Efficacy of smoking cessation therapy alone or integrated with prolonged exposure therapy for smokers with PTSD: Study protocol for a randomized controlled trial

Posttraumatic stress and probable post traumatic stress disorder as it relates to smoking behavior and beliefs among trauma exposed hispanic persons who smoke

There has been little scientific effort to evaluate the associations between cigarette smoking and cessation-related constructs and exposure to traumatic events, posttraumatic stress, and Posttraumatic Stress Disorder (PTSD) symptoms among Hispanic persons who smoke in the United States (US). Such trauma-related factors may pose unique difficulties for Hispanic persons who smoke and possess a desire to quit. As such, the present investigation sought to fill this gap in the literature and examine posttraumatic stress and probable PTSD in terms of their relations with several clinically significant smoking constructs among trauma-exposed Hispanic persons who smoke from the United States. Participants included 228 Spanish-speaking Hispanic persons who endorsed prior traumatic event exposure and smoked combustible cigarettes daily (58.3% female, Mage= 32.1 years, SD = 9.65). Results indicated that posttraumatic stress symptoms were related to increased cigarette dependence, perceived barriers for smoking cessation, and more severe problems when trying to quit with effect sizes ranging from small to moderate in adjusted models. Additionally, Hispanic persons who smoke with probable PTSD compared to those without probable PTSD showcased a statistically effect for perceived barriers for cessation (p < .008) and a severity of problems when trying to quit (p < .001). No effect was evident for cigarette dependence after alpha correction. Overall, the present study offers novel empirical evidence related to the role of posttraumatic stress symptoms and PTSD among Hispanic persons who smoke in the US. Such findings highlight the need to expand this line of research to better understand the role of posttraumatic stress and PTSD among Hispanic persons who smoke which can inform smoking cessation treatments for Hispanic persons who smoke experiencing trauma-related symptomology.

Trauma exposure and smoking outcomes: The indirect effects of anxious and depressive symptoms

With a direct link between traumatic stress and poor smoking outcomes established, there is a clinically important need to identify underlying, targetable mechanisms that maintain these relations. The present study employed a parallel mediation model to assess the competing explanatory significance of four distinct facets of depression and anxiety (general anxiety, anxious arousal, general depression, and anhedonic depression) in the relation between traumatic load and perceived barriers for quitting smoking, severity of psychosomatic problems experienced when attempting to quit smoking in the past, and negative reinforcement expectancies related to smoking among 98 adult trauma-exposed daily smokers (Mage = 44.64, SD = 10.66). Results showed that only general anxiety symptoms, when controlling for the competing facets of depression and anxiety, had a statistically significant indirect effect on the relation between traumatic load and all smoking processes, such that general anxiety symptoms significantly, indirectly influenced the relation between traumatic load and barriers for smoking cessation (ab = 0.95, 95% CI [0.163, 0.2.14]), smoking quit problems (ab = 0.07, 95% CI [0.009, 0.165]), and negative reinforcement smoking expectancies (ab = 0.16, 95% CI [0.025, 0.399]). Anxious arousal demonstrated an indirect effect for trauma load on only negative reinforcement smoking expectancies (ab = -0.15, 95% CI [-0.345, -0.023]). The current findings highlight the potential importance of general anxiety symptoms as a targetable mechanism for smoking cessation treatments for trauma-exposed smokers.

Prolonged exposure therapy for PTSD among spinal cord injury survivors: Study protocol for a randomized controlled trial

The National Spinal Cord Injury Statistical Center estimates 294,000 people in the US live with a spinal cord injury (SCI), with approximately 17,810 new cases each year. Although the physical outcomes associated with SCI have been widely studied, the psychological consequences of sustaining a SCI remain largely unexplored. Scant research has focused on posttraumatic stress disorder (PTSD) in this population, despite prevalence estimates suggesting that up to 60% of individuals with SCI experience PTSD post-injury, compared to only 7% of the general US population. Fortunately, prolonged exposure therapy (PE) is a well-researched and highly effective treatment for PTSD. However, no trauma focused exposure-based therapy for PTSD (e.g. PE) has not yet been tested in a SCI population. Thus, we aim to conduct the first test of an evidence-based intervention for PTSD among patients with SCI. Adults with SCI and PTSD (N = 60) will be randomly assigned to either: (1) 12-sessions of PE (2-3 sessions per week) or (2) a treatment as usual (TAU) control group who will receive the standard inpatient rehabilitation care for SCI patients. Primary outcomes will be assessed at 0, 6, 10, and 32 weeks.

Age and pre quit-day attrition during smoking cessation treatment

The present study aimed to replicate the finding that younger age predicts higher pre quit-day attrition. Our second aim was to explain this relation by examining empirically and theoretically informed age-related risk factors for low smoking cessation treatment engagement. 136 participants (Mage = 44.2 years, SD = 11.3 years; age = 22-64 years) were randomized to 15-weeks of either 1) an exercise intervention (n = 72) or 2) a wellness education control condition (n = 64). First, a logistic regression analysis was employed to test whether younger adults were more likely than older adults to drop prior to quit date. Next, we assessed whether smoking related health concerns, social expectancies, and/or perceived severity of craving affected the strength of the relation between age and attrition, by adding these three variables to the logistic regression along with age. The logistic regression model indicated that younger age and treatment condition were significantly related to the odds of dropping from treatment prior to the scheduled quit date. Further, health concerns, social expectancies, and/or perceived severity of cravings did not account for the effect of age on pre quit-day attrition. These findings highlight the importance of identifying empirically and theoretically informed variables associated with the pre quit-day attrition problem of young smokers.

Additional behavioural support as an adjunct to pharmacotherapy for smoking cessation

BACKGROUND

Pharmacotherapies for smoking cessation increase the likelihood of achieving abstinence in a quit attempt. It is plausible that providing support, or, if support is offered, offering more intensive support or support including particular components may increase abstinence further.

OBJECTIVES

To evaluate the effect of adding or increasing the intensity of behavioural support for people using smoking cessation medications, and to assess whether there are different effects depending on the type of pharmacotherapy, or the amount of support in each condition. We also looked at studies which directly compare behavioural interventions matched for contact time, where pharmacotherapy is provided to both groups (e.g. tests of different components or approaches to behavioural support as an adjunct to pharmacotherapy).

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP in June 2018 for records with any mention of pharmacotherapy, including any type of nicotine replacement therapy (NRT), bupropion, nortriptyline or varenicline, that evaluated the addition of personal support or compared two or more intensities of behavioural support.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in which all participants received pharmacotherapy for smoking cessation and conditions differed by the amount or type of behavioural support. The intervention condition had to involve person-to-person contact (defined as face-to-face or telephone). The control condition could receive less intensive personal contact, a different type of personal contact, written information, or no behavioural support at all. We excluded trials recruiting only pregnant women and trials which did not set out to assess smoking cessation at six months or longer.

DATA COLLECTION AND ANALYSIS

For this update, screening and data extraction followed standard Cochrane methods. The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically-validated rates, if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a random-effects model.

MAIN RESULTS

Eighty-three studies, 36 of which were new to this update, met the inclusion criteria, representing 29,536 participants. Overall, we judged 16 studies to be at low risk of bias and 21 studies to be at high risk of bias. All other studies were judged to be at unclear risk of bias. Results were not sensitive to the exclusion of studies at high risk of bias. We pooled all studies comparing more versus less support in the main analysis. Findings demonstrated a benefit of behavioural support in addition to pharmacotherapy. When all studies of additional behavioural therapy were pooled, there was evidence of a statistically significant benefit from additional support (RR 1.15, 95% CI 1.08 to 1.22, I² = 8%, 65 studies, n = 23,331) for abstinence at longest follow-up, and this effect was not different when we compared subgroups by type of pharmacotherapy or intensity of contact. This effect was similar in the subgroup of eight studies in which the control group received no behavioural support (RR 1.20, 95% CI 1.02 to 1.43, I² = 20%, n = 4,018). Seventeen studies compared interventions matched for contact time but that differed in terms of the behavioural components or approaches employed. Of the 15 comparisons, all had small numbers of participants and events. Only one detected a statistically significant effect, favouring a health education approach (which the authors described as standard counselling containing information and advice) over motivational interviewing approach (RR 0.56, 95% CI 0.33 to 0.94, n = 378).

AUTHORS' CONCLUSIONS

There is high-certainty evidence that providing behavioural support in person or via telephone for people using pharmacotherapy to stop smoking increases quit rates. Increasing the amount of behavioural support is likely to increase the chance of success by about 10% to 20%, based on a pooled estimate from 65 trials. Subgroup analysis suggests that the incremental benefit from more support is similar over a range of levels of baseline support. More research is needed to assess the effectiveness of specific components that comprise behavioural support.

Approach bias retraining to augment smoking cessation: Study protocol for a randomized controlled trial

Heavy users and addicted individuals have shown to develop an approach action tendency - or approach bias - toward stimuli related to the substance of interest. Emerging evidence points to approach bias retraining (ABR) as an effective aid for the treatment of addictive behaviors. The current study seeks to extend this work by testing, in a pilot study, whether standard smoking cessation treatment involving cognitive-behavioral therapy (CBT) and nicotine replacement therapy can be augmented by ABR. To this end, we will randomly assign 100 adult smokers to either ABR-augmented treatment or placebo-augmented treatment and compare the two conditions on short-term and long-term abstinence rates. The hope is that the findings of this study can inform treatment development for adult smokers.

E-cigarette use (vaping) is associated with illicit drug use, mental health problems, and impulsivity in university students

BACKGROUND

This study examined the prevalence of e-cigarette use ("vaping") among university students and its associations with psychosocial correlates.

METHODS

In this study, 9,449 students received a 156-item anonymous online survey assessed the use of e-cigarettes (ever or past year), alcohol and drug use, mental health issues, and impulsive and compulsive traits.

RESULTS

In total, 3,572 university students (57.1% female) responded to the survey. The prevalence of past 12-month e-cigarette use was 9.2%, with 9.8% reporting having used more than 12 months ago. E-cigarette use was associated with the use of multiple other drugs (eg, alcohol, opiates). Those who used e-cigarettes were significantly more likely to have mental health histories of attention-deficit/hyperactivity disorder, posttraumatic stress disorder, gambling disorder, and anxiety, to report low self-esteem, and to endorse traits of impulsivity.

CONCLUSIONS

Use of e-cigarettes is common in university students and appears to be associated with a variety of mental health and drug use problems. Clinicians should be aware that certain mental health conditions are more common in e-cigarette users. This study indicates the need for longitudinal research into the effects of chronic nicotine consumption on brain function and mental health, especially in young people, since such effects would be common to conventional tobacco smoking and vaping.

Posttraumatic stress disorder and cigarette smoking: A systematic review

BACKGROUND

Previous reviews of the PTSD and cigarette smoking literature showed high PTSD-smoking comorbidity and problematic smoking outcomes (Feldner et al., 2007, Clinical Psychology Review, 27, 14-45; Fu et al., 2007, Nicotine & Tobacco Research, 9, 1071-1084). However, past reviews also noted several prominent gaps in the literature, including a lack of etiological work examining underlying mechanisms and research on specialized PTSD-smoking treatments. The present review summarizes an extensive body of research conducted since the previous reviews targeting these areas of need.

METHODS

Literature searches identified 66 empirical studies specific to smoking and PTSD.

RESULTS

Smokers were approximately twice more likely to have PTSD than nonsmokers in the general population, and individuals with PTSD were approximately twice as likely to be current smokers. Smokers with PTSD evidenced more negative affect, trauma history, and comorbid psychiatric history, as well as quit attempts and higher relapse rates. PTSD symptoms were associated with expectations that smoking would reduce negative affect, which, in turn, was associated with increased smoking rate and nicotine dependence. Male sex was associated with nicotine dependence and PTSD avoidance, while the relationship between PTSD and smoking relapse due to withdrawal was stronger in females. Specialized, integrated PTSD and smoking cessation treatments showed promise in increasing quit success relative to standard care in randomized trials.

CONCLUSIONS

Rates of PTSD-smoking co-occurrence remain high. Notable gains have been made in relevant epidemiological and etiological research, although more work is needed in trauma-specific subpopulations. Several promising specialized treatments for comorbid smoking-PTSD have been developed and empirically tested but require replication.

Tobacco retail environment near housing programmes for patients with mental health conditions in New York City

OBJECTIVES

The current study sought to characterise the tobacco retail environment of supportive housing facilities for persons with mental health (MH) conditions in New York City (NYC) and to estimate the potential impact of a tobacco retail ban near public schools on the retail environment of MH housing in NYC.

METHODS

Texas A&M Geocoding Services was used to geocode the addresses of housing programmes for patients with MH conditions, non-MH residences, public schools and tobacco retailers in NYC. ESRI ArcMap was used to calculate the number of tobacco retailers within a 500-foot radius around each housing programme and school address point, and the Euclidean distance to the nearest retailer. Generalised linear models were used to compare retail counts and distance between MH and non-MH residences.

RESULTS

The mean number of tobacco retailers within 500 feet of an MH housing programme was 2.9 (SD=2.3) and the mean distance to nearest tobacco retailer was 370.6 feet (SD=350.7). MH residences had more retailers within 500 feet and a shorter distance to the nearest retailer compared with non-MH residences in Brooklyn, the Bronx and Staten Island (p<0.001). Banning tobacco licences within 350, 500 or 1000 feet of a school would significantly improve the tobacco retail environment of MH housing programmes and reduce disparities between MH and non-MH residences in some boroughs.

CONCLUSIONS

People with MH conditions residing in supportive housing in NYC encounter a heavy tobacco retail environment in close proximity to their home, and in some boroughs, one worse than non-MH residences. Implementing a ban on tobacco retail near public schools would improve the tobacco retail environment of MH housing programmes in NYC.