A review of epidemiologic research on smoking behavior among persons with alcohol and illicit substance use disorders

Daily cigarette smoking among inpatients for substance use disorders in France, 2010-2020: Commonalities and specificities across substances

INTRODUCTION

This study aims to estimate the prevalence and factors associated with cigarette smoking among patients in treatment for substance use disorders (SUD) in France.

METHODS

We analyze a nation-wide dataset retrieving information on patients entering treatment for alcohol, opioid and stimulant use disorders between 2010 and 2020. We conduct multilevel Poisson regressions to determine the main factors associated with daily cigarette smoking among all patients who entered treatment for alcohol (n=607122), opioid (n=283381) or stimulant (n=57189) use disorders, and zero-truncated negative-binomial regressions to predict the average number of cigarettes per day.

RESULTS

Daily cigarette smoking remains a widespread behavior among patients with SUD (overall prevalence: 72.2%, 95% CI: 72.1-72.3), with lower prevalence of daily cigarette smoking among patients treated for alcohol use disorders (69.9%, 95% CI: 69.8-70.0), and higher for patients treated for opioid (78.8%, 95% CI: 78.6-79.0) or stimulant use disorders (75.8%, 95% CI: 75.4-76.2). There was an overall increase in daily cigarette smoking over time (69.9%, 95% CI: 69.8-70.0 in 2010 vs 76.8%, 95% CI: 76.5-76.9 in 2020); however, the average number of cigarettes per day decreased (17.8 per day, 95% CI: 17.7-17.9 in 2010 vs 16.3 per day, 95% CI: 16.2-16.4 in 2020). The higher the education level, the fewer number of cigarettes per day; conversely, the higher the occupational status, the higher the number of cigarettes.

CONCLUSIONS

The high prevalence of smoking among patients treated for SUD in France departs from the decreasing trend observed in the general population and remains a source of concern. It is necessary to implement tailored prevention strategies that target specific patient subgroups and increase staff awareness.

Nicotine dependence and incident psychiatric disorders: prospective evidence from US national study

We examined the prospective associations between nicotine dependence and the likelihood of psychiatric and substance use disorders in the general adult population. Participants came from a nationally representative sample of US adults aged 18 years or older, who were interviewed 3 years apart in the National Epidemiologic Survey on Alcohol and Related Conditions (Wave 1, 2001-2002; Wave 2, 2004-2005). The primary analyses were limited to 32,671 respondents (13,751 male (47.9% weighted); mean age of 45 years (SD = 0.18)) who were interviewed in both waves. We used multiple regression and propensity score matching (PSM) to estimate the strength of independent associations between nicotine dependence related to the use of tobacco products at Wave 1 and incident psychiatric disorders at Wave 2. Psychiatric disorders were measured with a structured interview (Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV). All analyses adjusted for multiple potential confounders, including childhood (family history of substance use disorders, parental loss, vulnerable family environment), early-adolescence (self-esteem, social deviance, conduct disorder), late-adolescence (education, personality and psychiatric disorders), adulthood (divorce, stressful life events, social deviance, quality of life, history of alcohol or other substance use disorder), and sociodemographic factors. Multiple regression analysis and PSM converged in indicating that nicotine dependence was associated with significantly increased incidence of any psychiatric disorder (OR = 1.39(95%CI:1.20;1.60)), including substance use disorders (OR = 1.91(95%CI:1.47;2.47)), and anxiety disorders (OR = 1.31(95%CI:1.06;1.62)). Population Attributable Risk Proportions were substantial, ranging from 12.5%(95%CI:8.10;17.0) for any psychiatric disorder to 33.3%(95%CI:18.7;48.0) for any other drug use disorder. Supplementary analyses also indicated significant associations between nicotine dependence and persistence of psychiatric and substance use disorders among patients having a disorder at Wave 1. In the general adult population, nicotine dependence is associated with an increased likelihood for several psychiatric and substance use disorders. Given its high prevalence, these findings have important public health implications.

Factors associated with smoking cessation in Chinese psychiatric professionals: A cross-sectional survey

INTRODUCTION

Healthcare workers are integral to public smoking cessation; however, their own smoking behavior can create a significant obstacle to intervening in patients' cessation efforts. Conversely, their success in quitting can enhance their ability to support patients. Research on smoking behavior, particularly smoking cessation among Chinese psychiatric professionals is limited. This study addresses this gap by examining the factors associated with smoking cessation in this population, providing insights for targeted tobacco control policies.

METHODS

A cross-sectional survey was conducted, targeting psychiatric professionals including psychiatrists and psychiatric nurses, in 41 tertiary psychiatric hospitals in China. From January to March 2021, a WeChat-based questionnaire was distributed to collect demographic, occupational, and health-behaviors (including smoking) data. Statistical analyses, including the chi-squared test and adjusted binary logistic regression analysis, were conducted to identify the factors associated with smoking cessation.

RESULTS

Among the 12762 psychiatric professionals who participated in the survey, 11104 (87.0%) were non-smokers, 1196 (9.4%) were current smokers, and 462 (3.6%) were ex-smokers. Several factors were found to be associated with smoking cessation. Women had a higher prevalence of ex-smokers than men (AOR=1.88; 95% CI: 1.332-2.666, p<0.001). Compared to East China, the prevalence of ex-smokers among participants in Central and Northeast China was lower. Older age (≥50 years), higher level of education (Master's degree or higher), and non-drinkers, showed a higher likelihood of being ex-smokers. Notably, compared to current smokers, ex-smokers reported a lower prevalence of burnout (AOR=0.70; 95% CI: 0.552-0.892, p=0.004).

CONCLUSIONS

Smoking cessation interventions or health promotion programs should also focus on gender, age, education level, region, alcohol use, and burnout to effectively address smoking cessation within this specific professional group.

Prevalence of consumption of illicit drugs and associated factors from a nationwide epidemiological survey: The Singapore Health and Lifestyle Survey

Introduction

The primary aims of the current nationwide study were to establish the lifetime and 12-month prevalence of consumption of illicit drugs and its correlates in the general population of Singapore.

Method

A representative sample of 6509 Singapore residents (Singapore citizens and permanent residents) aged between 15 and 65 years were randomly selected for participation. Questionnaires were administered to assess the consumption of illicit drugs and collect information on correlates. All analyses were weighted to produce prevalence estimates for the consumption of drugs and other measured outcomes. Rao-Scott chi-square test and logistic regression analyses were performed to determine the association of sociodemographic and clinical characteristics with lifetime consumption of illicit drugs.

Results

The study was completed with a response rate of 73.2%. The lifetime prevalence of consuming illegal drugs was 2.3% (95% confidence interval [CI] 1.9-2.8) (n=180). Compared to individuals aged 15-34, those aged 50-65 (odds ratio [OR] 0.3, 95% CI 0.2-0.7) had lower odds of lifetime drug consumption. Current smokers (OR 4.7, 95% CI 2.7-8.3) and ex-smokers (OR 5.9, 95% CI 3.2-11.1) had significantly higher odds of lifetime drug consumption than non-smokers. Individuals with hazardous alcohol use (OR 3.3, 95% CI 1.7-6.5) had higher odds of lifetime drug consumption than those without hazardous alcohol use.

Conclusion

This is the first nationwide study to examine the prevalence of illicit drug consumption in the general population of Singapore. The results highlight the need to increase awareness of drug consumption in Singapore, especially among parents, teachers, healthcare workers and others who work with young people.

Challenges to smoking cessation in patients with substance use disorders

Despite significant progress in tobacco control measures and stringent smoking policies, cigarette smoking remains one of the largest preventable causes of death and disability worldwide. The World Health Organization estimates that over 8 million global deaths are attributed to smoking yearly, and in Singapore, more than 2,000 Singaporeans die prematurely due to smoking-related diseases each year.1,2

A smoking cessation intervention for rural veterans tailored to individual risk factors: A multicenter randomized clinical trial

INTRODUCTION

Rates of cigarette use remain elevated among those living in rural areas. Depressive symptoms, risky alcohol use, and weight concerns frequently accompany cigarette smoking and may adversely affect quitting. Whether treatment for tobacco use that simultaneously addresses these issues affects cessation outcomes is uncertain.

METHODS

The study was a multicenter, two-group, randomized controlled trial involving mostly rural veterans who smoke (N = 358) receiving treatment at one of five Veterans Affairs Medical Centers. The study randomly assigned participants to a tailored telephone counseling intervention or referral to their state tobacco quitline. Both groups received guideline-recommended smoking cessation pharmacotherapy, selected using a shared decision-making approach. The primary outcome was self-reported seven-day point prevalence abstinence (PPA) at three and six months. The study used salivary cotinine to verify self-reported quitting at six months.

RESULTS

Self-reported PPA was significantly greater in participants assigned to Tailored Counseling at three (OR = 1.66; 95 % CI: 1.07-2.58) but not six (OR = 1.35; 95 % CI: 0.85-2.15) months. Post hoc subgroup analyses examining treatment group differences based on whether participants had a positive screen for elevated depressive symptoms, risky alcohol use, and/or concerns about weight gain indicated that the cessation benefit of Tailored Counseling at three months was limited to those with ≥1 accompanying concern (OR = 2.02, 95 % CI: 1.20-3.42). Biochemical verification suggested low rates of misreporting.

CONCLUSIONS

A tailored smoking cessation intervention addressing concomitant risk factors enhanced short-term abstinence but did not significantly improve long-term quitting. Extending the duration of treatment may be necessary to sustain treatment effects.

Effects of dulaglutide on alcohol consumption during smoking cessation

BACKGROUNDAlcohol use disorder has a detrimental impact on global health and new treatment targets are needed. Preclinical studies show attenuating effects of glucagon-like peptide-1 (GLP-1) agonists on addiction-related behaviors in rodents and nonhuman primates. Some trials have shown an effect of GLP-1 agonism on reward processes in humans; however, results from clinical studies remain inconclusive.METHODSThis is a predefined secondary analysis of a double-blind, randomized, placebo-controlled trial evaluating the GLP-1 agonist dulaglutide as a therapy for smoking cessation. The main objective was to assess differences in alcohol consumption after 12 weeks of treatment with dulaglutide compared to placebo. The effect of dulaglutide on alcohol consumption was analyzed using a multivariable generalized linear model.RESULTSIn the primary analysis, participants out of the cohort (n = 255) who reported drinking alcohol at baseline and who completed 12 weeks of treatment (n = 151; placebo n = 75, dulaglutide n = 76) were included. The median age was 42 (IQR 33-53) with 61% (n = 92) females. At week 12, participants receiving dulaglutide drank 29% less (relative effect = 0.71, 95% CI 0.52-0.97, P = 0.04) than participants receiving placebo. Changes in alcohol consumption were not correlated with smoking status at week 12.CONCLUSIONThese results provide evidence that dulaglutide reduces alcohol intake in humans and contribute to the growing body of literature promoting the use of GLP-1 agonists in treatment of substance use disorders.TRIAL REGISTRATIONClinicalTrials.gov NCT03204396.FUNDINGSwiss National Foundation, Gottfried Julia Bangerter-Rhyner Foundation, Goldschmidt-Jacobson Foundation, Hemmi Foundation, University of Basel, University Hospital Basel, Swiss Academy of Medical Science.

A cluster-randomized trial of a brief multi-component intervention to improve tobacco outcomes in substance use treatment

BACKGROUND

Smoking prevalence is high among people in substance use disorder (SUD) treatment, and program interventions to address smoking are often complex and lengthy. This cluster-randomized trial tested whether a brief multi-component intervention impacted tobacco outcomes among staff and clients.

METHODS

Seven SUD treatment programs were randomly assigned to the multi-component intervention or to waitlist control. The 6-month intervention included a leadership motivation assessment, program incentives, 4 staff training sessions and a leadership learning community session. Survey data were collected from staff and clients at pre- and post-intervention. Outcomes were first compared across condition (intervention vs waitlist control), and then examined pre- to post-intervention with condition collapsed.

RESULTS

Staff in the intervention (n = 48) and control conditions (n = 26) did not differ at post-intervention on smoking prevalence, self-efficacy to help clients quit, or practices used to help clients quit smoking. Intervention clients (n = 113) did not differ from controls (n = 61) in smoking prevalence or receipt of tobacco services. Pre-post comparisons collapsed across condition showed a decrease in client and staff smoking prevalence, which could not be attributed to the intervention, and a decrease in client receipt of cessation medication.

CONCLUSION

The brief multi-component intervention did not support changes in smoking prevalence or in tobacco-related services received by clients. Other intervention features are needed to reduce smoking among SUD clients.

TRIAL REGISTRATION

Randomization occurred at the program level and outcomes measured are program-level measures. Accordingly, the trial is not registered.

Addressing nutrition and physical activity in substance use disorder treatment: Client reports from a wellness-oriented, tobacco-free policy intervention

Introduction

Interest in wellness interventions in substance use disorder (SUD) treatment is growing although evidence remains limited. This study evaluated nutrition, physical activity, nutrition and physical activity counseling, and relationships of counseling with wellness behavior before and after a wellness-oriented, tobacco-free policy intervention in 17 residential SUD programs.

Methods

Clients completed cross-sectional surveys reporting sugar-sweetened beverage consumption, physical activity, and receipt of nutrition and physical activity counseling before (n= 434) and after (n = 422) an 18-month intervention. Multivariable regression models assessed pre-post-intervention differences in these variables and examined associations of nutrition counseling with sugar-sweetened beverage consumption and physical activity counseling with physical activity.

Results

Post-intervention clients were 83% more likely than pre-intervention clients to report nutrition counseling (p = 0.024). There were no pre-post- differences for other variables. Past week sugar-sweetened beverage consumption was 22% lower among clients reporting nutrition counseling than for those who did not (p = 0.008) and this association did not vary by time (pre/post). There was a significant interaction of physical activity counseling receipt by time on past week physical activity (p = 0.008). Pre-intervention clients reporting physical activity counseling had 22% higher physical activity than those who did not; post-intervention clients reporting physical activity counseling had 47% higher physical activity.

Conclusion

A wellness policy intervention was associated with increased nutrition counseling. Nutrition counseling predicted lower sugar-sweetened beverage consumption. Physical activity counseling predicted higher physical activity, an association that was greater post-intervention. Adding wellness components to tobacco-related interventions may promote health among SUD clients.

Longitudinal determinants of insomnia among patients with alcohol use disorder

Insomnia is common among patients with AUD and can impair quality of life and cognitive functioning, as well as cause psycho-social problems and increased risk of relapse. Nonetheless, determinants of insomnia in patients with AUD have scarcely been studied. We aimed to examine prevalence and development of self-perceived insomnia among inpatients in treatment for AUD, and to examine factors in this group known to be associated with sleep disturbance in the general population. We examined self-reported information about sleep from 94 AUD inpatients in long-term treatment (up to 9 months) using a questionnaire identifying probable insomnia. Potential predictors identified in bivariate tests were used in binomial logistic regressions to examine the effect on sleep at baseline and at 6-week follow-up. Longitudinal multilevel analyses were used to examine factors affecting development of sleep quality during the treatment stay. At baseline, 54% of the patients reported sleep problems indicating insomnia. This was reduced to 35% at 6-week follow-up. In a cross-sectional analysis of sleep at baseline, we found that being male (OR 0.18, p = 0.042) and engaging in physical activity (OR 0.09, p < 0.001) were negatively associated with insomnia, while a high level of depressive symptoms (OR 1.10, p = 0.010) was positively associated after adjustment for age, history of trauma, and severity of dependence. Multilevel analyses of data over a 6-month period showed time interactions with physical activity, such that sleep improvement was greater in patients who initially had a low level of physical activity. This longitudinal study corroborates findings of high prevalence of insomnia among AUD patients and identifies factors in this group associated with insomnia, such as sex, depression, and physical activity. Future longitudinal studies are needed to examine the causal directions between sleep, depression, and physical activity and how these might be targeted in clinical settings.

A national analysis of the effect alcohol use disorder has on short-term complications and readmissions following total shoulder arthroplasty

Background

Alcohol use disorder has been associated with broad health consequences that may interfere with healing after total shoulder arthroplasty. The aim of this study was to explore the impact of alcohol use disorder on readmissions and complications following total shoulder arthroplasty.

Methods

We used data from the Healthcare Cost and Utilization Project National Readmissions Database (NRD) from 2016 to 2018. Patients were included based on International Classification of Diseases, 10th Revision (ICD-10) procedure codes for anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA). Patients with an alcohol use disorder (AUD) were identified using the ICD-10 diagnosis code F10.20. Demographics, complications, and 30-day and 90-day readmission were collected for all patients. A univariate logistic regression was performed to investigate AUD as a factor affecting readmission and complication rates. A multivariate logistic regression model was created to assess the impact of alcohol use disorder on complications and readmission while controlling for demographic factors.

Results

In total, 164,527 patients were included, and 503 (0.3%) patients had a prior diagnosis of AUD. Revision surgery was more common in patients with an alcohol use disorder (8.8% vs. 6.2%; p = 0.022). Postoperative infection (p = 0.026), dislocation (p = 0.025), liver complications (p < 0.01), and 90-day readmission (p < 0.01) were more common in patients with a diagnosed AUD. On multivariate analysis, patients with an AUD were found to be at increased odds for liver complications (OR: 46.8; 95% CI: [32.8, 66.8]; p < 0.01). Comparatively, mean age, length of stay, and over healthcare costs were also higher for patients with an AUD.

Conclusion

Patients with a diagnosis of AUD were more likely to suffer from shoulder dislocation, liver complications, and 90-day readmission, while also being younger and having longer hospital stays. Therefore, surgeons should take caution to anticipate and prevent complications and readmissions following total shoulder arthroplasty in patients with an AUD.

Substance Use and Adherence to Antiretroviral Therapy among People Living with HIV in the United States

People with HIV (PWH) report substance use at higher rates than HIV-uninfected individuals. The potential negative impact of single and polysubstance use on HIV treatment among diverse samples of PWH is underexplored. PWH were recruited from the Center for Positive Living at the Montefiore Medical Center (Bronx, NY, USA) from May 2017-April 2018 and completed a cross-sectional survey with measures of substance use, antiretroviral therapy (ART) use, and ART adherence. The overall sample included 237 PWH (54.1% Black, 42.2% female, median age 53 years). Approximately half of the sample reported any current substance use with 23.1% reporting single substance use and 21.4% reporting polysubstance use. Polysubstance use was more prevalent among those with current cigarette smoking relative to those with no current smoking and among females relative to males. Alcohol and cannabis were the most commonly reported polysubstance combination; however, a sizeable proportion of PWH reported other two, three, and four-substance groupings. Single and polysubstance use were associated with lower ART adherence. A thorough understanding of substance use patterns and related adherence challenges may aid with targeted public health interventions to improve HIV care cascade goals, including the integration of substance use prevention into HIV treatment and care settings.

High smoking and low cessation rates among patients in treatment for opioid and other substance use disorders

BACKGROUND

Smoking is a well-documented cause of health problems among individuals with substance use disorders. For patients in opioid maintenance treatment (OMT), the risk for somatic health problems, including preventable diseases associated with tobacco smoking, increases with age. Our aim was to describe smoking among patients entering substance use disorder (SUD) treatment, investigate changes in smoking from the start of treatment to 1-year follow-up, and explore factors related to smoking cessation.

METHODS

We employed data from the Norwegian Cohort of Patient in Opioid Maintenance Treatment and Other Drug Treatment Study (NorComt). Participants were 335 patients entering SUD treatment at 21 participating facilities across Norway. They were interviewed at the start of treatment and at 1-year follow-up. The main outcomes were smoking and smoking cessation by treatment modality. A logistic regression identified factors associated with smoking cessation.

RESULTS

High levels of smoking were reported at the start of treatment in both OMT (94%) and other SUD inpatient treatment patients (93%). At 1-year follow-up most patients in OMT were still smoking (87%), and the majority of the inpatients were still smoking (69%). Treatment as an inpatient was positively associated and higher age was negatively associated with smoking cessation. Most patients who quit smoking transitioned to smokeless tobacco or kept their existing smokeless habit.

CONCLUSION

As illustrated by the high smoking prevalence and relatively low cessation levels in our sample, an increased focus on smoking cessation for patients currently in OMT and other SUD treatment is warranted. Harm-reduction oriented smoking interventions may be relevant.

Alcohol Use

Unhealthy alcohol use-the consumption of alcohol at a level that has caused or has the potential to cause adverse physical, psychological, or social consequences-is common, underrecognized, and undertreated. For example, data from the 2020 National Survey on Drug Use and Health indicate that 7.0% of adults reported heavy alcohol use in the previous month, and only 4.2% of adults with alcohol use disorder received treatment. Primary care is an important setting for optimizing screening and treatment of unhealthy alcohol use to promote individual and public health.

The effect of a real-world intervention for smoking cessation in Adults with and without comorbid psychiatric and substance use disorders: A one-year follow-up study

This study evaluated short-term abstinence and prolonged abstinence following a real-world intervention for smoking cessation in a sample of 1,213 adults with nicotine dependence only (ND), nicotine dependence and past history of another substance use disorder (ND-SUD), nicotine dependence and a non-substance use mental health disorder (ND-MD), or nicotine dependence and comorbid substance use disorder and mental health disorder (ND-SUMD). Participants received six sessions of group Cognitive Behavioral Therapy (CBT) and pharmacotherapy. Abstinence was assessed following completion of treatment and at 12-month follow-up. Logistic regression and survival analyses were performed. Participants who were lost to follow-up were included as censored and baseline differences were used as covariates in multivariate analyses. Rates of short-term abstinence and prolonged abstinence were significantly different between ND and ND-SUMD (20.9% versus 36.5%; 14.9% versus 22.4%, respectively). Among participants with follow-up, 37.7% were abstinent at 12-month. Diagnostic group was not associated with abstinence at 12-month follow-up after adjusting for nicotine dependence severity, which was associated with lower likelihood of abstinence (HR=1.11;95%CI:1.03-1.19). CBT plus pharmacotherapy had a positive effect on smoking cessation among the participants in this study. Special attention should be given to adults with more severe nicotine dependence and comorbid psychiatric and substance use disorders.

Associations of tobacco cigarette use and dependence with substance use disorder treatment completion by sex/gender and race/ethnicity

INTRODUCTION

Individuals with substance use disorders (SUD) are approximately five times more likely to smoke cigarettes than the general population. Individuals who smoke cigarettes have greater odds of SUD relapse compared to individuals who do not smoke cigarettes, but we know little about how cigarette use is related to SUD treatment completion overall by sex/gender or race/ethnicity.

METHODS

This study examined 2855 adults (71.98 % male; >70 % racial/ethnic minority) in outpatient and residential SUD treatment at a New York-based treatment agency over a six-month period in 2018.

RESULTS

Overall, approximately three-fourths of SUD treatment-seeking participants smoked cigarettes, with high rates across sex/gender and racial/ethnic groups. Nicotine dependence did not differ by sex/gender, and White Non-Hispanic adults had the highest levels of nicotine dependence across racial/ethnic groups. Those who smoked cigarettes were significantly less likely to complete treatment compared to those who did not smoke cigarettes (OR = 0.69; 95 % CI: 0.58, 0.82). The study found no overall differences in SUD treatment completion and length of stay by sex/gender or race/ethnicity.

CONCLUSIONS

Given the high prevalence of cigarette smoking and lower odds of completing SUD treatment, the current system of care for SUD treatment may be enhanced by addressing cigarette smoking from onset of treatment.

Tobacco Screening Practices and Perceived Barriers to Offering Tobacco Cessation Services among Texas Health Care Centers Providing Behavioral Health Treatment

Tobacco use, and thus tobacco-related morbidity, is elevated amongst patients with behavioral health treatment needs. Consequently, it is important that centers providing health care to this group mandate providers' use of tobacco screenings to inform the need for tobacco use disorder intervention. This study examined the prevalence of mandated tobacco screenings in 80 centers providing health care to Texans with behavioral health needs, examined key factors that could enhance screening conduct, and delineated providers' perceived barriers to tobacco use intervention provision. The results indicated that 80% of surveyed centers mandated tobacco use screenings; those that did were significantly more likely than those that did not to have a hard stop for tobacco use status in health records and were marginally more likely to make training on tobacco screening available to providers. The most widespread barriers to tobacco use disorder care provision were relative perceived importance of competing diagnoses, lack of community resources to refer patients, perceived lack of time, lack of provider knowledge or confidence, and belief that patients do not comply with cessation treatment. Overall, the results suggest that there are opportunities for centers providing care to Texans with behavioral health needs to bolster their tobacco screening and intervention capacity to better address tobacco-related health disparities in this group. Health care centers can support their providers to intervene in tobacco use by mandating screenings, streamlining clinical workflows with hard stops in patient records, and educating providers about the importance of treating tobacco with brief evidence-based intervention strategies while providing accurate information about patients' interest in quitting and providers' potential impacts on a successful quit attempt.

A difference-in-difference approach to examining the impact of cannabis legalization on disparities in the use of cigarettes and cannabis in the United States, 2004-17

AIMS

To estimate the impact of recreational and medical cannabis laws (RCL, MCL) on the use of cannabis and cigarettes in the United States.

DESIGN

A difference-in-difference approach was applied to data from the 2004-17 National Survey on Drug Use and Health (NSDUH).

SETTING

United States.

PARTICIPANTS

Nationally representative cross-sectional survey of Americans aged 12 years and older (combined analytical sample for 2004-17, n = 783 663).

MEASUREMENTS

Data on past-month use of (1) cigarettes and (2) cannabis were used to classify respondents into four groups: cigarette and cannabis co-use, cigarette-only use, cannabis-only use or no cigarette or cannabis use. State of residence was measured by self-report. MCL/RCL status came from state government websites.

FINDINGS

Difference-in-difference analyses suggest that MCL was associated with an increase in cigarette-cannabis co-use overall [adjusted odds ratio (aOR) = 1.09; 95% confidence interval (CI) = 1.02-1.16], with the greatest increases among those aged 50 years and above (aOR = 1.60; CI = 1.39-1.84), married (aOR = 1.19; CI = 1.07-1.31), non-Hispanic (NH) black (aOR = 1.14; CI = 1.02-1.07) and with a college degree or above (aOR = 1.15; CI = 1.06-1.24). MCL was associated with increases in cigarette-only use among those aged 50 years and above (aOR = 1.07; CI = 1.01-1.14) and NH black (aOR = 1.16; CI = 1.06-1.27) and increases in cannabis-only use among those aged 50 years and above (aOR = 1.24; CI = 1.07-1.44) and widowed/divorced/separated (aOR = 1.18; CI = 1.01-1.37). RCL was associated with an increase in cannabis-only use overall (aOR = 1.21; 95% CI = 1.09-1.34), a decline in cigarette-only use overall (aOR = 0.89; 95% CI = 0.81-0.97) and increases in co-use among those who were married (aOR = 1.24; CI = 1.02-1.50) and aged 50 years and above (aOR = 1.37; CI = 1.03-1.84).

CONCLUSIONS

Recreational and medical cannabis legalization have had a varying impact on the use, and co-use, of cannabis and cigarettes in the United States.

Healthcare coverage and service access for low-income adults with substance use disorders

INTRODUCTION

Although health coverage facilitates service access to adults in the general population, uncertainty exists over the extent to which this relationship extends to low-income adults with substance use disorders.

METHODS

The health status and service use patterns of low-income adults with substance use disorders who had continuous, discontinuous, and no past year health coverage were compared using data from the 2015-2019 National Survey on Drug Use and Health (NSDUH). The NSDUH is a nationally representative survey of the civilian non-institutionalized population.

RESULTS

In the weighted sample (unweighted n = 9243), approximately 65.66% of low-income adults with substance use disorders had continuous coverage, 17.03% had discontinuous coverage, and 17.31% had no insurance coverage during the past year. Although few group differences were observed in self-reported health status, the uninsured group compared to the discontinously and continuously covered groups, respectively, was less likely to report a past year substance use treatment visit (11.03% vs. 14.83% vs. 15.61%), an outpatient care visit (53.39% vs. 71.27% vs. 79.04%), an emergency department visit (33.33% vs. 45.76% vs. 45.57%), or an inpatient admission (9.24% vs. 15.11% vs. 15.58%).

CONCLUSIONS

Although the cross sectional design limits causal inferences, the correlations between lacking health insurance and low rates of substance use treatment and healthcare use raise the possibility that increasing healthcare coverage might increase access to substance use treatment and other needed healthcare services for low-income adults with substance use disorders.

The incentive amplifying effects of nicotine: Roles in alcohol seeking and consumption

Nicotine has a unique profile among drugs of abuse. To the noninitiated user, nicotine has powerful aversive effects and its relatively weak euphorigenic effects undergo rapid tolerance. Despite this, nicotine is commonly abused despite negative heath consequences, and nicotine users have enormous difficulty quitting. Further, nicotine is one of the most commonly co-abused substances, in that it is often taken in combination with other drugs. One explanation of this polydrug use is that nicotine has multiple appetitive and consummatory conditioning effects. For example, nicotine is a reinforcement enhancer in that it can potently increase the incentive value of other stimuli, including those surrounding drugs of abuse such as alcohol. In addition, nicotine also has a unique profile of neurobiological effects that alter regulation of alcohol intake and interoception. This review discusses the psychological and biological mechanisms surrounding nicotine's appetitive conditioning and consummatory effects, particularly its interactions with alcohol.

Risk of somatic disease and mortality in individuals of parents with alcohol use disorder: a register-based cohort study

AIMS

To estimate the risks of 12 types of somatic disease-alcohol-related, blood, cancer, circulatory, digestive, endocrine and metabolic, genitourinary, infectious, musculoskeletal, nervous, respiratory and skin-in individuals with parental alcohol use disorder (AUD) versus a reference population, and to estimate the risks of all-cause mortality and of death from an alcohol-related cause.

DESIGN

Matched cohort study followed-up through nation-wide health registries. Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs).

SETTING

Denmark.

PARTICIPANTS

A total of 14 008 individuals born 1962-2003 of parents with AUD and 139 087 reference offspring randomly selected from the Danish Civil Registration System were followed from their 15th birthday and onward during 1970-2018. Follow-up time ranged between 2 423 955 and 3 208 366 person-years for somatic diseases and was 3 214 411 person-years for all-cause and alcohol-related mortality.

MEASUREMENTS

Information on somatic disease was obtained from the Danish National Patient Registry. Causes of death were obtained from the Danish Cause of Death Registry.

FINDINGS

Individuals of parents with AUD had a higher risk of alcohol-related diseases (HR = 2.70, 95% CI = 2.24-3.24) compared with the reference individuals. Higher HRs among individuals with parental AUD compared with reference individuals were also observed in all other somatic diseases except for cancer. All-cause mortality (HR = 1.80, 95% CI = 1.63-2.00) and alcohol-related mortality (HR = 3.28, 95% CI = 2.11-5.08) were higher among individuals of parents with AUD compared with the reference individuals. No significant differences were found in relation to the gender of either parents or offspring.

CONCLUSIONS

In Denmark, parental alcohol use disorder appears to predict alcohol-related and non-alcohol-related somatic morbidity and mortality in offspring.

Assessing Sex, Gender Identity, Sexual Orientation, Race, Ethnicity, Socioeconomic Status, and Mental Health Concerns in Tobacco Use Disorder Treatment Research: Measurement Challenges and Recommendations From a Society for Research on Nicotine and Tobacco Pre-conference Workshop

This paper reports on topics discussed at a Society for Research on Nicotine and Tobacco pre-conference workshop at the 2019 annual Society for Research on Nicotine and Tobacco meeting. The goal of the pre-conference workshop was to help develop a shared understanding of the importance of several tobacco-related priority groups in tobacco use disorder (TUD) treatment research and to highlight challenges in measurement related to these groups. The workshop focused on persons with minoritized sex, gender identity, and sexual orientation identities; persons with minoritized racial and ethnic backgrounds; persons with lower socioeconomic status (SES); and persons with mental health concerns. In addition to experiencing commercial tobacco-related health disparities, these groups are also underrepresented in tobacco research, including TUD treatment studies. Importantly, there is wide variation in how and whether researchers are identifying variation within these priority groups. Best practices for measuring and reporting sex, gender identity, sexual orientation, race, ethnicity, SES, and mental health concerns in TUD treatment research are needed. This paper provides information about measurement challenges when including these groups in TUD treatment research and specific recommendations about how to measure these groups and assess potential disparities in outcomes. The goal of this paper is to encourage TUD treatment researchers to use measurement best practices in these priority groups in an effort to conduct meaningful and equity-promoting research. Increasing the inclusion and visibility of these groups in TUD treatment research will help to move the field forward in decreasing tobacco-related health disparities. Implications: Tobacco-related disparities exist for a number of priority groups including, among others, women, individuals with minoritized sexual and gender identities, individuals with minoritized racial and ethnic backgrounds, individuals with lower SES, and individuals with mental health concerns. Research on TUD treatments for many of these subgroups is lacking. Accurate assessment and consideration of these subgroups will provide needed information about efficacious and effective TUD treatments, about potential mediators and moderators, and for accurately describing study samples, all critical elements for reducing tobacco-related disparities, and improving diversity, equity, and inclusion in TUD treatment research.

Effects of Alcohol Reduction Interventions on Blood Pressure

PURPOSE OF REVIEW

Much of alcohol's purported negative impact on a population's health can be attributed to its association with increased blood pressure, rates of hypertension, and incidence of cardiovascular disease (CVD). Less attention, however, has been placed on the association of the positive impact of alcohol reduction interventions on physical health.

RECENT FINDINGS

This review delineates the evidence of blood pressure reductions as a function of alcohol reduction interventions based on current care models. The findings of this review suggest two things: (1) sufficient evidence exists for a relationship between alcohol reductions and blood pressure generally, and (2) little evidence exists for the relationship between alcohol reductions and blood pressure for any one care model currently employed in the health system. The evidence base would benefit from more studies using established alcohol reduction interventions examining the impact of these interventions on blood pressure.

A novel smoking-specific self-control task: An initial study of feasibility, acceptability, and changes in self-control and cigarette smoking behaviors among adults using cigarettes

Objective: Self-control is a key factor in quitting cigarettes and practicing general self-control tasks may strengthen self-control. This study examined the feasibility and acceptability of a novel smoking-related self-control task. Method: Seventy-five adults with current cigarette smoking (Mage = 44.8, 74.7% male, 63.5% Black, 74.3% non-Latinx) were randomly assigned to practice a smoking-specific self-control task (Delay Smoking Task, n = 39) or a general self-control task (Posture Task, n = 36) for 1 week. Assessments included cigarettes per day (CPD), motivation to quit smoking, self-control, and task acceptability. Results: Most participants completed both appointments with no difference between task groups (p = .69). The Delay Smoking Task group rated the task as more difficult (p = .04) and more helpful for quitting smoking (p = .005) than did the Posture Task group. Self-control task groups did not differ in task effort (p = .66), task success (p = .14), or self-control used to practice the task (p = .13). Both task groups reported increased quit desire, expected quit success, quit confidence, and quit motivation (p < .05; partial η²s = 0.108-0.333). The time by task group interaction approached significance for expected quit success (p = .06; partial η² = .053), with the Delay Smoking Task group showing greater increases than the Posture Task group. Over the week, smoking decreased an average of 1.0 CPD with no difference between groups (p = .72; partial η² = 0.165). Conclusions: Practicing self-control was associated with increases in motivation to quit, confidence in quitting, and expected success at quitting smoking with similar changes for those practicing a smoking-specific versus a general self-control task. Self-control tasks may be useful for increasing motivation to quit cigarettes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Tobacco use among substance use disorder (SUD) treatment staff is associated with tobacco-related services received by clients

BACKGROUND

Despite disproportionately high rates of smoking among people in residential substance use disorder (SUD) treatment, few receive tobacco cessation services. Little is known about how smoking among treatment staff may impact this disparity. We explored the relationship between staff tobacco use and client tobacco use. Additionally, we examined the relationship between staff tobacco use and tobacco-related services reported by staff and clients.

METHODS

Staff (n = 363) and clients (n = 639) in 24 California publicly-funded residential SUD treatment programs were surveyed in 2019-20. Staff self-reported current tobacco use, as well as their beliefs, self-efficacy, and practices regarding smoking cessation. Clients reported their tobacco use and they services received while in treatment. Regression analyses examined the adjusted and unadjusted associations between staff and client tobacco use and other outcomes.

RESULTS

Use of any tobacco product by staff ranged from 0% to 100% by program, with an average of 32% across programs. Adjusted analyses found that higher rates of staff tobacco use were associated with higher rates of client tobacco use, and with fewer clients receiving tobacco-related counseling. In programs that had higher rates of staff tobacco use, staff were less likely to believe that clients should quit smoking in treatment and had lower self-efficacy to address smoking.

CONCLUSION

Higher rates of tobacco use among staff are associated with higher rates of client tobacco use and fewer clients receiving cessation counseling. Efforts to reduce tobacco use among SUD clients should be supported by efforts to reduce tobacco use among staff. SUD treatment programs, and agencies that fund and regulate those programs, should aim to reduce the use of tobacco products among staff.

The impact of cigarette smoking on life expectancy in schizophrenia, schizoaffective disorder and bipolar affective disorder: An electronic case register cohort study

Severe mental disorders are associated with a life expectancy that is 10-20 years shorter than the general population's. The prevalence of cigarette smoking in these populations is very high. We examined the effect of smoking on life expectancy and survival in patients with a diagnosis of schizophrenia, schizoaffective disorder or bipolar affective disorder from 2007 to 2018 in South East London, UK. Smoking status was determined using unstructured text data extracted from electronic health records. A total of 21,588 patients were identified of which 16,717, (77.4%) were classified as current smokers and 3438 (15.9%) as non-smokers. In female participants, life expectancy at birth was 67.6 years in current smokers (95% CI: 66.4-68.8) and 74.9 years in non-smokers (95% CI: 72.8-77.0), a difference of 7.3 years. In male participants, life expectancy at birth was 63.5 years in current smokers (95% CI: 62.5-64.5) and 68.5 years in non-smokers (95% CI, 64.4-72.6), a difference of 5.0 years. Adjusted survival models found that current smoking status was associated with an increased mortality risk for both females (aHR: 1.42, 95% CI: 1.21-1.66, p < 0.001) and males (aHR: 1.49; 95% CI: 1.25-1.79, p < 0.001). In terms of the effect sizes, these risks were similar to those associated with a diagnosis of co-morbid alcohol or opioid use disorder. Smoking may account for a substantial proportion of the reduced life expectancy in patients with psychotic disorders. Increased emphasis on reducing cigarette smoking in these populations may be the most effective way to reduce the mortality gap with the general population.

Smoking Beyond Prison Bans: The Impact of Prison Tobacco Bans on Smoking Among Prison Entrants

This study aims to determine whether previous exposure to a total prison smoking ban is associated with a reduction in daily smoking postrelease and to identify the factors associated with daily tobacco use. Demographics, incarceration history, and substance use data were collected from the 2016 National Prisoner Entrants' Blood Borne Virus Survey for 389 Australian prison entrants. Predictors of daily smoking among those exposed to a smoking ban were illicit drug use and Indigenous status. No significant association was found between current daily smoking and recent exposure to a prison smoking ban, suggesting that the majority of Australian prisoners exposed to a tobacco ban while incarcerated will return to smoking once released. Complementary and culturally specific interventions supporting abstinence postrelease should be considered.

Cigarette dependence is more prevalent and increasing among US adolescents and adults who use cannabis, 2002-2019

SIGNIFICANCE

Cannabis use is increasing among cigarette smokers. If cannabis use is associated with cigarette dependence, a barrier to smoking cessation, this could have public health implications for tobacco control. The current study estimated the prevalence of cigarette dependence among US individuals who smoke cigarettes by cannabis use status, and investigated trends in cigarette dependence from 2002 to 2019 among cigarette smokers by cannabis use status and cigarette consumption (ie, cigarettes per day, CPD).

METHODS

Data were drawn from the 2002-2019 annual National Survey on Drug Use and Health and included US individuals aged 12+ years who used cigarettes at least once in the past month (n=231 572). Logistic regression was used to estimate the prevalence of cigarette dependence, measured as time to first cigarette <30 min, by past-month cannabis use (no use, non-daily use, daily use), and to estimate trends in cigarette dependence from 2002 to 2019 overall and stratified by cannabis use and smoking level (light, 1-5 CPD; moderate, 6-15 CPD; heavy, 16+ CPD).

RESULTS

Across all levels of cigarette use, cigarette dependence was significantly more common among individuals with daily cannabis use compared with those with non-daily or no cannabis use. From 2002 to 2019, cigarette dependence increased among cigarette smokers with non-daily cannabis use, and among light and moderate cigarette smokers with no cannabis use.

CONCLUSIONS

US individuals who use both cigarettes and cannabis report a higher prevalence of cigarette dependence relative to individuals who use cigarettes and do not use cannabis at virtually all levels of cigarette consumption. Further, cigarette dependence is increasing in the USA both among those who use and do not use cannabis. Given the increase in cannabis use among those using cigarettes, efforts to elucidate the nature of the association between cannabis and cigarette dependence are needed.

Changes in Tobacco Use Patterns among Veterans in San Diego during the Recent Peak of the COVID-19 Pandemic

The prevalence of tobacco use increases in times of stress; however, during the initial stage of the COVID-19 pandemic, tobacco use rates stayed the same in most populations. Previous work focused on the initial months of the pandemic, while this study examined the changes in tobacco use during a later peak period of the pandemic. We used data from 61,852 visits to the VA San Diego Healthcare System from November 2019 to February 2021, divided into pre-, early, and peak pandemic periods. Multinomial logistic regression was used to test whether the odds of being a daily or non-daily tobacco user varied over time, by demographic group, or with the presence of specific psychiatric diagnoses. Younger Veterans had a greater reduction in the prevalence of non-daily tobacco use between the early and peak periods, while older Veterans had a rise in daily use from pre- to the early pandemic, which returned to baseline during the peak. Individuals with substance use disorder and serious mental illness diagnoses were more likely to report tobacco use, but psychiatric diagnoses did not predict change over time. These findings demonstrate factors that potentially contribute to changes in tobacco use during a public health crisis and may help guide future targeted cessation efforts.

Smoking Cessation Apps: A Systematic Review of Format, Outcomes, and Features

Smoking cessation interventions are effective, but they are not easily accessible for all treatment-seeking smokers. Mobile health (mHealth) apps have been used in recent years to overcome some of these limitations. Smoking cessation apps can be used in combination with a face-to-face intervention (FFSC-Apps), or alone as general apps (GSC-Apps). The aims of this review were (1) to examine the effects of FFSC-Apps and GSC-Apps on abstinence, tobacco use, and relapse rates; and (2) to describe their features. A systematic review was conducted following the internationally Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Of the total 6016 studies screened, 24 were included, of which nine used GSC-Apps and 15 FFSC-Apps. Eight studies reported significant differences between conditions in smoking cessation outcomes, with three of them being in favor of the use of apps, and two between different point-assessments. Concerning Apps features, most GSC-Apps included self-tracking and setting a quit plan, whereas most of the FFSC-Apps included self-tracking and carbon monoxide (CO) measures. Smartphone apps for smoking cessation could be promising tools. However, more research with an adequate methodological quality is needed to determine its effect. Nevertheless, smartphone apps' high availability and attractiveness represent a great opportunity to reach large populations.

Illicit drug use and oral health

People with drug use disorders (PWDUD) have elevated prevalence of oral diseases, in particular dental caries (tooth decay), periodontal (gum) disease and xerostomia (dry mouth). When left untreated, these oral health conditions may progress and lead to tooth ache, abscesses and tooth loss, and in turn, to poor chewing functioning and digestion, dental aesthetic problems and reduced wellbeing. Illicit drug use may, per se, cause xerostomia, which in turn increases vulnerability for dental caries. However, the other main drivers of oral diseases and their progression-poor oral hygiene, frequent sugar intake and infrequent dental visits-can mainly be ascribed to the irregular lifestyle, poor economy and mental health problems that often accompany illicit drug use. Establishment of good oral health habits is essential in the dental care for PWDUD. Dental treatment is often comprehensive and challenging; because the patients may have extensive treatment needs but also difficulties adhering to preventive measures and dental appointments. An integrated care approach for PWDUD would likely benefit both their oral and general health.

An audit of the cervical screening programme in the National Drug Treatment Centre (NDTC)

BACKGROUND

Women diagnosed with substance use disorders (SUDs) have higher rates of major medical conditions compared to women without SUDs. Cervical cancer is the second leading cause of cancer death in women aged 20-39 years worldwide and women with SUDs have an increased risk of cervical cancer compared to women without SUD. The National Drug Treatment Centre (NDTC) cervical screening programme, derived from the national CervicalCheck programme, offers free cervical screening to patients attending for treatment of SUDs.

AIMS

This study aimed to audit adherence to the NDTC Cervical Screening guidelines before and after the implementation of an awareness-raising educational intervention.

METHODS

The electronic clinical records of women aged between 25 and 60 years attending the lead consultant's (M.S.) outpatient clinic were reviewed for documentary evidence indicating that information about the cervical screening programme had been discussed. This was completed before and one month after the implementation of an awareness-raising educational intervention.

RESULTS

All women (n = 46, mean age 36.3 (SD = 6.5) years) had an opioid use disorder; 85% had a benzodiazepine use disorder, and 24% had an alcohol use disorder. Of these, 80% had at least one chronic medical condition, 76% had a psychiatric disorder, and 59% were homeless. Adherence to the NDTC cervical screening guideline, as indicated by documentary evidence in clinical records, was 33% (14/43) at baseline, and rose to 88% (36/41) (p < 0.0001) one month after the intervention.

CONCLUSIONS

This completed audit cycle shows that an awareness-raising educational intervention can significantly improve adherence to a cervical screening programme in women with SUDs.

Nicotine Enhances Goal-Tracking in Ethanol and Food Pavlovian Conditioned Approach Paradigms

Rationale

Nicotine promotes alcohol intake through pharmacological and behavioral interactions. As an example of the latter, nicotine can facilitate approach toward food- and alcohol-associated stimuli ("sign-tracking") in lever-Pavlovian conditioned approach (PavCA) paradigms. However, we recently reported that nicotine can also enhance approach toward locations of reward delivery ("goal-tracking") triggered by ethanol-predictive stimuli when the location of ethanol delivery is non-static (i.e., a retractable sipper bottle).

Objective

To determine whether the non-static nature of the reward location could have biased the development of goal-tracking in our previous study (Loney et al., 2019); we assessed the effect of nicotine in a lever-PavCA paradigm wherein the location of ethanol delivery was static (i.e., a stationary liquid receptacle). Then, to determine whether nicotine's enhancement of goal-tracking is unique to ethanol-predictive stimuli, we assessed the effect of systemic nicotine on approach triggered by food-predictive stimuli in a lever-PavCA paradigm.

Methods

Long-Evans rats were used in two PavCA experiments wherein a lever predicted the receipt of ethanol (15% vol/vol; experiment 1) or food (experiment 2) into a stationary receptacle. Prior to testing, rats were administered nicotine (0.4 mg/kg subcutaneously) or saline systemically.

Results

In both experiments, nicotine increased measures of goal-tracking, but not sign-tracking.

Conclusion

Nicotine can facilitate approach to reward locations without facilitating approach to reward-predictive stimuli. As such, conceptualization of the mechanisms by which nicotine affects behavior must be expanded to explain an enhancement of goal-tracking by nicotine.

Factors associated with dual and polytobacco use among people in residential substance use disorder treatment

BACKGROUND AND OBJECTIVES

Little is known about whether people in substance use disorder (SUD) treatment are at risk for multiple-tobacco use. We examined the factors associated with dual- and polytobacco use among clients in SUD treatment.

METHODS

A cross-sectional survey was conducted in 2019 among 562 clients (M_age  = 39, 74% male) in 20 residential SUD treatment programs in California, USA. The outcomes included single-, dual- (use of two products), and polytobacco use (use of three of more products). Independent variables were nicotine dependence, quitting-related factors, blunt/spliff use, and health-related factors. A multinomial model examined associations between the independent variables and the outcome, controlling for demographics, and time in treatment.

RESULTS

Overall, 32.6%, 18.9%, and 14.0% of the sample were single-, dual-, and polytobacco users, respectively. Factors associated with increased odds of polytobacco use included greater nicotine dependence (adjusted odds ratio [AOR] = 1.60; 95% CI = 1.19, 2.16), ever using e-cigarettes for quitting (AOR = 4.56; 95% CI = 2.23, 9.34), and past 30-day use of blunt/spliff (AOR = 2.96; 95% CI = 1.48, 5.89). Factors associated with increased odds of dual use were ever using e-cigarettes for quitting (AOR = 3.19; 95% CI = 1.79, 5.66) and reporting more mentally unhealthy days (AOR = 1.05; 95% CI = 1.02, 1.07).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This study extends the literature on tobacco use among people in SUD treatment by revealing the high prevalence of dual- and polytobacco use and the unique characteristics of users. The findings have implications for interventions reducing all types of tobacco use in this understudied population.

Implementing Clinical Practice Guidelines for Tobacco Cessation in a Women's Residential Substance Use Treatment Facility

BACKGROUND

Tobacco is the leading cause of preventable death, and over 200,000 women die each year of diseases caused by tobacco. Women with substance use disorders (SUDs) are disproportionately affected. Smoking prevalence among individuals enrolled in SUD treatment is 2-4 times higher than that of the general population, yet less than half of all treatment facilities offer tobacco treatment services. However, when individuals combine treatment, they have a greater likelihood of long-term abstinence from alcohol and other substances of use.

METHODS

A quality improvement project was undertaken to implement the U.S. Public Health Service guideline for tobacco cessation in a women's residential substance use treatment facility. Tobacco users were advised on their health risk and recommended to cut down or quit. They were advised that help was available using nicotine replacement therapy, behavioral counseling, or both.

RESULTS

Upon admission, 67% of clients received brief advice to quit, and 30% participated in an intensive treatment aimed at reducing or eliminating cigarette use. At discharge, counseling participants (n = 21) smoked an average of nine cigarettes per day, reduced from 23, which was statistically significant.

IMPLICATIONS FOR PRACTICE

Interventions reduced cigarette smoking in a population at a high risk for adverse outcomes related to use. Results suggest that more clients are interested in tobacco treatment than previously estimated. Increased administrative, clinical, and pharmacy support can sustain and further assist clients with cessation efforts.

The co-occurrence of smoking and alcohol use disorder in a hospital-based population: Applying a multimorbidity framework using geographic information system methods

Tobacco and alcohol use are leading causes of premature mortality in the US and concurrent use is associated with even greater health risks. A cross-sectional study of 20,310 patients admitted to a Mid-Atlantic acute health care system between July 1, 2018 and June 30, 2019 were categorized according to smoking and alcohol use disorder (AUD) status. Of the total admissions, 1464 (7.2%) were current smokers with an AUD. These patients were younger (52.4 vs. 63.9), more likely to be male (64.1% vs. 38.0%) and covered by Medicaid (46.9% vs. 11.6%), and resided in proximity to higher counts of tobacco (10.3 vs. 4.72) and alcohol (2.24 vs. 1.14) retailers than never smokers without an AUD. Clinically, these patients had higher rates of other substance use disorders (60.4% vs. 6.1%), depression (64.6% vs. 34.8%), HIV/AIDS (3.3% vs. 0.6%), and liver disease (40.7% vs. 13.2%) than never smokers without an AUD. Patients who concurrently smoke and have an AUD face unique and serious health risks. A multimorbidity framework can guide clinical and community-based interventions for individuals with concurrent psychiatric and chronic medical conditions, complex social needs, and adverse environmental exposures.

Cigarette Use and Cannabis Use Disorder Onset, Persistence, and Relapse: Longitudinal Data From a Representative Sample of US Adults

Objective: The current study prospectively investigated the relationship between cigarette use and the onset of, persistence of, and relapse to cannabis use disorder (CUD) 3 years later among adults in the United States. Methods: Analyses included respondents who completed Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (2001-2002 and 2004-2005, respectively) and responded to questions about cigarette use, cannabis use, and CUD (n = 34,653). CUDs were defined by DSM-IV criteria using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic Version IV. Multivariable logistic regression models were used to calculate the odds of CUD onset, persistence, and relapse at Wave 2 by Wave 1 cigarette use status. Analyses were adjusted for sociodemographics, psychiatric disorders, nicotine dependence, and alcohol and other substance use disorders. Results: Cigarette use at Wave 1 was associated with onset of CUD at Wave 2 among those without Wave 1 cannabis use (adjusted odds ratio [AOR] = 1.62; 95% CI, 1.35-1.94) but not among those with Wave 1 cannabis use (AOR = 1.00; 95% CI, 0.83-1.19). Cigarette use at Wave 1 was also associated with persistence of CUD at Wave 2 among those with CUD at Wave 1 (AOR = 1.63; 95% CI, 1.30-2.00) and relapse to CUD at Wave 2 among those with remitted CUD at Wave 1 (AOR = 1.23; 95% CI, 1.09-1.45). Conclusions: Among adults, cigarette use is associated with increased onset and persistence of and relapse to CUD 3 years later. Additional attention to cigarette use in community prevention and clinical treatment efforts aimed at reducing CUD may be warranted.

Evidence for the Confluence of Cigarette Smoking, Other Substance Use, and Psychosocial and Mental Health in a Sample of Urban Sexual Minority Young Adults: The P18 Cohort Study

BACKGROUND

Sexual minority men (SMM) and transgender women (TW) are more likely to smoke cigarettes than heterosexual and cisgender peers, which may exacerbate existing disparities in mental and psychosocial health and substance use.

PURPOSE

As few existing studies have examined the confluence of these factors, we sought to examine tobacco use in a diverse sample of SMM and TW and describe its relationship with other substance use and health.

METHODS

Data were drawn from a study of syndemic conditions among SMM and TW, which included measures assessing tobacco use, substance use, and mental, psychosocial, and general health.

RESULTS

A majority of the racially/ethnically and socioeconomically diverse sample (n = 665) reported ever smoking a cigarette, and more than half of them were current smokers. Current smoking was associated with more frequent recent substance use and poorer mental, psychosocial, and general health. In multivariable analyses, current smoking was predicted by more frequent substance use and more severe anxiety, when adjusting for demographic, substance use, and health factors.

CONCLUSIONS

A syndemic approach to health conditions such as substance use, mental health, and psychosocial burden dictates a framework of interrelation and mutual exacerbation. In doing so, we found that current cigarette use was associated with more frequent alcohol and marijuana use and more severe anxiety, suggesting a confluence of cigarette smoking, other substance use, and mental health burden. We recommend a holistic approach to treating tobacco use in sexual and gender minority populations that addresses both substance use and the myriad psychosocial burdens that sexual and gender minority communities experience.

Psychiatric Comorbidity and Multimorbidity in the EAGLES Trial: Descriptive Correlates and Associations With Neuropsychiatric Adverse Events, Treatment Adherence, and Smoking Cessation

INTRODUCTION

Psychiatric and substance use disorders represent barriers to smoking cessation. We sought to identify correlates of psychiatric comorbidity (CM; 2 diagnoses) and multimorbidity (MM; 3+ diagnoses) among smokers attempting to quit and to evaluate whether these conditions predicted neuropsychiatric adverse events (NPSAEs), treatment adherence, or cessation efficacy (CE).

AIMS AND METHODS

Data were collected from November 2011 to January 2015 across sixteen countries and reflect the psychiatric cohort of the EAGLES trial. Participants were randomly assigned to receive varenicline, bupropion, nicotine replacement therapy, or placebo for 12 weeks and were followed for an additional 12 weeks posttreatment. NPSAE outcomes reflected 16 moderate-to-severe neuropsychiatric symptom categories, and CE outcomes included continuous abstinence at weeks 9-12 and 9-24.

RESULTS

Of the 4103 participants included, 36.2% were diagnosed with multiple psychiatric conditions (20.9% CM, 15.3% MM). Psychiatric CM and MM were associated with several baseline factors, including male gender, nonwhite race or ethnicity, more previous quit attempts, and more severe mental health symptoms. The incidence of moderate-to-severe NPSAEs was significantly higher (p < .01) in participants with MM (11.9%) than those with CM (5.1%) or primary diagnosis only (4.6%). There were no significant (ps > .05) main effects or interactions with treatment condition for diagnostic grouping on treatment adherence or CE outcomes.

CONCLUSIONS

While having multiple psychiatric diagnoses increased risk of developing moderate-to-severe NPSAEs during a quit attempt, neither CM nor MM were associated with treatment adherence or odds of quitting. These findings reassure providers to advise smokers with multiple stable psychiatric conditions to consider using Food and Drug Administration (FDA)-approved medications when trying to quit.

IMPLICATIONS

Psychiatric MM may be associated with development of NPSAEs when smokers make a medication-assisted quit attempt, but it does not appear to be differentially associated with medication compliance or efficacy. Prescribing healthcare professionals are encouraged to not only promote use of FDA-approved pharmacotherapies by smokers with complex psychiatric presentations, but also to closely monitor such smokers for neuropsychiatric side effects that may be related to their mental health conditions.

NCT #

NCT01456936.

Co-use and Mixing Tobacco With Cannabis Among Ontario Adults

INTRODUCTION

The legalization of nonmedical cannabis in 2018 may have important implications for tobacco use in Canada. There is a risk of renormalizing tobacco use with co-use of tobacco and cannabis introducing nontobacco users to tobacco. Co-use is the use of both substances by the same individual at the same time or on different occasions, as well as mixed together. This study assessed the prevalence of co-use and mixing of tobacco and cannabis among Ontario adults and the characteristics of the users.

AIMS AND METHODS

Data from the 1996 to 2017 cycles of the Centre for Addiction and Mental Health Monitor (n = 4481) were used to examine trends in prevalence and the proportion of Ontario adults co-using and mixing tobacco and cannabis. Logistic regression was used to study associations between user characteristics and co-use and mixing.

RESULTS

Co-use of cigarettes and cannabis among cannabis users declined from 59.8% in 1996 to 41.7% in 2017. Past-year e-cigarette use was the only predictor of co-use. From 2015 to 2017, 31.1% (95% confidence interval 27.0, 35.9) of Ontario adults who used cannabis reported mixing it with tobacco in the past year. Being white, past-year e-cigarette use, having moderate or high nicotine dependence, and having moderate or high risk for cannabis problems were significant predictors of mixing among cannabis users.

CONCLUSION

Given the well-established negative health effects associated with tobacco use, alongside a growing evidence base for negative health effects of cannabis smoking, co-use and mixing could pose a considerable public health concern in the context of legalization.

IMPLICATIONS

Considerable effort has been expended to reduce tobacco smoking. However, current efforts to reduce tobacco smoking may be diminished since this study found the prevalence of mixing tobacco and cannabis among cannabis users in Ontario to be higher than expected. Mixing tobacco and cannabis may introduce nontobacco smokers to tobacco, exposing them to health risks associated with both cannabis and tobacco smoke. Therefore, there is a need to monitor changes in tobacco use and understanding implications for tobacco control and cessation programs within the changing environment of cannabis legalization in Canada and other jurisdictions.

History and Correlates of Smoking Cessation Behaviors Among Smokers With Serious Mental Illness

INTRODUCTION

Individuals with serious mental illness (SMI) smoke at rates two to three times greater than the general population but are less likely to receive treatment. Increasing our understanding of correlates of smoking cessation behaviors in this group can guide intervention development.

AIMS AND METHODS

Baseline data from an ongoing trial involving smokers with SMI (N = 482) were used to describe smoking cessation behaviors (ie, quit attempts, quit motivation, and smoking cessation treatment) and correlates of these behaviors (ie, demographics, attitudinal and systems-related variables).

RESULTS

Forty-three percent of the sample did not report making a quit attempt in the last year, but 44% reported making one to six quit attempts; 43% and 20%, respectively, reported wanting to quit within the next 6 months or the next 30 days. Sixty-one percent used a smoking cessation medication during their quit attempt, while 13% utilized counseling. More quit attempts were associated with lower nicotine dependence and carbon monoxide and greater beliefs about the harms of smoking. Greater quit motivation was associated with lower carbon monoxide, minority race, benefits of cessation counseling, and importance of counseling within the clinic. A greater likelihood of using smoking cessation medications was associated with being female, smoking more cigarettes, and receiving smoking cessation advice. A greater likelihood of using smoking cessation counseling was associated with being male, greater academic achievement, and receiving smoking cessation advice.

CONCLUSIONS

Many smokers with SMI are engaged in efforts to quit smoking. Measures of smoking cessation behavior are associated with tobacco use indicators, beliefs about smoking, race and gender, and receiving cessation advice.

IMPLICATIONS

Consideration of factors related to cessation behaviors among smokers with SMI continues to be warranted, due to their high smoking rates compared to the general population. Increasing our understanding of these predictive characteristics can help promote higher engagement in evidence-based smoking cessation treatments among this subpopulation.

Association of Cigarette Use and Substance Use Disorders among US Adults with and without a Recent Diagnosis of Cancer

Background: Few studies have examined substance use disorders (SUDs) in cancer patients and it is unclear whether SUDs differentially impact cigarette smoking in patients with vs. without cancer. This study used epidemiological data to estimate current cigarette smoking prevalence and quit ratios among US adults with and without SUDs by cancer status. Methods: Data were drawn from the 2015–2018 National Survey on Drug Use and Health (n = 170,111). Weighted current smoking prevalence and quit ratios were estimated across survey years by SUDs (with vs. without) and by cancer status (with vs. without). Results: Among those with cancer, current smoking prevalence was higher for those with vs. without SUDs (47% vs. 13%, p < 0.001) and quit ratios lower for those with vs. without SUDs (45% vs. 71%, p = 0.002). A similar pattern was observed in adults without cancer, with higher smoking prevalence (56% vs. 21%, p < 0.001) and lower quit ratios (23% vs. 51%, p < 0.001) observed for those with vs. without SUDs, respectively. In adjusted logistic regressions, the SUD × cancer status interaction was not significant for smoking prevalence or quit ratios (AOR = 1.2; 95% CI: 0.7, 2.1, p = 0.56; AOR = 1.0; 95% CI: 0.5, 2.0, p = 0.91, respectively), though smoking prevalence was lower and quit ratios higher for adults with vs. without cancer (ps < 0.05). Conclusions: Among US adults with and without cancer, individuals with SUDs evidenced higher cigarette smoking and lower quit ratios than those without SUDs. Addressing SUDs and their impact on smoking cessation is critical in cancer patients with implications for improving health and treatment outcomes.

A Comparison of Mental and Behavioral Health Risks Factors Associated With Current Dual Use of Electronic Cigarette and Conventional Tobacco Cigarettes With Exclusive Tobacco Cigarette Use and Nonuse Among Adults in the United States

BACKGROUND AND OBJECTIVES

While health risks associated with tobacco cigarette use are well-known, additional risks of dual use are poorly understood. This study compared mental and behavioral health risk factors associated with the current dual use of e-cigarettes and conventional tobacco cigarettes with current exclusive users of tobacco cigarettes and nonusers of either e-cigarettes or tobacco cigarettes.

METHODS

Data from the 2016 National Behavioral Risk Factor Surveillance System (BRFSS) were analyzed (N = 277,034). Current dual use was defined as the current use of tobacco cigarettes and the use of e-cigarettes, everyday or some days. Multivariate logistic regression analysis was used to assess associations between dual use and mental and behavioral health risks compared with exclusive tobacco cigarette users and nonusers.

RESULTS

Compared with nonusers, current dual use was associated with increased odds of having more than 14 days of self-reported poor physical health (adjusted odd ratio [AOR], 1.9; P < .01), more than 14 days of self-reported poor mental health (AOR, 1.8; P < .01), a diagnosis of depression (AOR, 2.2; P < .001); using smokeless tobacco products (AOR, 1.6; P < .05), alcohol use (AOR, 1.6; P < .01), and marijuana use (AOR, 8.3; P < .001) than current exclusive users of tobacco cigarettes.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The concurrent use of e-cigarettes and tobacco cigarettes is associated with increased odds of having behavioral and mental health problems. These findings may be indicative of increased health risks associated with dual use, compared with the exclusive use of tobacco cigarettes, and have important implications for public health interventions and policies aimed at mitigating health risk behaviors. (Am J Addict 2020;00:00-00).

Cannabis and Alcohol Co-Use in a Smoking Cessation Pharmacotherapy Trial for Adolescents and Emerging Adults

INTRODUCTION

The co-use of cannabis and alcohol among tobacco-using youth is common. Alcohol co-use is associated with worse tobacco cessation outcomes, but results are mixed regarding the impact of cannabis on tobacco outcomes and if co-use leads to increased use of non-treated substances. This secondary analysis from a youth smoking cessation trial aimed to (1) evaluate the impact of cannabis or alcohol co-use on smoking cessation, (2) examine changes in co-use during the trial, and (3) explore secondary effects of varenicline on co-use.

METHODS

The parent study was a 12-week, randomized clinical trial of varenicline for smoking cessation among youth (ages 14-21, N = 157; Mage = 19, 40% female; 76% White). Daily cigarette, cannabis, and alcohol use data were collected via daily diaries during treatment and Timeline Follow-back for 14 weeks post-treatment.

RESULTS

Baseline cannabis co-users (68%) had double the odds of continued cigarette smoking throughout the trial compared with noncannabis users, which was pronounced in males and frequent cannabis users. Continued smoking during treatment was associated with higher probability of concurrent cannabis use. Baseline alcohol co-users (80%) did not have worse smoking outcomes compared with nonalcohol users, but continued smoking was associated with higher probability of concurrent drinking. Varenicline did not affect co-use.

CONCLUSIONS

Inconsistent with prior literature, results showed that alcohol co-users did not differ in smoking cessation, whereas cannabis co-users had poorer cessation outcomes. Youth tobacco treatment would benefit from added focus on substance co-use, particularly cannabis, but may need to be tailored appropriately to promote cessation.

IMPLICATIONS

Among youth cigarette smokers enrolled in a pharmacotherapy evaluation clinical trial, alcohol and/or cannabis co-use was prevalent. The co-use of cannabis affected smoking cessation outcomes, but more so for males and frequent cannabis users, whereas alcohol co-use did not affect smoking cessation. Reductions in smoking were accompanied by concurrent reductions in alcohol or cannabis use. Substance co-use does not appear to affect all youth smokers in the same manner and treatment strategies may need to be tailored appropriately for those with lower odds of smoking cessation.

Cannabis Use Is Associated With Increased Risk of Cigarette Smoking Initiation, Persistence, and Relapse Among Adults in the United States

INTRODUCTION

Despite increasing use of cannabis, it is unclear how cannabis use is related to cigarette transitions. This study examined cannabis use and smoking initiation, persistence, and relapse over 1 year among a nationally representative sample of US adults.

METHODS

Data were from US adults (≥18 years) who completed two waves of longitudinal data from the Population Assessment of Tobacco and Health Study (Wave 1, 2013-2014; Wave 2, 2014-2015; n = 26 341). Logistic regression models were used to calculate the risk of Wave 2 incident smoking among Wave 1 never-smokers, smoking cessation among Wave 1 smokers, and smoking relapse among Wave 1 former smokers by Wave 1 cannabis use. Analyses were adjusted for age, gender, race/ethnicity, income, and education.

RESULTS

Among Wave 1 never-smokers, cannabis use was associated with increased odds of initiation of nondaily (adjusted odds ratio [AOR] = 5.50, 95% confidence limits [CL] = 4.02-7.55) and daily cigarette smoking (AOR = 6.70, 95% CL = 4.75-9.46) 1 year later. Among Wave 1 daily smokers, cannabis use was associated with reduced odds of smoking cessation (AOR = 0.36, 95% CL = 0.20-0.65). Among Wave 1 former smokers, cannabis use was associated with increased odds of relapse to daily and nondaily cigarette smoking (daily AOR = 1.90, 95% CL = 1.11-3.26; nondaily AOR = 2.33, 95% CL = 1.61-3.39).

CONCLUSIONS

Cannabis use was associated with increased cigarette smoking initiation, decreased smoking cessation, and increased smoking relapse among adults in the United States. Increased public education about the relationship between cannabis use and cigarette smoking transitions may be needed as cannabis use becomes more common among US adults.

IMPLICATIONS

As cannabis use increases in the United States and other countries, an evaluation of the relationships of cannabis use to other health-related behaviors (eg, cigarette smoking) is needed to understand the population-level impact of legalization. Little is known about associations between cannabis use and cigarette smoking transitions (1) using recent longitudinal data, (2) among adults, and (3) examining transitions other than smoking initiation (eg, smoking relapse). Our results suggest that among US adults, cannabis use was associated with increased cigarette smoking initiation among never-smokers, decreased cigarette smoking cessation among current smokers, and increased cigarette smoking relapse among former smokers.

Medical Burden of Disease Among Individuals in Recovery From Alcohol and Other Drug Problems in the United States: Findings From the National Recovery Survey

OBJECTIVES

The medical sequalae of alcohol and other drug (AOD) problems exact a prodigious personal and societal cost, but little is known about the specific prevalence of such medical problems, and their relationship to quality of life and indices of well-being among those recovering from problematic AOD use. To better characterize the lifetime physical disease burden, this study investigated the prevalence of medical conditions commonly caused or exacerbated by excessive and chronic AOD exposure in a nationally representative sample of US adults in AOD problem recovery. Comparisons were made to the general US population. Demographic and clinical correlates of disease prevalence were also investigated along with the relationship between distinct medical conditions and indices of quality of life/well-being.

METHODS

Cross-sectional nationally representative survey of the US adult population who report resolving an AOD problem (n = 2002). Weighted lifetime prevalence of common medical conditions were estimated and compared to the US population. Demographic and clinical correlates of medical conditions, and also overall disease burden, were estimated using logistic regression.

RESULTS

Relative to the general population, prevalence of hepatitis C, chronic obstructive pulmonary disease, heart disease, and diabetes were elevated. Likelihood of having a lifetime diagnosis of a specific disease was related to primary substance used and sex. Quality of life was lower among those with physical disease histories relative to those without.

CONCLUSIONS

Findings highlight the increased medical burden associated with AOD problems, and speak to the need for earlier and more sustained intervention for AOD problems, greater integration of addiction treatment and primary health care, and longitudinal research to explore the complex, dynamic relationships between AOD use and physical disease.

Predicting relapse after alcohol use disorder treatment in a high-risk cohort: The roles of anhedonia and smoking

On average, two-thirds of individuals treated for alcohol use disorder (AUD) relapse within six months. There is a critical need to identify modifiable risk factors associated with relapse that can be addressed during AUD treatment. Candidate factors include mood disorders and cigarette smoking, which frequently co-occur with AUD. We predicted that co-occurrence of mood disorders, cigarette smoking, and other modifiable conditions will predict relapse within six months of AUD treatment. Ninety-five Veterans, 23-91 years old, completed assessments of multiple characteristics including demographic information, co-occurring psychiatric disorders, and medical conditions during residential treatment for AUD. Participants' alcohol consumption was monitored over six months after participation. Logistic regression was used to determine if, mood disorders, cigarette smoking status, alcohol consumption, educational level, and comorbid general medical conditions are associated with relapse after AUD treatment. Sixty-nine percent of Veterans (n = 66) relapsed within six months of study while 31% remained abstinent (n = 29). While education, comorbid general medical conditions, and mood disorder diagnoses were not predictors of relapse, Veterans with greater symptoms of anhedonia, active smokers, and fewer days of abstinence prior to treatment showed significantly greater odds for relapse within six months. Anhedonia and cigarette smoking are modifiable risk factors, and effective treatment of underlying anhedonic symptoms and implementation of smoking cessation concurrent with AUD-focused interventions may decrease risk of relapse.