 minutes, the lung cancer odds ratios for TTFC of 31 to 60 minutes, 6 to 30 minutes, and 5 or fewer minutes (by increasing dependency) were 2.57 (95% confidence interval [CI] = 2.03 to 3.26), 2.27 (95% CI = 1.79 to 2.88), and 3.50 (95% CI = 2.64 to 4.64), respectively (P trend < .0001). The average lung cancer incidence rates for smokers of 1 to 10, 11 to 20, 21 to 30 and more than 30 cigarettes per day were consistently higher among smokers with TTFC of 60 or fewer minutes vs more than 60 minutes (64.1 vs 11.7; 125.6 vs 28.6; 130.1 vs 40.7; and 260.8 vs 108.9 per 100000 person-years, respectively). The slopes of increase in lung cancer rates with smoking duration and pack-years were statistically significantly greater among smokers with higher dependency (P interaction < .001).

CONCLUSIONS

Lung cancer risk increases with shorter TTFC; this simple nicotine dependency measure increases lung cancer risk stratification beyond standard smoking measures. Assessing TTFC may improve lung cancer risk prediction and could be useful in lung cancer screening and smoking cessation programs.

Everyday discrimination is associated with nicotine dependence among African American, Latino, and White smokers

INTRODUCTION

Discrimination is a commonly perceived stressor among African Americans and Latinos, and previous research has linked stress with substance dependence. Although studies have shown a link between discrimination and smoking, little is known about the relationship between discrimination and nicotine dependence.

METHODS

A total of 2,376 African American (33.4%; n = 794), Latino (33.1%; n = 786), and White (33.5%; n = 796) smokers completed an online survey. Everyday discrimination experiences were described in total and by race/ethnicity. Covariate-adjusted linear regression analyses were conducted to evaluate the associations between everyday discrimination and indicators of nicotine dependence.

RESULTS

Most participants (79.1%), regardless of race/ethnicity, reported experiencing everyday discrimination. However, total scores on the discrimination measure were higher among Latinos and African Americans than among Whites (p < .001). Race/ethnicity/national origin was the most commonly perceived reason for everyday discrimination among African Americans and Latinos, whereas physical appearance was the most commonly perceived reason among Whites. Regression analyses indicated that everyday discrimination was positively associated with indicators of nicotine dependence, including the Heaviness of Smoking Index (HSI; p < .001) and the Brief Wisconsin Inventory of Smoking Dependence Motives (WISDM) scales (all ps < .001). There was a significant interaction between race/ethnicity and discrimination, such that discrimination was associated with the HSI only among Latinos. Similarly, discrimination was most strongly associated with the WISDM scales among Latinos.

CONCLUSIONS

Analyses indicated that discrimination is a common stressor associated with nicotine dependence. Findings suggest that greater nicotine dependence is a potential pathway through which discrimination may influence health.

Time to first cigarette predicts 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) in adolescent regular and intermittent smokers, National Health and Nutrition and Examination Survey (NHANES) 2007-10

BACKGROUND AND AIMS

The time to first cigarette (TTFC) of the day is an indicator of nicotine intake in adults and adolescents. However, the relation between TTFC and biological markers of nicotine addiction and health risk in youths has not been well described. The current study examined whether an earlier TTFC predicts higher levels of a tobacco-specific carcinogen, 4-(methylnitrosamino)-1-(3-pyridal)-1 (NNAL), in regular and intermittent adolescent smokers and if this relation is mediated by nicotine intake (measured by cotinine) or cigarettes per day (CPD).

DESIGN

A cross-sectional analysis of a nationally representative subsample of adolescents.

SETTING

A general community sample from the 2007-08 and 2009-10 National Health and Nutrition and Examination Survey.

PARTICIPANTS

A total of 215 adolescents in the United States between the ages of 12 and 19 years who reported smoking at least once in the 5 days prior to data collection.

MEASUREMENTS

The primary outcome measure was urinary levels of NNAL.

FINDINGS

In both regular and intermittent smokers, earlier TTFC was associated dose-dependently with higher levels of NNAL (P < 0.03 in both cases). TTFC had an indirect effect on NNAL, mediated by nicotine intake (cotinine) in both regular [β = -0.08, standard error (SE) = 0.03, 95% confidence interval (CI) = -0.15, -0.03] and intermittent (β = -0.02, SE = 0.01, 95% CI = -0.05, -0.002) smokers. CPD was not found to be an important mediator of the relation between TTFC and NNAL.

CONCLUSIONS

Time between waking and the first cigarette of the day is correlated in daily and non-daily adolescent smokers with overall nicotine and therefore carcinogen intake.

Cigarette smoking and pancreatic cancer risk: a revisit with an assessment of the nicotine dependence phenotype

BACKGROUND

Cigarette smoking is a well-established risk factor of pancreatic cancer (PC). Although an association between nicotine dependence phenotype, namely time to first cigarette (TTFC) after waking, and the risk of several smoking-related cancers has been reported, an association between TTFC and PC risk has not been reported. We assessed the impact of smoking behavior, particularly TTFC, on PC risk in a Japanese population.

MATERIALS AND METHODS

We conducted a case-control study using 341 PC and 1,705 non-cancer patients who visited Aichi Cancer Center in Nagoya, Japan. Exposure to risk factors, including smoking behavior, was assessed from the results of a self-administered questionnaire. The impact of smoking on PC risk was assessed with multivariate logistic regression analysis adjusted for potential confounders to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Cigarettes per day (CPD) and/or smoking duration were significantly associated with PC risk, consistent with previous studies. For TTFC and PC risk, we found only a suggestive association: compared with a TTFC of more than 60 minutes, ORs were 1.15 (95%CI, 0.65- 2.04) for a TTFC of 30-60 minutes and 1.35 (95%CI, 0.85-2.15) for that of 0-30 minutes (p trend=0.139). After adjustment for CPD or smoking duration, no association was observed between TTFC and PC.

CONCLUSIONS

In this study, we found no statistically significant association between TTFC and PC risk. Further studies concerning TTFC and PC risk are warranted.

What Do Young New Zealanders Want in Terms of Smoking Cessation?

This study examines young New Zealand smokers’ views of what would help them quit smoking. A qualitative investigation using 10 focus groups with 66 current young smokers, aged between 15 and 17 years, was conducted throughout New Zealand, in late 2011. Transcripts from the focus groups were analysed using NVivo, and common themes and categories within themes were identified. Around half the participants had made a quit attempt in the past, some had tried multiple times using a range of methods; all were unsuccessful. They described both mental and physical difficulties for young people quitting. The participants developed an array of ideas for how to help young people quit smoking, encompassing having supportive people around them, making personal changes and adopting alternative behaviours to smoking, legislative changes, and ideas that were unique to young people. Cessation strategies which reach high risk smokers such as young people, Māori and Pacific peoples, are going to be vital for achieving a smokefree Aotearoa by 2025.

Time to first cigarette and lung cancer risk in Japan

BACKGROUND

Cigarette smoking is the major cause of lung cancer (LC). Although the time to first cigarette (TTFC) of the day is a distinct indicator of nicotine dependence, little information is available on its possible relation to LC.

PATIENTS AND METHODS

This case-control study includes a total of 1572 incident LC cases and 1572 non-cancer controls visiting for the first time the Aichi Cancer Center Hospital between 2001 and 2005. We estimated the odds ratio (OR) and 95% confidence interval (CI) for TTFC using a logistic regression model after adjustment for several potential confounders.

RESULTS

TTFC was inversely associated with the risk of LC. This association was consistent across histological subtypes of LC. For all LCs considered among ever smokers and after accurate allowance for smoking quantity and duration, besides other relevant covariates, compared with TTFC >60 min, the adjusted ORs were 1.08 (95% CI, 0.73-1.61) for TTFC of 31-60 min, 1.40 (0.98-2.01) for 6-30 min and 1.86 (1.28-2.71) for within 5 min (Ptrend, < 0.001). Statistically marginally significant heterogeneity by histological subtype was observed (Pheterogeneity, 0.002).

CONCLUSIONS

Nicotine dependence, as indicated by the TTFC, is associated with increased risk of LC and is therefore an independent marker of exposure to tobacco smoking.

Clustering of modifiable biobehavioral risk factors for chronic disease in US adults: a latent class analysis

AIMS

Examining the co-occurrence patterns of modifiable biobehavioral risk factors for deadly chronic diseases (e.g. cancer, cardiovascular disease, diabetes) can elucidate the etiology of risk factors and guide disease-prevention programming. The aims of this study were to (1) identify latent classes based on the clustering of five key biobehavioral risk factors among US adults who reported at least one risk factor and (2) explore the demographic correlates of the identified latent classes.

METHODS

Participants were respondents of the National Epidemiologic Survey of Alcohol and Related Conditions (2004-2005) with at least one of the following disease risk factors in the past year (N = 22,789), which were also the latent class indicators: (1) alcohol abuse/dependence, (2) drug abuse/dependence, (3) nicotine dependence, (4) obesity, and (5) physical inactivity. Housing sample units were selected to match the US National Census in location and demographic characteristics, with young adults oversampled. Participants were administered surveys by trained interviewers.

RESULTS

Five latent classes were yielded: 'obese, active non-substance abusers' (23%); 'nicotine-dependent, active, and non-obese' (19%); 'active, non-obese alcohol abusers' (6%); 'inactive, non-substance abusers' (50%); and 'active, polysubstance abusers' (3.7%). Four classes were characterized by a 100% likelihood of having one risk factor coupled with a low or moderate likelihood of having the other four risk factors. The five classes exhibited unique demographic profiles.

CONCLUSIONS

Risk factors may cluster together in a non-monotonic fashion, with the majority of the at-risk population of US adults expected to have a high likelihood of endorsing only one of these five risk factors.

Racial differences in the relationship between tobacco dependence and nicotine and carcinogen exposure

AIMS

To investigate the relationships between tobacco dependence, biomarkers of nicotine and carcinogen exposure and biomarkers of nicotine and carcinogen exposure per cigarette in back and white smokers.

DESIGN, SETTING AND PARTICIPANTS

A total of 204 healthy black (n = 69) and white (n = 135) smokers were enrolled into two clinical studies.

MEASUREMENT

Nicotine equivalents (nicotine and its metabolites), 4-(methylnitrosamino)-1-(3)pyridyl-1-butanol (NNAL) and polycyclic aromatic hydrocarbon (PAH) metabolites were measured in urine. The Fagerström Test for Nicotine Dependence (FTND) and time to first cigarette (TFC) measured tobacco dependence.

FINDINGS

Average TFC and FTND for blacks and whites were not significantly different. Urine NNAL and nicotine equivalents increased with increasing FTND in whites but did not increase in blacks (race × FTND interaction, both P < 0.031). The interaction term was not significant for PAHs. An inverse relationship was seen between FTND and nicotine equivalents, NNAL and PAH metabolites per cigarette in blacks but remained flat in whites (race × FTND interaction, all P ≤ 0.039). Regardless of dependence (low dependence, TFC >15 minutes; high dependence, TFC ≤15 minutes), FTND and TFC were not correlated significantly with urine nicotine equivalents and carcinogen exposure in blacks. We found moderate correlations between FTND and TFC and nicotine equivalents and carcinogen exposure among whites of low dependence and non-significant correlations among whites of high dependence.

CONCLUSION

In the United States, tobacco dependence measures were related linearly to nicotine intake and carcinogen exposure in white but not in black smokers. The relationship between dependence measures and tobacco biomarkers in black smokers regardless of level of dependence resembled highly dependent white smokers.

The nicotine dependence phenotype, time to first cigarette, and larynx cancer risk

PURPOSE

Cigarette smoking is the major cause of laryngeal cancer. The time to first cigarette after waking in the morning is a behavior associated with several dimensions of nicotine dependence including the dose of smoke uptake. We hypothesized that a short TTFC increases the risk of laryngeal cancer.

METHODS

The analysis was based on data from a hospital-based case-control study of laryngeal cancer. The current analysis included only subjects who were ever cigarette smokers, including 570 cases and 343 controls (832 whites and 81 blacks). Odds ratios (OR) and 95% confidence intervals (CI) were calculated using unconditional logistic regression adjusting for smoking history and other potential confounders. Incidence data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute from 1975 to 2006 were analyzed for trends in laryngeal cancer.

RESULTS

There was a dose-response relationship between TTFC and supraglottic cancer. Compared to subjects who smoked more than 60 min after waking, the adjusted odds ratio was 1.51 (95% CI, 0.63-3.61) for 30-60 min and 3.13 (95% CI, 1.56-6.30) for 0-30 min. No association was observed between TTFC and cancer of the glottis. In blacks, the TTFC was not associated with the risk of laryngeal cancer. Trends in SEER rates were similar for cancer of the glottis and supraglottis, indicating that the site-specific differences were not affected by unknown confounders.

CONCLUSION

A nicotine dependence behavior that is associated with cigarette smoke uptake increases the risk of cancer of the supraglottis larynx, but not glottis larynx.