Psychiatric disorders in smokers seeking treatment for tobacco dependence: relations with tobacco dependence and cessation

Exercise and Smoking Cessation

Smoking is a public health crisis, leading to a multitude of health complications. Exercise is associated with numerous health benefits and is accepted by health professionals and smokers as a potentially effective smoking cessation aid. This chapter discusses the extant literature on the relation between exercise and smoking, including cross-sectional studies, experiments, and randomized clinical trials. There is robust evidence for exercise's efficacy in reducing cigarette craving, tobacco withdrawal symptoms, and negative affect. Further, exercise-based interventions appear to boost short-term abstinence yet may fall short of facilitating long-term abstinence. Methodological limitations of extant work are reviewed. We conclude with a discussion of the next steps in this line of work to fine-tune exercise interventions and their application for smoking cessation.

The 'revolving door' of mental illness: A meta-analysis and systematic review of current versus lifetime rates of psychological disorders

OBJECTIVES

Therapists have long observed a phenomenon referred to as the 'revolving door' of mental health services, in which individuals often develop, seek treatment for, and recover from multiple mental illnesses across their life. However, this has not been systematically examined. If this phenomenon is widespread, one would expect that the number of lifetime disorders would exceed that of current disorders. The aim of this meta-analysis was to test this hypothesis.

METHODS

A search was conducted of the following databases: MEDLINE, PsycINFO and Web of Science. In total, 38 studies were included in the current review; 27 of these contained sufficient quantitative data to be included in the meta-analysis, addressing the primary research aim. The remaining 11 studies were included in the systematic review only.

RESULTS

Meta-analyses of the 27 studies indicated that the average number of lifetime disorders was 1.84 times that of current disorders. Previous treatment significantly moderated this relationship, while the clinical nature of the sample did not. Examination of the remaining studies revealed common temporal sequences, indicating disorders which typically develop first or consequently to other disorders.

CONCLUSIONS

These findings provide support for the revolving door of mental illness, suggesting a need for transdiagnostic treatments and broader conceptualisation of relapse prevention.

Neuropsychological assessment fails to predict relapse among cigarette smokers: A prospective study of neurocognitive abilities

OBJECTIVES

Understanding the factors that lead to relapse is a major challenge for the clinical support of smoking cessation. Neurocognitive abilities such as attention, executive functioning and working memory, are possible predictors of relapse and can be easily assessed in everyday clinical practice. In this prospective longitudinal study, we investigated the relationship between pre-smoking cessation neurocognitive performance and relapse at six months in a sample of patients being treated for their tobacco dependence.

METHODS

130 tobacco consumers were included in the study. They completed a comprehensive neuropsychological and clinical assessment before smoking cessation. The targeted abilities were intelligence, inhibition, shifting, working memory updating, verbal fluency and decision-making.

RESULTS

The rate of tobacco relapse at 6 months was 58%. Logistic regressions were used to assess which variables best explained relapse. None of the neuropsychological tests was a significant predictor of relapse at either 1, 3 or 6 months, either alone, or controlling for other covariates acting as significant predictors of relapse.

CONCLUSIONS

Common neuropsychological tests, even those specifically targeting executive functioning such as inhibition, are not useful predictors of the success of a smoking cessation program in a clinical setting. Other variables, such as motivation to quit smoking or the presence of comorbid depression or anxiety disorders, appear to be more useful predictors of relapse.

Methodological approach for an integrated female-specific study of anxiety and smoking comorbidity

Two primary ovarian hormones that fluctuate across the female menstrual cycle-estradiol and progesterone-have been independently linked in separate literatures to nicotine reinforcement and anxiety psychopathology. We identify existing methodological limitations in these literatures, describe an example protocol that was developed to address such limitations, highlight case examples, and offer insights on the resulting advantages and challenges. This protocol was an observational, prospective, within-subjects study of female cigarette smokers who were followed over the course of a complete menstrual cycle. Non-treatment seeking, female cigarette smokers (N = 50), between the ages of 18-40 who have a normal menstrual cycle (25-35 days in length) were recruited from the community. Females with anxiety or mood psychopathology represented 38.0% of the sample. Salivary progesterone and estradiol were assessed each morning via at-home saliva collection methods. Self-reported within-day momentary ratings of anxiety and nicotine reinforcement were collected using ecological momentary assessment (EMA) via a mobile app. Protocol compliance was >85%. Within- and between-subjects heterogeneity was observed in the progesterone and estradiol, anxiety, and nicotine craving measures, especially in the context of anxiety psychopathology. We aimed to integrate the anxiety and nicotine dependence literatures and advance the empirical study of the role of ovarian hormones. This protocol reflects an intensive, yet feasible approach to collecting daily-level naturalistic data related to estradiol, progesterone, anxiety, and nicotine reinforcement.

The Role of Perceived Neighborhood Cohesion in the Association between Depressive Symptoms and Cigarette Smoking

BACKGROUND

Greater depression has been linked to increased smoking rates. However, the mechanisms underlying this association are not fully understood. It is possible that high perceived neighborhood cohesion may serve as one such mechanism given its associations with decreased depression and smoking. Having increased levels of depression likely impacts one's perceptions of neighborhood cohesion, which could lead to further increases in depression and a need to manage these symptoms via cigarette smoking. As a first test of this theory, the current study examined the effect of neighborhood cohesion on the association between depressive symptoms and smoking frequency and quantity among past 30-day cigarette smokers.

METHODS

Participants were 201 combustible cigarette smokers (Mage = 48.33, SD = 11.64; 63.2% female; 68.2% White) who completed self-report measures as part of a larger study of environmental influences on cardiac health.

RESULTS

Greater depressive symptoms were associated with lower levels of perceived neighborhood cohesion, and there was a significant indirect effect of greater depressive symptoms on heavier smoking through decreased neighborhood cohesion (b = .07, SE = .04, 95% CI [.003, .15]). There was no significant indirect effect for daily smoking.

CONCLUSION

These results suggest that neighborhood cohesion is an important contextual factor that serves as one explanatory mechanism for the well-established relationship between depression and smoking quantity. Thus, there may be utility in implementing interventions focused on increasing neighborhood cohesion as a way to decrease smoking behavior.

Acceptance and Commitment Therapy Wellness Program for Latine Adults Who Smoke and Have Psychological Distress: Protocol for a Feasibility Study

BACKGROUND

Tobacco smoking is a major independent risk factor for chronic disease, and the prevalence of smoking among people with behavioral health disorders is 2-fold in comparison with the general population. Smoking rates remain high for various subgroups within the Latine community, the largest ethnic minority group in the United States. Acceptance and commitment therapy (ACT) is a theoretically sound and clinically validated therapeutic approach for several behavioral health conditions with growing evidence of its effectiveness for smoking cessation. Unfortunately, the evidence of ACT effectiveness for smoking cessation among Latine individuals is scarce, and none of the existing studies have tested a culturally targeted intervention for this population.

OBJECTIVE

This study aims to address the co-occurrence of smoking and mood-related challenges among Latine adults via the development and testing of a culturally tailored ACT-based wellness program: Project PRESENT.

METHODS

This study entails 2 phases. Phase 1 consists of the intervention development. Phase 2 entails the pilot testing of the behavioral intervention along with the administration of baseline and follow-up measures to 38 participants. Primary outcomes include feasibility of recruitment and retention, and treatment acceptability. Secondary outcomes are smoking status and depression and anxiety scores at end of treatment and 1-month follow-up.

RESULTS

This study received institutional review board approval. Phase 1 outputs were the health counselors' treatment manual and participant guide. Recruitment was completed in 2021. Phase 2 outcomes will be determined after project implementation and data analyses are complete, which are expected by May 2023.

CONCLUSIONS

Findings from this study will determine the feasibility and acceptability of an ACT-based, culturally relevant intervention for Latine adults who smoke and have probable depression and/or anxiety. We expect feasibility of recruitment, retention and treatment acceptability, and reductions in smoking status, depression, and anxiety. If feasible and acceptable, the study will inform large-scale trials, which will ultimately contribute to narrowing the gap between research and clinical practice for the co-occurrence of smoking and psychological distress among Latine adults.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44146.

Boredom Susceptibility and Quit Smoking: The Role of Anxiety Symptoms

Boredom is one of the main reported motives for smoking. However, scarce research has examined the relationship between boredom susceptibility and abstinence achievement in treatment-seeking smokers. The aim of this study is to examine the mediating effect of anxiety symptoms in the relationship between boredom susceptibility and abstinence at the end of a smoking cessation treatment. The sample was composed of 481 Spanish smokers who received a cognitive-behavioral treatment to quit (M_age= 45.51, SD = 11.16; 60.6% female). The Boredom Susceptibility subscale of the Sensation Seeking Scale Form-V and the Beck Anxiety Inventory were used. Pearson correlations and mediation analyses were conducted to examine the relationships between the study variables. Boredom susceptibility was significantly and positively correlated to anxiety symptoms, but not to abstinence. Anxiety symptoms were significantly and negatively correlated to abstinence. A significant indirect effect of boredom susceptibility on abstinence at the end of treatment through anxiety symptoms was found. There was no direct relation between boredom susceptibility and abstinence. These findings extend previous literature by showing that higher boredom susceptibility is associated with less likelihood to be abstinent at the end of the treatment through higher anxiety symptoms. These results highlight the relevance of considering the inclusion of boredom and anxiety management techniques in smoking cessation interventions.

[Multicomponent treatment of tobacco in primary care: Follow-up over 5years]

OBJECTIVES

To analyze the effectiveness of a multicomponent treatment for smoking cessation carried out in primary care and to evaluate the evolution of the consumption of tobacco that the people who participated had, more than 5 years after the end of the treatment.

DESIGN

Longitudinal study of 307 participants in a multicomponent program in group format of tobacco cessation.

EMPLACEMENT

Santander (Spain) Primary Care Health Center.

PARTICIPANTS

Smokers from the basic health zone who wanted to quit smoking between 2006 and 2012 and requested help.

INTERVENTIONS

Multicomponent treatment of 5face-to-face sessions and follow-up for up to 12 months.

PRIMARY MEASUREMENTS

The activity was evaluated in 263 participants more than 5years after the end of treatment. The results of continuous and punctual withdrawal were obtained by self-declaration and the data recorded in the medical record. The punctual was also validated with co-oximetry.

RESULTS

After a year 42.7% of participants declared continuous abstinence. From 5 to 12 years later, the continuous declared abstinence further than 12 months was 40.7%. They did not smoke again since the end of the treatment 66 people; 68.0% of those who relapsed made new attempts and 45.5% of them requested help to quit smoking.

CONCLUSIONS

The proposed multi-component treatment is effective. Abstinence at 12 months predicts long-term maintenance and participating in disabling groups favors further attempts in case of relapse and the request for help to quit smoking.

Latinx Individuals Who Smoke Daily with and without a Probable Anxiety Disorder: Differences in Smoking Behavior and Beliefs about Abstinence

There is a well-established relation between anxiety psychopathology and smoking in the general population. However, little work focuses on Latinx/Hispanic (hereafter Latinx) persons who smoke from this comorbidity perspective. The present investigation aimed to explore differences among English-speaking Latinx adults who live in the United States (US) and smoke cigarettes with and without a probable anxiety disorder in terms of cigarette dependence, perceived barriers for quitting, severity of problems when quitting, and smoking abstinence expectancies. The sample included 338 adult Latinx daily cigarette smokers (Mage = 35.53 years; SD = 8.65; age range 18-61; 37.3% female) who identified as Latinx and were recruited nationally throughout the US. Results indicated that among Latinx persons who smoke, those with a probable anxiety disorder (compared to those without) were more likely to demonstrate higher levels of cigarette dependence, severity of problems when trying to quit, perceived barriers for quitting, and negative abstinence expectancies after adjusting for key variables linked to smoking and anxiety (e.g., hazardous drinking, education). The current findings are the first to document probable anxiety disorder status as a clinically relevant factor for a wide range of smoking variables and beliefs about abstinence among Latinx persons who smoke.

Perceived Stress and Smoking Cessation: The Role of Smoking Urges

Despite the fact that perceived stress is related to abstinence smoking outcomes, no studies have investigated the mediational effect of specific tobacco-related variables on this relationship. This study aimed to explore the indirect effect of perceived stress on abstinence at the end of treatment through smoking urges. The sample comprised 260 treatment-seeking smokers (58.5% female; Mage = 46.00; SD = 11.1) who underwent psychological smoking cessation treatment. The brief version of the Questionnaire of Smoking Urges (QSU) and the Perceived Stress Scale (PSS14) were used. Mediation analyses were conducted in which smoking urges and their dimensions were potential mediators in the relationship between perceived stress and abstinence at the end of treatment. The results showed a non-significant direct effect of perceived stress on abstinence. However, a significant indirect effect was found through smoking urges (QSU-total) and, specifically, through smoking urges associated with the expectation of negative affect relief (QSU-Factor 2). A non-significant indirect effect through smoking urges related to the expectation of tobacco use as a pleasurable experience (QSU-Factor 1) was also found. Analyzing possible mediator variables could contribute to understanding previous conflicting data. These findings point to potential interest in including treatment components targeting perceived stress and smoking urges to improve the effectiveness of smoking cessation treatments.

The effects of varenicline, bupropion, nicotine patch, and placebo on smoking cessation among smokers with major depression: A randomized clinical trial

IMPORTANCE

Improving treatment outcomes for smokers with major depressive disorder (MDD) can have significant public health implications.

OBJECTIVE

To evaluate the safety and efficacy of smoking cessation pharmacotherapy among smokers with MDD.

DESIGN

Secondary analysis of a randomized, double-blind, active- (nicotine patch) and placebo-controlled trial of 12 weeks of either varenicline or bupropion with a 12-week follow-up.

PARTICIPANTS

Community volunteers 18-75 years of age; smoke 10+ cigarettes/day; with clinically stable MDD (N = 2635) or no psychiatric disorder (N = 4028), from 140 sites in 16 countries.

INTERVENTION

Twelve weeks of pharmacotherapy (placebo [PLA], nicotine replacement therapy [NRT], bupropion [BUP], varenicline [VAR]) plus brief cessation counseling.

MEASURE(S)

Primary safety outcome: the occurrence of ≥1 treatment-emergent, moderate to severe neuropsychiatric adverse event (NPSAE). Primary efficacy outcome: biochemically confirmed continuous abstinence (CA) during the final 4 weeks of treatment (Weeks 9-12).

RESULTS

A total of 6653 participants (56% female; 39% MDD) ~47 years old. Risk of NPSAEs did not differ by medication for MDD. MDD had higher risk (p < .0001) for NPSAEs than the NPC. Efficacy (6653; intent-to-treat): CA rates for MDD versus NPC respectively were 31.2% versus 38.0% VAR; 23.0% versus 26.1% BUP; 22.6% versus 26.4% NRT; and 13.4% versus 13.7% PLA but no differential treatment effect was noted within the cohorts. All active treatments differed from PLA but VAR showed the largest effect.

CONCLUSIONS

Results suggest that for MDD smokers, inclusive of those with recurrent episode, varenicline plus counseling may be the best pharmacological option for the treatment of smoking given its greater efficacy effect size and similar risk of NPSAEs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01456936. https://clinicaltrials.gov/ct2/show/NCT01456936.

Comparison of an automated smartphone-based smoking cessation intervention versus standard quitline-delivered treatment among underserved smokers: protocol for a randomized controlled trial

BACKGROUND

Smoking is the leading cause of preventable morbidity and mortality in the United States. Individuals with low socioeconomic status have disproportionately high smoking rates and greater difficulty quitting smoking. Efficiently connecting underserved smokers to effective tobacco cessation programs is crucial for disease prevention and the elimination of health disparities. Smartphone-based interventions have the potential to enhance the reach and efficacy of smoking cessation treatments targeting underserved smokers, but there is little efficacy data for these interventions. In this study, we will partner with a large, local hunger-relief organization to evaluate the efficacy and economic impact of a theoretically-based, fully-automated, and interactive smartphone-based smoking cessation intervention.

METHODS

This study will consist of a 2-group randomized controlled trial. Participants (N = 500) will be recruited from a network of food distribution centers in West Central Florida and randomized to receive either Standard Treatment (ST, n = 250) or Automated Treatment (AT, n = 250). ST participants will be connected to the Florida Quitline for telephone-based treatment and will receive a 10-week supply of nicotine replacement therapy (NRT; transdermal patches and lozenges). AT participants will receive 10 weeks of NRT and a fully-automated smartphone-based intervention consisting of interactive messaging, images, and audiovisual clips. The AT intervention period will span 26 weeks, with 12 weeks of proactive content and 26 weeks of on-demand access. ST and AT participants will complete weekly 4-item assessments for 26 weeks and 3-, 6-, and 12-month follow-up assessments. Our primary aim is to evaluate the efficacy of AT in facilitating smoking abstinence. As secondary aims, we will explore potential mediators and conduct economic evaluations to assess the cost and/or cost-effectiveness of ST vs. AT.

DISCUSSION

The overall goal of this project is to determine if AT is better at facilitating long-term smoking abstinence than ST, the more resource-intensive approach. If efficacy is established, the AT approach will be relatively easy to disseminate and for community-based organizations to scale and implement, thus helping to reduce tobacco-related health disparities.

TRIAL REGISTRATION

Clinical Trials Registry NCT05004662 . Registered August 13, 2021.

Evaluating the Efficacy of Automated Smoking Treatment for People With HIV: Protocol for a Randomized Controlled Trial

Background

Smoking prevalence rates among people with HIV are nearly 3 times higher than those in the general population. Nevertheless, few smoking cessation trials targeting smokers with HIV have been reported in the literature. Efforts to develop and evaluate sustainable, low-cost, and evidence-based cessation interventions for people with HIV are needed. Given the widespread proliferation of mobile phones, the potential of using mobile health apps to improve the reach and efficacy of cessation interventions is promising, but evidence of efficacy is lacking, particularly among people with HIV.

Objective

This study will consist of a 2-group randomized controlled trial to evaluate a fully automated smartphone intervention for people with HIV seeking cessation treatment.

Methods

Participants (N=500) will be randomized to receive either standard treatment (ST; 250/500, 50%) or automated treatment (AT; 250/500, 50%). ST participants will be connected to the Florida Quitline and will receive nicotine replacement therapy in the form of transdermal patches and lozenges. This approach, referred to as Ask Advise Connect, was developed by our team and has been implemented in numerous health systems. ST will be compared with AT, a fully automated behavioral treatment approach. AT participants will receive nicotine replacement therapy and an interactive smartphone-based intervention that comprises individually tailored audiovisual and text content. The major goal is to determine whether AT performs better in terms of facilitating long-term smoking abstinence than the more resource-intensive ST approach. Our primary aim is to evaluate the efficacy of AT in facilitating smoking cessation among people with HIV. As a secondary aim, we will explore potential mediators and moderators and conduct economic evaluations to assess the cost and cost-effectiveness of AT compared with ST.

Results

The intervention content has been developed and finalized. Recruitment and enrollment will begin in the fall of 2021.

Conclusions

There is a critical need for efficacious, cost-effective, and sustainable cessation treatments for people with HIV who smoke. The AT intervention was designed to help fill this need. If efficacy is established, the AT approach will be readily adoptable by HIV clinics and community-based organizations, and it will offer an efficient way to allocate limited public health resources to tobacco control interventions.

Trial Registration

ClinicalTrials.gov NCT05014282; https://clinicaltrials.gov/ct2/show/NCT05014282

International Registered Report Identifier (IRRID)

PRR1-10.2196/33183

The Relationship Between Trauma Exposure and Adult Tobacco Use: Analysis of the National Epidemiologic Survey on Alcohol and Related Conditions (III)

INTRODUCTION

Previous research has examined cigarette smoking in trauma exposed populations. However, the relationships between trauma exposure and use of other tobacco products (eg, cigars, e-cigarettes) and specific trauma exposure characteristics that may be associated with tobacco use are understudied.

AIMS AND METHODS

Using the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (N = 36 151 adults), we conducted weighted bivariate analyses of tobacco use among participants with no trauma exposure, trauma exposure, and trauma exposure with post-traumatic stress disorder (trauma + PTSD), stratified by tobacco product use. We also performed weighted logistic regressions testing relationships between trauma exposure and tobacco use, controlling for behavioral health (BH) conditions (mood, anxiety, substance use, personality disorders) and sociodemographics.

RESULTS

Approximately 44% of participants had experienced trauma; 6% experienced trauma + PTSD. Trauma exposed participants had a higher prevalence of tobacco use (30%--46% vs. 22%) and poly-tobacco use (34%--35% vs. 28%) than unexposed participants. Cigarettes were the most used tobacco product; trauma + PTSD (19%), and trauma (15%) participants had a higher prevalence of e-cigarette use than unexposed participants (11%). Trauma exposure was associated with current tobacco use (AOR = 1.36 trauma + PTSD; 1.23 trauma) (but not former use), particularly among participants exposed to violence/abuse (AOR = 1.23). Personality and substance use disorders were strongly associated with current and former tobacco use.

CONCLUSIONS

Trauma exposure, PTSD, and experiences of violence/abuse are associated with current tobacco use. BH conditions may also play a role in current and former tobacco use. Recognizing and addressing trauma exposure and BH conditions among tobacco users may improve cessation rates in these populations.

IMPLICATIONS

This study contributes to research on tobacco use disparities in behavioral health populations by providing a comprehensive examination of tobacco use in trauma exposed individuals. Prior research has examined cigarette smoking, but not other tobacco product use in these populations. This study presents findings on multiple tobacco use behaviors (tobacco product, poly-tobacco use, cessation attempts) in trauma exposed populations and characteristics of trauma exposure (severity, type of traumatic event) associated with tobacco use. These findings underscore the importance of further examining the implications of trauma exposure for tobacco use and of screening and addressing trauma in cessation treatment.

Dynamic associations between anxiety, depression, and tobacco use in older adults: Results from The Irish Longitudinal Study on Ageing

Evidence supports moderate-to-large reductions in anxiety, depression, and perceived stress after smoking cessation; however, much of the available evidence has focused on young adults. Therefore, this study quantified associations between smoking and smoking cessation on prevalent and incident generalised anxiety disorder (GAD) and major depression (MDD) in a nationally representative sample of Irish older adults. Participants (n = 6201) were community dwelling adults aged ≥50 years resident in Ireland. Smoking status and self-reported doctor diagnosis of anxiety or depression prior to baseline were assessed at baseline (i.e., Wave 2). At baseline and 2-, 4-, and 6-year follow-up (i.e., Waves 3-5), GAD and MDD were assessed by the Composite International Diagnostic Interview Short-Form. Logistic regression quantified cross-sectional and prospective associations (odds ratios (ORs) and 95% confidence intervals (95%CIs)) between smoking status and mental health. Prevalence and incidence of GAD was 9.1% (n = 566) and 2.8% (n = 148), respectively. Prevalence and incidence of depression was 11.1% (n = 686) and 6.4% (n = 342), respectively. Following full adjustment, current smokers had higher odds of prevalent GAD (OR = 1.729, 1.332-2.449; p < 0.001) and MDD (OR = 1.967, 1.548-2.499; p < 0.001) than non-smokers. Former smokers had higher odds of prevalent GAD than non-smokers (OR = 1.276, 1.008-1.616; p < 0.001). Current smokers did not have higher odds of incident MDD (OR = 1.399, 0.984-1.990; p = 0.065) or GAD than non-smokers (1.039, 0.624-1.730; p = 0.881). Findings may have important implications for interventions designed to curb tobacco abuse, which tend to be less successful among those with anxiety and depression.

The modulating impact of cigarette smoking on brain structure in panic disorder: a voxel-based morphometry study

Cigarette smoking increases the likelihood of developing anxiety disorders, among them panic disorder (PD). While brain structures altered by smoking partly overlap with morphological changes identified in PD, the modulating impact of smoking as a potential confounder on structural alterations in PD has not yet been addressed. In total, 143 PD patients (71 smokers) and 178 healthy controls (62 smokers) participated in a multicenter magnetic resonance imaging (MRI) study. T1-weighted images were used to examine brain structural alterations using voxel-based morphometry in a priori defined regions of the defensive system network. PD was associated with gray matter volume reductions in the amygdala and hippocampus. This difference was driven by non-smokers and absent in smoking subjects. Bilateral amygdala volumes were reduced with increasing health burden (neither PD nor smoking > either PD or smoking > both PD and smoking). As smoking can narrow or diminish commonly observed structural abnormalities in PD, the effect of smoking should be considered in MRI studies focusing on patients with pathological forms of fear and anxiety. Future studies are needed to determine if smoking may increase the risk for subsequent psychopathology via brain functional or structural alterations.

Stress, Depression and Quit Attempt Outcomes among Unmotivated Smokers

INTRODUCTION

Stress and depressive symptoms have been linked to a reduced likelihood of sustaining smoking cessation. Because stress and depressive symptoms may negatively affect motivation to quit, stress and depression may also be important for whether or not smokers make a quit attempt.

OBJECTIVE

To examine the relationship between perceived stress and depressive symptoms and initiating a quit attempt in a smoking cessation induction trial.

METHODS

We conducted a secondary analysis of existing data from a randomized clinical trial (N = 255) comparing motivational interviewing to health education and brief advice for smoking cessation induction in smokers with low motivation to quit.

RESULTS

We observed positive associations between baseline predictors and quit attempts at week 12 (r = 0.192, p < 0.01 for depressive symptoms and r = 0.136, p < 0.05 for perceived stress). Logistic regression models revealed similar significant positive associations between baseline perceived stress and baseline depressive symptoms and making a quit attempt by week 12 (OR = 1.5, CI:1.03, 2.19 and OR = 1.03, 95% CI: 1.01, 1.06; respectively).

CONCLUSION

Unexpectedly, this study found generally small but consistently positive associations between baseline depressive symptoms and baseline perceived stress and making a quit attempt by week 12. The results can be viewed as encouraging in that interventions to encourage quit attempts do not appear counter-productive for individuals higher in stress and depressive symptoms, but these patients very likely will need additional supports to sustain abstinence.

Biopsychosocial mechanisms associated with tobacco use in smokers with and without serious mental illness

Smokers with serious mental illness (SMI) are less responsive to cessation treatments than those without SMI. In this study, we compared smokers with and without SMI on validated measures of biological and psychosocial factors associated with tobacco use. Smokers with (n = 58) and without SMI (n = 83) who were enrolled in parallel clinical trials were compared on measures of carbon monoxide (CO) exposure, nicotine exposure, tobacco-specific nitrosamine exposure, craving, smoking motives, affect, perceived stress, environmental exposure to smoke/smokers, respiratory symptoms, tobacco-related health risk perceptions, and whether they had received recent advice to quit smoking from a health care provider. Data were collected between 2013 and 2017 in Providence, Rhode Island, USA. Samples were compared using independent-sample t-tests and chi-squared tests. Smokers with SMI had higher CO, nicotine, and tobacco-specific nitrosamine exposure levels, greater cigarette dependence, higher craving, and higher scores on eight out of eleven smoking motives (p's < 0.05). Smokers with SMI reported more severe respiratory symptoms but lower perceived health risks of tobacco (p's < 0.05). These smokers were more likely to report having received advice to quit from a medical provider in the past 6 weeks (p < 0.05). Affect, stress, and exposure to smoke/smokers did not differ across samples. Our findings advance the understanding of the elevated smoking rates of people with SMI by comparing smokers with and without SMI on validated biopsychosocial measures. There is a need for interventions that reduce craving, reduce smoking motives, and increase risk awareness among smokers with SMI.

Anxiety Sensitivity and Distress Tolerance in Smokers: Relations With Tobacco Dependence, Withdrawal, and Quitting Success†

INTRODUCTION

This study examined relations of two affective vulnerabilities, high anxiety sensitivity (AS) and low distress tolerance (DT), with tobacco dependence, withdrawal, smoking cessation, and pharmacotherapy response.

METHODS

Smokers interested in quitting (N = 1067; 52.2% female, 28.1% African American) were randomized to 12 weeks of nicotine patch, nicotine patch plus nicotine lozenge, or varenicline. Baseline questionnaires assessed AS, DT, negative affect, anxiety, and dependence. Withdrawal was assessed the first-week post-quit via ecological momentary assessment.

RESULTS

DT, but not AS, predicted biochemically confirmed point-prevalence abstinence at multiple endpoints: weeks 4, 12, 26, and 52 post-quit (ps < .05); relations remained after controlling for pharmacotherapy treatment, AS, baseline negative affect, anxiety, and anxiety disorder history (ps < .05). Additional exploratory analyses examining week 4 abstinence showed DT predicted abstinence (p = .004) even after controlling for baseline dependence, post-quit withdrawal (craving and negative affect), and treatment. DT moderated treatment effects on abstinence in exploratory analyses (interaction p = .025); those with high DT were especially likely to be abstinent at week 4 with patch plus lozenge versus patch alone.

CONCLUSIONS

DT, but not AS, predicted abstinence over 1 year post-quit (higher DT was associated with higher quit rates), with little overlap with other affective measures. DT also predicted early abstinence independent of dependence and withdrawal symptoms. Results suggest low DT may play a meaningful role in motivation to use tobacco and constitute an additional affective risk factor for tobacco cessation failure beyond negative affect or clinical affective disorders.

IMPLICATIONS

People in a stop-smoking study who reported a greater ability to tolerate distress were more likely to quit smoking and remain smoke-free 1 year later. Smokers with high DT were more likely to be smoke-free 4 weeks after their target quit day if they received nicotine patch plus nicotine lozenge rather than nicotine patch alone.

TRIAL REGISTRATION

NCT01553084.

The Role of Anxiety in Smoking Onset, Severity, and Cessation-Related Outcomes: a Review of Recent Literature

PURPOSE OF REVIEW

Anxiety is one of the most common mental health conditions globally and co-occurs with smoking at a markedly high rate. The present review offers a narrative overview of the most recent research on the role of anxiety in smoking onset, maintenance, and cessation-related outcomes. Additionally, given the rise in electronic cigarette use, we review the emerging literature on the influence of anxiety on e-cigarette use.

RECENT FINDINGS

Evidence across studies varied as to the role of anxiety or anxiety symptoms in smoking behavior. The most consistent findings suggested that those with anxiety are more likely to be a smoker, supporting a high rate of co-occurrence across these conditions. Less consistent evidence was observed for the association between anxiety and onset, indicators of severity, and cessation outcomes. Although there is robust evidence for an association between smoking and anxiety, there were considerable discrepancies for the precise role of anxiety in smoking onset, severity, and cessation outcomes. Future work utilizing more sophisticated methodologies is needed to identify causal relations as well as putative moderators and mediators of the anxiety-smoking relation.

Predictors of client retention in a state-based tobacco quitline

Introduction

Quitlines are standard care for smoking cessation; however, retaining clients in services is a problem. Little is known about factors that may predict dropout.

Aims

To examine predictors of retention while in-program and at follow-up for clients enrolling in a state quitline.

Methods

This was a retrospective analysis of quitline enrolled clients from 2011 to 2017 (N = 49,347). Client retention in-program was categorized as (a) low adherence to treatment (receiving zero coaching calls), moderate (1–2 calls), and high adherence (3+ calls). Dropout at follow-up included participants who were not reached for the 7-month follow-up.

Results

More than half the sample dropped out during treatment; 61% were not reached for follow-up. Women (odds ratio (OR) = 1.21; 95% confidence interval (CI) = [1.16, 127]) and those with high levels of nicotine dependence (OR = 1.03; 95% CI = [1.02, 1.04]) were more likely to have moderate adherence to treatment (1–2 coaching calls). Dropout at follow-up was more likely among clients who used nicotine replacement therapy (OR = 1.14; 95% CI = [1.09, 1.19]) and less likely among those who had high treatment adherence (OR = 0.41; 95% CI = [0.39, 0.42]).

Conclusion

Given the relapsing nature of tobacco use and the harms related to tobacco use, quitlines can improve their impact by offering tailored services to enhance client engagement and retention in-treatment and at follow-up.

Enhancing panic and smoking reduction treatment with D-Cycloserine: A pilot randomized clinical trial

In this placebo-controlled randomized clinical trial, we examined the efficacy of 250 mg d-cycloserine (DCS) for enhancing the effects of cognitive behavior therapy targeting anxiety sensitivity reduction in the context of smoking cessation treatment among adults with a history of panic attacks. We hypothesized that DCS would enhance treatment of our mechanistic targets-anxiety sensitivity and panic and related symptoms-and result in greater smoking abstinence. A total of 53 smokers were randomized to a 7-week integrated treatment and received study medication (DCS or placebo) prior to sessions 3-5; these sessions emphasized interoceptive exposure practice. Nicotine replacement therapy was initiated at session 5 (quit date). We found that DCS augmentation led to greater reductions of one (anxiety sensitivity) of two of our mechanistic targets at early but not late assessments, and that engaging that target predicted better smoking outcomes. However, there was no evidence of group (DCS vs. placebo) differences in smoking cessation success at treatment endpoint or follow-up evaluations. Hence, although we found that DCS can enhance treatment targeting a smoking maintaining factor, additional strategies appear to be needed to significantly affect smoking outcomes.

Factors associated with tobacco cessation attempts among inpatients in a psychiatric hospital

Introduction

Several effective evidence-based tobacco treatment approaches can optimize cessation attempts; however, little is known about the utilization of such strategies by people with mental illnesses (MI) during their cessation attempts.

Aims

To examine methods used during and factors associated with tobacco cessation attempts among people with MI.

Methods

Self-administered cross-sectional survey data were obtained from 132 tobacco using inpatients from a psychiatric facility in Kentucky, USA.

Results

Our study found ‘cold turkey’ as the most reported method by inpatient tobacco users with MI in their prior cessation attempts regardless of the psychiatric diagnosis category. Multivariate logistic regression found ethnicity (OR 26.1; 95% CI 2.9–237.1), age at 1st smoke (OR 1.1; 95% CI 1.0–1.1), importance to quit (OR 1.2; 95% CI 1.0–1.4), and receipt of brief tobacco treatment interventions (OR 1.1; 95% CI 1.0–1.3) significantly associated with quit attempt in the past year.

Conclusion

Despite the existence of various evidence-based approaches to enhance tobacco cessation among people with MI, ‘cold-turkey’ was the most preferred method in this sample. In addition, this study highlighted ethnicity, importance to quit, age at 1st smoke, and receipt of brief interventions as important factors to consider when tailoring tobacco cessation in this population. Though ethnicity is a non-modifiable factor, an informed provider may intervene skillfully by addressing socio-cultural barriers specific to an ethnic group. Lower ratings on the motivation ruler and early age of smoking initiation could also inform providers when using motivational interviewing and other evidence-based tobacco-cessation approaches.

Psychiatric comorbidities in a comparative effectiveness smoking cessation trial: Relations with cessation success, treatment response, and relapse risk factors

BACKGROUND

Comorbid psychiatric diagnoses have been shown to predict cessation failure. The relative impact of various diagnoses on cessation and other cessation processes is rarely studied, particularly among a general population. The impact of psychiatric history among primary care patients seeking cessation services on nicotine dependence, cessation outcomes, treatment effects and adherence, and withdrawal symptoms was examined.

METHODS

Secondary data analysis of a multi-site comparative effectiveness smoking cessation trial was conducted. Adult smokers (n  = 1051; 52.5 % Female, 68.1 % white) completed a structured clinical interview at baseline to assess psychiatric diagnostic history (past-year and lifetime). Nicotine dependence was assessed via self-report measures at baseline. Point-prevalence abstinence was assessed at 8 weeks and 6 months post-quit. Withdrawal symptoms were assessed for one week pre- and post-quit using ecological momentary assessment. Treatment adherence was self-reported at 1, 4, 8, and 12 weeks post-quit.

RESULTS

Past-year substance use disorder, lifetime mood disorder, and > one lifetime diagnosis, were related to lower rates of short-term, but not long-term, cessation. Lifetime psychiatric diagnosis was related to elevated nicotine dependence, particularly to secondary dependence motives associated with instrumental tobacco use. History of psychiatric diagnosis was associated with increased withdrawal-related craving. There was little evidence that psychiatric diagnostic status moderated the effects of the tested pharmacotherapies on long-term abstinence.

CONCLUSIONS

Psychiatric diagnoses affect risk factors that exert their effects early in the post-quit process and highlight the potential utility of examining transdiagnostic risk factors to better understand the relations between psychiatric vulnerabilities and the smoking cessation process.

Acute Effects of Aerobic Exercise on Affect and Smoking Craving in the Weeks Before and After a Cessation Attempt

Introduction

Aerobic exercise may improve smoking abstinence via reductions in craving and negative affect and increases in positive moods. Acute changes in craving and affect before and after structured exercise sessions have not been examined during the weeks prior to and following quit attempts nor has smoking status been examined in relation to these effects. Given that regular cigarette smoking can be perceived as affect enhancing and craving reducing, it is not known whether exercise could contribute additional affective benefit beyond these effects.

Method

Participants (N = 57; 68.4% women) were low-active daily smokers randomized to cessation treatments plus either group-based aerobic exercise (AE) or a health-education control (HEC). Mood, anxiety, and craving were assessed before and after each intervention session for each of the 12 weeks. Carbon monoxide (CO) breath samples ≤ 5ppm indicated smoking abstinence.

Results

During the prequit sessions, significantly greater decreases in anxiety following AE sessions relative to HEC sessions were observed. Changes in mood and craving were similar after AE and HEC sessions prior to quitting. Postquit attempt, significant reductions in craving and anxiety were observed after AE sessions but not following HEC. During the postquit period, positive mood increased following AE sessions relative to HEC only among individuals who were abstinence on that day.

Conclusions

AE may be effective in acutely reducing anxiety prior to a quit attempt and both anxiety and craving following the quit attempt regardless of abstinence status. The mood-enhancing effects of AE may occur only in the context of smoking abstinence.

Implications

The current findings underscore the importance of examining the acute effects of aerobic exercise prior to and after a cessation attempt and as a function of smoking status. Given the equivocal results from previous studies on the efficacy of exercise for smoking cessation, increasing our understanding of how aerobic exercise produces its reinforcing benefits for smokers attempting to quit could potentially inform the refinement (e.g., timing/sequencing) of exercise interventions within smoking cessation programs.

Oral and dental health status in patients with eating disorders in Madrid, Spain

Background

The aim of the present study was to describe and compare the oral and dental health status of two groups, one diagnosed with eating disorders (EDs), and another group without this pathology, assessing the following oral manifestations: dental alterations, periodontal disorders, soft tissue disorders, non-stimulated salivary flow, and oral pH.

Material and Methods

This comparative transversal epidemiological study included 179 participants, of whom 59 were diagnosed with EDs (Eating Disorder Group: EDG) and 120 had no antecedents of EDs (No Eating Disorder Group: NEDG). All patients fulfilled the following inclusion criteria: women aged over 18 years, diagnosed with an ED by a specialist, patients who had undergone at least 1 year monitoring by the Clinical Nutrition Unit, and had not received any periodontal treatment during the previous 6 months. Both groups were homogeneous in terms of sex, age, education, and socioeconomic level. Oral exploration was performed, registering clinical variables, as well as sociodemographic and socioeconomic data, oral hygiene habits, and smoking. Statistical significance was established as p<0.05 (confidence level > 95%).

Results

The dental erosion (DE) was the most significative feature of dental alterations. The degree of DE was significantly greater in the EDG (p<0.001). A significant association between soft tissue lesions and EDs was found (p<0.001) A notable difference in non-stimulated salivary flow was found between the groups (p<0.001). No significant differences between the groups were found for periodontal status, dental caries, or oral hygiene practices.

Conclusions

On the basis of the results obtained, it is necessary to carry out oral/dental examination as soon as an ED is diagnosed with regular check-ups thereafter.

Key words:Eating disorders, anorexia nervosa, bulimia nervosa, oral health, dental erosion.

Integrated Cognitive Behavioral Therapy for Anxiety and Smoking Cessation

Smokers suffer from high rates of anxiety disorders, presumably because some individuals with anxiety disorders rely on smoking as a maladaptive attempt to manage anxiety. Cognitive behavioral therapy (CBT) is an efficacious smoking cessation treatment, yet outcomes are worse for patients with elevated anxiety. The integration of CBT for smoking cessation with False Safety Behavior Elimination Therapy (FSET) may be useful with anxious smoking cessation patients, as smoking to manage anxiety and associated negative affect can be targeted as a false safety behavior (i.e., behavior aimed at decreasing anxiety in the short-term but which may maintain or exacerbate it in the long-term). Here, we describe the integrated treatment, Treatment for Anxiety and Smoking Cessation (TASC), and the successful use of it with two smoking cessation patients—one with comorbid generalized anxiety disorder (GAD) and one with clinically elevated social anxiety that did not meet diagnostic threshold for an anxiety disorder. Data support the feasibility of TASC as a viable approach to smoking cessation treatment for patients with comorbid anxiety disorder and with elevated anxiety that does not meet diagnostic threshold. Future controlled trials are now warranted to further evaluate the intervention.

Tobacco Use and Cognitive Functioning in Veterans of the Conflicts in Iraq and Afghanistan

Tobacco use is a prevalent problem in the general population as well as among military veterans. Despite the fact that tobacco users are at an increased risk of many medical and psychiatric comorbidities, the risk of cognitive impairment in younger active tobacco users is less studied. Military veterans from the conflicts in Iraq and Afghanistan (n = 113) were administered a neuropsychological protocol. Even after controlling for the severity of PTSD symptoms, tobacco use was negatively related to performance on measures of processing speed, memory, and executive functioning. The current findings have implications for the neuropsychological evaluation of tobacco users.

Anxiety Sensitivity is Associated with Lower Enjoyment and an Anxiogenic Response to Physical Activity in Smokers

Background

The subjective affective response to, and enjoyment of, physical activity are strong predictors of engagement in physical activity. Anxiety sensitivity, the fear of bodily sensations, is a cognitive factor that may inhibit the pleasurable affective experience of physical activity, possibly contributing to low levels of physical activity. The current study evaluated anxiety sensitivity in relation to PA enjoyment and affective experience before and after exercise in smokers.

Method

Participants were low-active treatment-seeking smokers (n = 201) enrolled in a smoking cessation intervention. At baseline, participants completed self -report assessments of anxiety sensitivity, cigarette dependence, and physical activity enjoyment. State affect was also reported before and after a submaximal exercise test to index pre-exercise activity affect and affective response to exercise.

Results

Anxiety sensitivity was significantly negatively correlated with physical activity enjoyment, specifically lower enjoyable physical feelings of physical activity. Anxiety sensitivity was significantly correlated with lower state mood and higher state anxiety prior to the submaximal exercise test, and higher anxiety immediately after the exercise test. Additionally, anxiety sensitivity predicted increased anxiety, but not lower mood, in response to the submaximal exercise test.

Conclusions

This is the first study to document an association of anxiety sensitivity with affective determinants of physical activity behavior in smokers. Anxiety sensitivity was associated with lower physical activity enjoyment, higher negative affect prior to after exercise testing, and an anxiogenic response to exercise. Future work is needed to understand how the current findings generalize beyond smokers.

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

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

Perceived cancer-related benefits of quitting smoking and associations with quit intentions among recently diagnosed cancer patients

One third of smokers diagnosed with cancer continue smoking, perhaps due to low perceived cancer-related benefits of cessation. To examine perceived cancer-related benefits of quitting among newly diagnosed cancer patients who smoke and associations with quit intentions, baseline measures from patients (N = 303) enrolled in a randomized controlled trial were analyzed using hierarchical regression models and bootstrapping. Higher perceived cancer-related benefits of quitting were associated with having a smoking-related cancer and less education. Perceived cancer-related benefits of quitting and quit intentions were positively correlated, particularly among patients with smoking-related cancers. For smokers with smoking-related cancers, perceived cancer-related benefits of quitting are correlated with quit intentions.

Co-use of Electronic Nicotine Delivery Systems and Combustible Cigarettes, and Their Association with Internalizing Pathology and Vulnerabilities

Nicotine use and psychological distress exert negative bidirectional effects on one another, and are impacted by shared vulnerabilities. Little work has examined the extent to which these relations differ between adult electronic nicotine delivery system (ENDs) users with varied combustible cigarette use histories. The current study examined differences in internalizing symptoms and vulnerabilities between adult dual and single ENDs users with and without a history of combustible cigarette use. Single ENDs users without combustible use histories reported significantly greater stress and anxiety symptoms than single ENDs users with combustible use histories. Single ENDs users without combustible use histories reported greater anxiety and difficulty regulating their emotions than dual-users. Dual-and single users with prior combustible use histories did not differ in internalizing pathology or vulnerability presentations. This suggests that pathology and vulnerability presentation among nicotine users are influenced by both current and past nicotine use history.

Worry, anxiety sensitivity, and electronic cigarettes among adults

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

Situational fears: Association with negative affect-related smoking cognition among treatment seeking smokers

Despite the consistent clinically-significant relation between smoking and anxiety and its disorders, there is limited understanding of how specific fears relate to smoking processes. To isolate therapeutic targets for smoking-anxiety treatment development, there is a need to identify the underlying situational fears most related to smoking processes. Thus, the present study examined the association between interoceptive, agoraphobic, and social fears in terms of clinically significant negative affect-related smoking cognitions including negative affect reduction expectancies, coping motives, and perceived internal barriers to cessation. Participants were 469 treatment seeking smokers (48.2% female, Mage = 36.59, SD = 13.58) enrolled in a smoking cessation trial and completed baseline measures of smoking cognitions and situational fears. Results indicated that the there was a significant effect for social fears, relative to interoceptive and agoraphobic fears, for each of the studied clinically relevant smoking variables. Overall, this study offers initial empirical evidence that social fears are significantly and consistently related to several clinically-significant types of smoking cognition.

Effects of behavioural activation on substance use and depression: a systematic review

INTRODUCTION

Substance use and depression co-occurrence is a frequent phenomenon and an important public health concern. Given the clinical implications and the high prevalence of both disorders, effective interventions are needed.

METHODS

The aim of this study is to review Behavioural Activation (BA) intervention effects to improve substance use behaviour and depression. A systematic review was conducted using MEDLINE, EMBASE, and PsycINFO. The Effective Public Health Practice Project Quality Assessment Tool (EPHPP) was used to assess the methodological quality of included studies. Two authors independently screened titles and abstracts, reviewed selected studies, and extracted data.

RESULTS

Of the 7286 studies identified, eight met inclusion criteria. Designs of the studies included six randomized controlled trials (RCTs), and two pre-post design studies. One trial received weak methodological quality, six moderate, and one strong. Three studies addressed smoking behaviour; two targeted opiate dependence; two focused on alcohol/drug dependence; and, one on crystal methamphetamine abuse. Results showed that BA had a positive effect on substance use outcomes in seven of the eight reviewed studies, and improved depression over time in six studies.

CONCLUSIONS

Although studies conducted so far are limited by their heterogeneity and sample sizes, results are promising. There is a need of well controlled and powered studies to establish and to confirm the effectiveness of BA for the treatment of substance use and depression. Future studies should include stronger methodological designs, larger sample sizes, and long-term follow-ups.

TRIAL REGISTRATION

PROSPERO registration number: CRD42016039412 .

Emotion Regulation Difficulties in Relation to Anxiety, Depression, and Functional Impairment Among Treatment-Seeking Smokers

Psychological distress is elevated among smokers and plays a key role in the maintenance of smoking behavior. Although research has implicated emotion regulation (ER) difficulties as a transdiagnostic construct for psychological distress, empirical work has not yet investigated ER difficulties among treatment-seeking smokers. The purpose of the current study was to increase understanding of ER difficulties in relation to depression, anxious arousal, and functional impairment among treatment-seeking smokers. Participants included adult daily treatment-seeking smokers (N = 568; Mage = 37, SD = 13.46; 51.9% male). Results indicated that global ER difficulties were significantly related to depression, anxious arousal, and functional impairment. Analyses focused on the lower-order facets of ER and indicated that limited access to ER strategies, difficulty engaging in goal-directed behavior, and lack of emotional clarity were significantly related to depression; limited access to ER strategies, nonacceptance of emotions, and impulsivity were significantly associated with anxious arousal; and limited access to ER strategies and difficulty engaging in goal-directed behavior were significantly related to functional impairment. The significant ER effects were evident above and beyond the variance accounted for by neuroticism and tobacco dependence. These findings highlight the importance of considering ER difficulties to better understand psychological distress among smokers.

Self-perceived Mental Health and Population-level Tobacco Use Disparities

Objectives

Poor mental health is associated with increased cigarette smoking, yet whether this extends to alternative tobacco product use remains unknown.

Methods

Wave 1 data from the Population Assessment of Tobacco and Health study assessed relationships between self-perceived mental health (SPMH) and prevalence of and motives for tobacco use among US adults (N = 32,320).

Results

Fair/poor SPMH, as compared to good/excellent SPMH, was associated with increased current cigarette (AOR = 2.91, 95% CI = 2.64, 3.20), e-cigarette (AOR = 1.35, 95% CI = 1.20, 1.53), cigarillo (AOR = 1.38, 95% CI = 1.22, 1.56), filtered cigar (AOR = 1.43, 95% CI = 1.21, 1.70), and smokeless tobacco (AOR = 1.17, 95% CI = 1.01, 1.36), but not traditional cigar use (AOR = 1.04, 95% CI = 0.90, 1.20). Whereas most motives for tobacco use were similar across SPMH rating, those with fair/poor SPMH, as compared to good/excellent SPMH, were more likely to report using traditional cigars due to affordability (AOR = 1.56, 95% CI = 1.23, 1.98) and e-cigarettes (AOR = 1.43, 95% CI = 1.15, 1.79) and smokeless tobacco (AOR = 1.84, 95% CI = 1.19, 2.83) due to appealing advertising.

Conclusions

Although individuals with poor SPMH are more likely to use alternative tobacco products than those with better SPMH, most motives for use are strikingly similar. These findings highlight the importance of continual monitoring of tobacco use trends among vulnerable populations.

Positive Affect as a Predictor of Smoking Cessation and Relapse: Does It Offer Unique Predictive Value among Depressive Symptom Domains?

BACKGROUND

Prior studies have suggested that, among the domains of depressive symptoms, low positive affect (PA) may have a distinct relationship with smoking cessation and relapse. However, the empirical basis for PA-focused interventions cessation is limited, with some mixed findings.

OBJECTIVES

Using a large, diverse sample of treatment-seeking smokers, this study tested the hypothesis that PA adds unique predictive value beyond the effects of the other symptom domains in models of cessation and relapse.

METHODS

Adult smokers participating in a smoking cessation trial (n = 450) were included in this post hoc analysis. Cessation outcomes included smoking abstinence at end of treatment and at 6-month follow-up. Relapse was defined as recurrence of smoking at 6-month follow-up among the end-of-treatment abstainers. Depressive symptoms were assessed at baseline using the Center for Epidemiologic Studies-Depression (CES-D) scale.

RESULTS

With the exception of PA, all of the CES-D domains predicted reduced likelihood of smoking abstinence at end of treatment and cotinine-confirmed (but not self-reported) abstinence at 6 months, as did total CES-D score (all p-values < .05). None of the symptom domains predicted relapse. Conclusions/Importance: Our results provide further evidence that current depressive symptoms predict worse cessation outcomes, but they fail to support recent work suggesting that low PA has incremental predictive value for cessation or relapse beyond the other depressive symptom domains. To improve quit rates for smokers with depressive symptoms, evidence-based mood management interventions should be included in treatment planning.

Direct and Indirect Effects of Psychological Distress on Stress-Induced Smoking

OBJECTIVE

Numerous studies have modeled the effects of stress in the laboratory, demonstrating that smokers who are exposed to experimental stressors exhibit significant increases in acute psychological distress. Whether these stress reactions are predictive of stress-induced smoking during an actual quit attempt, however, has not been examined. Furthermore, the possibility that such effects are particularly strong among smokers with higher ambient levels of distress has not been addressed.

METHOD

Nicotine-dependent smokers (N = 60; 40 women, 20 men) completed the Brief Symptoms Index (BSI) and then participated in a laboratory stress task 1 week before a quit attempt. Acute psychological distress was measured immediately before and after exposure to stressful and neutral stimuli. After they quit, participants completed a smoking diary for 14 days in which they recorded the degree to which their smoking was precipitated by emotional stress.

RESULTS

Consistent with our hypotheses, BSI scores predicted both exaggerated laboratory stress responses (p < .005) and smoking that was attributable to stress during the 14-day postquit period (p < .01). Laboratory stress reactions were predictive of stress-induced smoking (p < .01), and acute psychological stress reactions mediated the effects of BSI on stress-induced smoking.

CONCLUSIONS

Acute psychological stress reactivity is a potential mechanism underlying the effect of stress-induced smoking during a quit attempt.

Offer and Use of Smoking-Cessation Support by Depression/Anxiety Status: A Cross-Sectional Survey

Introduction: Higher levels of anxiety and depression have been found to be associated with greater difficulty in stopping smoking. This raises the question as to whether mood disturbance may be associated with exposure to, and use of, quitting support.

Aims: This study examined whether General Practitioner (GP) advice and/or offer of support, or stop-smoking service use differed between smokers reporting or not reporting depression/anxiety.

Methods: Data came from the Smoking Toolkit Study. Participants were 1,162 English adults who reported currently smoking or having stopped within the past 12 months, aged 40+ years, surveyed between April and September 2012. Anxiety/depression was assessed by the mood disturbance item of the EuroQol five dimensions questionnaire (EQ-5D). This was compared to recall of GP quit advice and/or support, and stop-smoking aid use adjusting for age, gender, and social grade.

Results/Findings: Smokers reporting depression/anxiety were more likely to recall being offered advice and support to stop smoking by their GP (OR = 1.50, 95% C.I. = 1.05–2.13). However, there were no significant differences in use of stop-smoking aids during the past year.

Conclusions: Smokers reporting depression/anxiety are more likely to be offered stop-smoking support by their GPs, but this does not appear to translate into stop-smoking aid use, despite high motivation to quit. Given higher nicotine dependence in this group, mental health specific support may need to be offered, and more needs to be done to make this offer of aid attractive.

Anhedonia and Abstinence as Predictors of the Subjective Pleasantness of Positive, Negative, and Smoking-Related Pictures

Introduction

Anhedonia-diminished interest or pleasure in response to rewards-is a dimension implicated in several psychiatric disorders linked to smoking. This laboratory study sought to identify motivational mechanisms linking anhedonia and tobacco addiction by testing the hypothesis that anhedonia, abstinence, and their interaction would predict excesses and deficits in the perceived pleasantness of smoking-related and positive pictures, respectively. We assessed the pleasantness of negative pictures as a secondary outcome.

Methods

After a baseline session involving self-report measures of anhedonia and other factors, 125 regular smokers attended two counterbalanced experimental sessions (overnight abstinent and non-abstinent) at which they rated the pleasantness of positive, smoking-related, negative, and neutral (control) pictures presented via computer. The difference in pleasantness ratings of positive, smoking-related, and negative pictures relative to neutral pictures served as the index of participants' appraisal of the motivational salience of nondrug reward, drug reward, and aversive signals, respectively.

Results

With and without adjusting for sex and depressive symptoms, greater anhedonia significantly or marginally predicted greater pleasantness of smoking (vs. neutral), lower pleasantness of positive (vs. neutral), less unpleasantness of negative (vs. neutral) pictures (|βs| = 0.18 to 0.35, ps = .007 to .07). Anhedonia by abstinence interaction effects on pleasantness ratings of each stimulus category (vs. neutral) were not significant (|βs| ≤ 0.02, ps ≥ .36).

Conclusions

Anhedonia and abstinence additively increase the salience of smoking-related cues in anhedonic smokers. Smoking cessation efforts that attenuate sensitization to smoking stimuli may benefit anhedonic smokers early in quit attempts.

Implications

Taken together, these findings provide tentative evidence that anhedonia is associated with a relative imbalance in the motivational salience of drug relative to nondrug rewards and may be associated with a generalized hypo-reactivity to both positive and negative stimuli. Though some prior smoking research has evidenced this relative imbalance in anhedonia with self-report or a smoking-choice task, we additionally show that this pattern may extend to hyper-affective reactivity to smoking-related stimuli being coincident with hypo-affective reactivity to nondrug-related positive stimuli (ie, may extend to greater pleasantness ratings of smoking pictures being accompanied by lower pleasantness ratings of positive pictures).

A retrospective analysis of the comparative effectiveness of smoking cessation medication among individuals with mental illness in community-based mental health and addictions treatment settings

WHAT IS KNOWN ON THE SUBJECT?: Persons with different mental illnesses smoke for reasons based on their particular diagnosis. As compared to those without, persons with mental illnesses are less able to quit smoking when using smoking cessation medications. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper shows that there may be differences in the ability to quit smoking between persons with different mental illness diagnoses. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Clinicians should be aware that persons with anxiety disorders may find it more difficult to quit smoking as compared to those with other mental illnesses. Clinicians should be aware that of all medications, varenicline seems to help those with mood disorders to quit the best. Clinicians should be aware that persons with psychotic disorders likely need longer treatment durations for smoking cessation as compared to persons with other mental illnesses.

ABSTRACT

Introduction Individuals with mental illnesses (MI) have diagnosis-specific reasons for smoking and achieve low smoking cessation when using cessation medications. Aim To assess differences in smoking cessation outcomes by MI diagnosis and cessation medications in outpatient mental health and addictions treatment settings in Vancouver, Canada. Method This is a retrospective analysis of tobacco treatment outcomes from 539 participants. The programme consists of cessation pharmacotherapy with 8 to 12 weeks of behavioural counselling and 12 weeks of support group. Smoking cessation was verified by expired carbon monoxide levels. Generalized estimating equations models assessed differences in cessation by type of medication in both total and stratified samples. Results There were no significant differences in cessation by pharmacotherapy in the total sample. Individuals with a mood disorder were two times more likely to achieve cessation as compared to those with an anxiety disorder. Among individuals with mood disorders, receiving varenicline alone resulted in three times the likelihood of cessation as compared to receiving single NRT. Discussion The differences in outcomes by MI diagnosis suggest the need for more diagnosis-specific approaches to optimize cessation. Implications for Practice Compared with other diagnoses, persons with anxiety disorders may have a greater challenge quitting and those with a psychotic disorder may require longer treatment durations.

Psychopathology and tobacco demand

INTRODUCTION

Behavioral economic measurement of the relative value of tobacco (Cigarette Purchase Task; CPT) is used to examine individual differences in motivation for tobacco under certain contexts. Smokers with psychopathology, relative to those without, may demonstrate stronger demand for tobacco following a period of smoking deprivation, which could account for disparate rates of smoking and cessation among this subgroup.

METHOD

Participants (n=111) were community-recruited adult daily smokers who completed the CPT after a deprivation period of approximately 60min. Presence of psychopathology was assessed via clinical interview; 40.5% (n=45) of the sample met criteria for past-year psychological diagnosis. Specifically, 31.5% (n=35) had an emotional disorder (anxiety/depressive disorder), 17.1% (n=19) had a substance use disorder, and 19.1% of the sample had more than one disorder.

RESULTS

Smokers with any psychopathology showed significantly higher intensity (demand at unrestricted cost; $0) and O_max (peak expenditure for a drug) relative to smokers with no psychopathology. Intensity was significantly higher among smokers with an emotional disorder compared to those without. Smokers with a substance use disorder showed significantly higher intensity and O_max, and lower elasticity, reflecting greater insensitivity to price increases. Having≥2 disorders was associated with higher intensity relative to having 1 or no disorders.

DISCUSSION

Findings suggest that presence of psychopathology may be associated with greater and more persistent motivation to smoke. Future work is needed to explore the mechanism linking psychopathology to tobacco demand.

Anxiety sensitivity explains associations between anxious arousal symptoms and smoking abstinence expectancies, perceived barriers to cessation, and problems experienced during past quit attempts among low-income smokers

Disproportionately more smokers report low-income and mental health problems relative to non-smokers. Low-income smokers may use smoking to alleviate negative emotional states resulting from exposure to multiple stressors. Yet, little work has been devoted to elucidating mechanisms that may explain the association between negative emotional states and smoking-related processes among low-income smokers. The present study sought to address this gap by examining anxiety sensitivity, a transdiagnostic factor related to both anxiety and smoking, as a potential mediator for the influence of anxiety symptoms on smoking-related processes, including threat-related smoking abstinence expectancies (somatic symptoms and harmful consequences), perceived barriers for cessation, and problems experienced during past quit attempts. Participants included treatment-seeking daily cigarette smokers (n=101; 68.3% male; Mage=47.1; SD=10.2). Results indicated that anxiety symptoms exerted a significant indirect effect through anxiety sensitivity for threat-related smoking abstinence expectancies (somatic symptoms and harmful consequences), perceived barriers for cessation, and problems experienced during past quit attempts. The present results provide empirical support that anxiety sensitivity may be an underlying mechanism that partially explains the relation between anxiety symptoms and smoking processes among low-income treatment-seeking smokers. Findings broaden current theoretical understanding of pathways through which anxiety symptoms contribute to maladaptive smoking processes and cognitions among socioeconomically disadvantaged smokers.

Cognitive-behavioral treatment with behavioral activation for smokers with depressive symptomatology: study protocol of a randomized controlled trial

BACKGROUND

Smoking is an important risk factor for mental health-related problems. Numerous studies have supported a bi-directional association between cigarette smoking and depression. Despite the advances in understanding the comorbidity between both problems, the most effective psychological treatment that simultaneously targets smoking and depressive symptomatology remains unclear. The objective of this study is to assess the effectiveness of a cognitive-behavioral intervention for smoking cessation with components of behavioral activation for managing depressed mood.

METHOD

A single blind, three-arm, superiority randomized controlled trial is proposed. Participants will be smokers over 18 years old, who smoke at least 8 cigarettes per day. Participants will be randomized to one of three conditions, using a 2:2:1 allocation ratio: 1) standard cognitive-behavioral smoking cessation treatment; 2) standard cognitive-behavioral smoking cessation treatment plus behavioral activation; or 3) a three-month delayed treatment control group. The primary outcome measures will be biochemically verified point-prevalence abstinence (carbon monoxide in expired air) and significant change from baseline in depressive symptoms to the end of treatment, and at the 3-, 6-, and 12-month follow-up.

DISCUSSION

This study aims to assess the efficacy of a cognitive-behavioral intervention with behavioral activation components for smoking cessation and depressive symptoms, compared to a standard cognitive-behavioral intervention to quit smoking. As the relation between depressive symptoms, even at subclinical levels, and quitting smoking difficulties is well known, we expect that such intervention will allow obtaining higher abstinence rates, lower relapse rates, and mood improvement.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02844595 . Retrospectively registered 19th July, 2016. The study started in January 2016, and the recruitment is ongoing.

Toward precision smoking cessation treatment I: Moderator results from a factorial experiment

BACKGROUND

The development of tobacco use treatments that are effective for all smokers is critical to improving clinical and public health. The Multiphase Optimization Strategy (MOST) uses highly efficient factorial experiments to evaluate multiple intervention components for possible inclusion in an optimized tobacco use treatment. Factorial experiments permit analyses of the influence of patient characteristics on main and interaction effects of multiple, relatively discrete, intervention components. This study examined whether person-factor and smoking characteristics moderated the main or interactive effects of intervention components on 26-week self-reported abstinence rates.

METHODS

This fractional factorial experiment evaluated six smoking cessation intervention components among primary care patients (N=637): Prequit Nicotine Patch vs. None, Prequit Nicotine Gum vs. None, Preparation Counseling vs. None, Intensive Cessation In-Person Counseling vs. Minimal, Intensive Cessation Telephone Counseling vs. Minimal, and 16 vs. 8 Weeks of Combination Nicotine Replacement Therapy (NRT; nicotine patch+nicotine gum).

RESULTS

Both psychiatric history and smoking heaviness moderated intervention component effects. In comparison with participants with no self-reported history of a psychiatric disorder, those with a positive history showed better response to 16- vs. 8-weeks of combination NRT, but a poorer response to counseling interventions. Also, in contrast to light smokers, heavier smokers showed a poorer response to counseling interventions.

CONCLUSIONS

Heavy smokers and those with psychiatric histories demonstrated a differential response to intervention components. This research illustrates the use of factorial designs to examine the interactions between person characteristics and relatively discrete intervention components. Future research is needed to replicate these findings.

Correlates of nicotine withdrawal severity in smokers during a smoke-free psychiatric hospitalization

Psychiatric hospitals are increasingly adopting smoke-free policies. Tobacco use is common among persons with mental illness, and nicotine withdrawal (NW), which includes symptoms of depression, anxiety, anger/irritability, and sleep disturbance, may confound psychiatric assessment and treatment in the inpatient setting. This study aimed to characterize NW and correlates of NW severity in a sample of smokers hospitalized for treatment of mental illness in California. Participants (N=754) were enrolled between 2009 and 2013, and averaged 17 (SD=10) cigarettes/day prior to hospitalization. Though most (70%) received nicotine replacement therapy (NRT) during hospitalization, a majority (65%) reported experiencing moderate to severe NW. In a general linear regression model, NW symptoms were more severe for women, African American patients, and polysubstance abusers. Though invariant by psychiatric diagnostic category, greater NW was associated with more severe overall psychopathology and greater cigarette dependence. The full model explained 46% of the total variation in NW symptom severity (F [19, 470]=23.03 p<0.001). A minority of participants (13%) refused NRT during hospitalization. Those who refused NRT reported milder cigarette dependence and stated no prior use of NRT. Among smokers hospitalized for mental illness, NW severity appears multidetermined, related to cigarette dependence, demographic variables, psychiatric symptom severity, and other substance use. Assessment and treatment of NW in the psychiatric hospital is clinically warranted and with extra attention to groups that may be more vulnerable or naïve to cessation pharmacotherapy.