Associations between smoking and psychiatric comorbidity in U.S. Iraq- and Afghanistan-era veterans

Tobacco use, trauma exposure and PTSD: a systematic review

Tobacco use remains one of the most significant preventable public health problems globally and is increasingly concentrated among vulnerable groups, including those with trauma exposure or diagnosed with PTSD. The goal of this systematic review was to update and extend previous reviews. Of the 7224 publications that met the initial criteria, 267 were included in the review. Summary topic areas include conceptual frameworks for the relation between trauma or PTSD and tobacco use; associations between trauma exposure or PTSD and tobacco use; number and type of trauma exposures and tobacco use; PTSD symptoms and tobacco use; Treatment-related studies; and the examination of causal relations. Evidence continues to indicate that individuals exposed to trauma or diagnosed with PTSD are more likely to use tobacco products, more nicotine dependent and less likely to abstain from tobacco even when provided evidence-based treatments than individuals without trauma. The most commonly cited causal association proposed was use of tobacco for self-regulation of negative affect associated with trauma. A small proportion of the studies addressed causality and mechanisms of action. Future work should incorporate methodological approaches and measures from which we can draw causal conclusions and mechanisms to support the development of viable therapeutic targets.

Cigarette Smoking and Depression Among U.S. Veterans: Longitudinal Associations With Posttraumatic Stress Disorder

INTRODUCTION

Cigarette smoking and depression are associated with morbidity and mortality. Among veterans, approximately 22% are current smokers and 11%-15% have been diagnosed with depression. Although prior research suggests a strong association between smoking and depression among veterans, little research has examined trajectories of smoking and depressive symptoms and their correlates over time in this population.

AIMS AND METHODS

Using parallel process growth curve modeling, we examined the longitudinal relationship between smoking and depression and tested whether posttraumatic stress disorder (PTSD) symptoms predict smoking and depression trajectories over 18 months (February 2020-August 2021). Veterans were recruited for an online, longitudinal study and responded to surveys across five-time points (baseline N = 1230; retention = 79.3%-83.3% across waves).

RESULTS

Associations indicated that more frequent smoking at baseline was associated with steeper increases in depression symptom severity, and greater depression severity at baseline was associated with a less steep decrease in smoking frequency over time. PTSD was associated with less smoking at time 1 but more frequent smoking at times 3-5 as well as greater depression across all time points.

CONCLUSIONS

Findings provide support that the growth trajectories of smoking and depression are linked, and PTSD symptoms are associated with these trajectories among veterans. Addressing these factors simultaneously in veteran treatment centers or through tobacco cessation efforts may be beneficial.

IMPLICATIONS

This study offers strong evidence that the growth trajectories of smoking and depression are linked, and PTSD symptoms affect these trajectories among veterans, who represent a largely understudied population despite high rates of substance use and mental health problems. Results of this study strengthen the case for a more integrated treatment approach in which both smoking and mental health concerns are simultaneously addressed, which may yield more beneficial physical health and clinical outcomes for post-9/11 veterans.

A Qualitative Exploration of the Use of Service Dogs in Veterans with Post Traumatic Stress Disorder and Traumatic Brain Injury

Objective

This qualitative research was conducted to add to the body of knowledge that supports the benefits of service dogs (SDs), as a tertiary treatment modality, to veterans with post-traumatic stress disorder (PTSD) and/or traumatic brain injury (TBI).

Methods

This grounded theory research design utilized open-ended, semi-structured interviews with veterans (n = 10) who were using SDs as a treatment modality for PTSD and/or TBI. Transcripts were analyzed using NVivo qualitative software until data saturation was achieved.

Results

Results from the data analysis identified 4 major themes with concurrent subthemes. The most prominent themes were functional status, impact of a SD, recognition of symptoms of PTSD and/or TBI by the SD, and barriers and challenges to the acquisition of a SD. Participants reported that the SD increased socialization and was a positive adjunct to treatment modalities for PTSD and/or TBI.

Conclusions

Our study highlights the benefits of using a SD as a tertiary treatment for PTSD and/or TBI in veterans. Veterans in our study articulated the benefits of using a SD as a tertiary treatment option, and the need to make this a standard treatment option for all veterans who suffer from PTSD and/or TBI.

Co-use of Tobacco Products and Cannabis among Veterans: A Preliminary Investigation of Prevalence and Associations with Mental Health Outcomes

While tobacco product (such as combustible cigarettes and nicotine vaping products) and cannabis use rates remain high in the general United States (U.S.) population, veterans from the conflicts in Iraq and Afghanistan (i.e., OEF/OIF veterans) are at high risk of high rates of cannabis and tobacco use. Co-use of tobacco and cannabis (i.e., using both substances within a specified period of time or combining the drugs within the same device for use) is of growing prevalence in the U.S. However, little is understood about the prevalence rates of tobacco and cannabis co-use among U.S. veterans and its associations with mental health symptomatology. The current study conducted a preliminary analysis of co-use patterns of tobacco and cannabis and associated mental health outcomes among a sample of OEF/OIF veterans (N = 1,230). Results indicated high rates of lifetime and past 30-day use of both substances. Past 30-day co-users endorsed significantly higher levels of stress, PTSD, depression, and anxiety compared to singular product users. Results suggest that the addition of cannabis use in conjunction with tobacco use may be associated with greater mental health symptoms among veterans. Findings indicate veteran tobacco and cannabis co-users may benefit from mental health care to help mitigate poor mental health symptoms.

Smoking, obesity, and their co-occurrence in the U.S. military veterans: results from the national health and resilience in veterans study

BACKGROUND

Smoking and obesity are major public health concerns, though little is known about the mental and physical health burden of co-occurring obesity and smoking.

METHODS

Using a nationally representative sample of U.S. military veterans, we examined the prevalence of mental and physical co-morbidities, physical and mental functioning, and quality of life between obese only; smoking only; and obese smokers.

RESULTS

Among current smokers, 31.7% were obese; among obese veterans, 16.4% were current smokers; and in the total sample, 5.4% were obese and current smokers. Relative to the obese-only group, obese smokers were more likely to be younger, male, non-white, non-married, unemployed and VA-served, and have lower household incomes. These also reported higher levels of perceived stress and trauma and were more likely to endorsed current suicidal ideation and lifetime suicide attempts (odds ratio [OR]=2.0), medical (2.3<=OR<=3.9) and psychiatric (1.5<=OR<=2.9) comorbidities, and lower overall health status and quality of life. Compared to the smoking-only group, obese smokers were more likely to endorse current suicidal ideation (OR=2.0) and nicotine dependence (OR=1.5), and reported poorer physical health and overall quality of life. Analyses were adjusted for sociodemographic and military characteristics.

LIMITATIONS

The cross-sectional study design precludes causal inference.

CONCLUSIONS

These findings suggest that co-occurring obesity and smoking is associated with substantial mental and physical health burden in U.S. veterans. Collectively, they underscore the importance of multicomponent interventions targeting, obesity, smoking, and co-occurring issues, such as trauma and internalizing disorders, in this population.

A review of tobacco regulatory science research on vulnerable populations

In 2013 the U.S. Food and Drug Administration and National Institutes of Health established fourteen Tobacco Centers of Regulatory Science (TCORS) to advance scientific knowledge relevant to conducting evidence-based tobacco regulation. This report reviews TCORS-funded research with adult vulnerable populations. The literature search included a list of all TCORS-funded publications compiled by the TCORS coordinating center; all TCORS were requested to share publications not in the coordinating-center's list. Only TCORS-funded reports describing an empirical study with an adult vulnerable population published in a peer-reviewed journal between September 2013 and June 2018 were included. 71 reports met inclusion criteria; 39% (28/71) examined tobacco use among those with mental health and medical comorbidities, 34% (24/71) socioeconomic disadvantage, 31% (22/71) women of reproductive age, 30% (21/71) racial/ethnic minorities, 18% (13/71) rural residents, and 3% (2/71) each among active military/veterans and sexual/gender minorities. Regarding scientific domains, 63% (45/71) investigated behavior, 37% (26/71) addiction, 24% (17/71) health effects, 20% (14/71) impact analyses, 18% (13/71) toxicity, 8% (6/71) marketing influences, and 7% (5/71) communications. Totals exceed 100% because some reports addressed multiple populations/domains. TCORS funding has generated a substantial, multidisciplinary body of new scientific knowledge on tobacco use in adult vulnerable populations. However, considerable variability was noted in the amount of research conducted across the various vulnerable populations and scientific domains. Most notably, relatively few studies focused on active military/veterans or sexual/gender minorities, and the scientific domains of marketing influences and communications were conspicuously underrepresented. These are important knowledge gaps to address going forward.

Cigarette smoking rates among veterans: Association with rurality and psychiatric disorders

AIMS

Compared to the general U.S. population, military veterans and those living in rural areas disproportionately smoke cigarettes at higher rates, leading to increased health consequences. In the current study, prevalence and severity of cigarette smoking in Iraq and Afghanistan era veterans was assessed across rural and urban areas and comorbid mental health disorders.

METHOD

Iraq/Afghanistan era veterans who participated in the Post-Deployment Mental Health study from 2005 to 2017 (N = 3229) were cross-sectionally assessed for the probability of being a current cigarette smoker based on locality status and psychiatric comorbidity. Multivariate logistic and linear regressions, adjusted for demographic characteristics, were used to model the odds of being a current smoker and the severity of nicotine dependence, respectively.

RESULTS

Veterans residing in rural regions, veterans with psychiatric comorbidities, and the interaction of locality and psychiatric disorders were significantly associated with smoking rates. Those veterans living in extremely rural areas and, independently, those living with psychiatric comorbidities were also more severely dependent on nicotine compared to urban veterans and veterans without psychiatric conditions.

CONCLUSIONS

Rural veterans and veterans with psychiatric comorbidities are at increased risk of smoking and are more severely dependent on nicotine than urban veterans. These findings underscore the need to reduce barriers for treatment both for smoking cessation and mental healthcare for veterans residing in the most rural areas.

Posttraumatic stress disorder and tobacco use: A systematic review and meta-analysis

Posttraumatic stress disorder (PTSD) and tobacco use are prevalent conditions that co-occur at striking rates in the US. Previous reviews examined prevalence and factors associated with cigarette smoking among individuals with PTSD but have not been summarized since 2007. Moreover, none explored rates and factors associated with the use of other tobacco products. This study aimed to systematically review the most recent literature examining the comorbidity of PTSD and tobacco use to provide prevalence rates, as well as summarize the literature exploring other factors associated with tobacco use among individuals with PTSD. Studies were identified using a systematic search of keywords related to tobacco use and PTSD within the following databases: PubMed, PsycINFO, Web of Knowledge, CINAHL, PsycARTICLES, and Cochrane Clinical Trials Library. The studies included in this review (N = 66) showed that the prevalence of current use of tobacco products in individuals with PTSD was 24.0% and the rate of PTSD among users of tobacco products was 20.2%. Additionally, results demonstrated that individuals with PTSD present with high levels of nicotine dependence and heavy use of tobacco products, as well as underscore the importance of negative emotional states as a contributing factor to tobacco use among individuals with PTSD. It is imperative that future studies continue monitoring tobacco use among individuals with PTSD while also assessing factors identified as having a prominent role in tobacco use among individuals with PTSD. These findings also demonstrate the need for more innovative approaches to reduce the pervasive tobacco use among individuals with PTSD.

Validation of Veterans Affairs Electronic Medical Record Smoking Data Among Iraq- and Afghanistan-Era Veterans

BACKGROUND

Research using the Veterans Health Administration (VA) electronic medical records (EMR) has been limited by a lack of reliable smoking data.

OBJECTIVE

To evaluate the validity of using VA EMR "Health Factors" data to determine smoking status among veterans with recent military service.

DESIGN

Sensitivity, specificity, area under the receiver-operating curve (AUC), and kappa statistics were used to evaluate concordance between VA EMR smoking status and criterion smoking status.

PARTICIPANTS

Veterans (N = 2025) with service during the wars in Iraq/Afghanistan who participated in the VA Mid-Atlantic Post-Deployment Mental Health (PDMH) Study.

MAIN MEASURES

Criterion smoking status was based on self-report during a confidential study visit. VA EMR smoking status was measured by coding health factors data entries (populated during automated clinical reminders) in three ways: based on the most common health factor, the most recent health factor, and the health factor within 12 months of the criterion smoking status data collection date.

KEY RESULTS

Concordance with PDMH smoking status (current, former, never) was highest when determined by the most commonly observed VA EMR health factor (κ = 0.69) and was not significantly impacted by psychiatric status. Agreement was higher when smoking status was dichotomized: current vs. not current (κ = 0.73; sensitivity = 0.84; specificity = 0.91; AUC = 0.87); ever vs. never (κ = 0.75; sensitivity = 0.85; specificity = 0.90; AUC = 0.87). There were substantial missing Health Factors data when restricting analyses to a 12-month period from the criterion smoking status date. Current smokers had significantly more Health Factors entries compared to never or former smokers.

CONCLUSIONS

The use of computerized tobacco screening data to determine smoking status is valid and feasible. Results indicating that smokers have significantly more health factors entries than non-smokers suggest that caution is warranted when using the EMR to select cases for cohort studies as the risk for selection bias appears high.

The Post-Deployment Mental Health (PDMH) study and repository: A multi-site study of US Afghanistan and Iraq era veterans

The United States (US) Department of Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) Post-Deployment Mental Health (PDMH) multi-site study examines post-deployment mental health in US military Afghanistan/Iraq-era veterans. The study includes the comprehensive behavioral health characterization of over 3600 study participants and the genetic, metabolomic, neurocognitive, and neuroimaging data for many of the participants. The study design also incorporates an infrastructure for a data repository to re-contact participants for follow-up studies. The overwhelming majority (94%) of participants consented to be re-contacted for future studies, and our recently completed feasibility study indicates that 73-83% of these participants could be reached successfully for enrollment into longitudinal follow-up investigations. Longitudinal concurrent cohort follow-up studies will be conducted (5-10+ years post-baseline) to examine predictors of illness chronicity, resilience, recovery, functional outcome, and other variables, and will include neuroimaging, genetic/epigenetic, serum biomarker, and neurocognitive studies, among others. To date, the PDMH study has generated more than 35 publications from the baseline data and the repository has been leveraged in over 20 publications from follow-up studies drawing from this cohort. Limitations that may affect data collection for a longitudinal follow-up study are also presented.

Electronic Cigarette Expectancies in Smokers with Psychological Distress

OBJECTIVES

Very few studies have evaluated perceptions of electronic nicotine delivery systems (ENDS) among smokers with mental illness. This study assessed expectancies about the effects of smoking combustible cigarettes or using ENDS among current smokers with and without severe psychological distress (SPD).

METHODS

We used a crowdsourcing system to survey 268 smokers on their expectancies for the effects of combustible cigarettes and ENDS. Positive expectancies assessed included negative affect reduction, stimulation, positive social effects and weight control, and negative expectancies included negative physical effects, negative psychosocial effects and future health concerns.

RESULTS

Smokers with SPD had higher positive expectancies for weight control and social effects of both products compared to those without such distress, and higher expectancies for stimulation from combustible cigarettes compared to ENDS. All participants had significantly lower negative expectancies for ENDS compared to combustible cigarettes, with no significant differences between the groups.

CONCLUSIONS

Smokers with SPD may be more vulnerable toward ENDS use, as they are for combustible cigarette use, due to greater positive expectancies of the products. Challenging positive expectancies may increase the efficacy of tobacco control efforts in this vulnerable population.

Cigarette Smoking and Sociodemographic, Military, and Health Characteristics of Operation Enduring Freedom and Operation Iraqi Freedom Veterans: 2009-2011 National Health Study for a New Generation of US Veterans

OBJECTIVE

We examined the sociodemographic, military, and health characteristics of current cigarette smokers, former smokers, and nonsmokers among Operation Enduring Freedom (OEF) / Operation Iraqi Freedom (OIF) veterans and estimated smoking prevalence to better understand cigarette use in this population.

METHODS

We analyzed data from the US Department of Veterans Affairs (VA) 2009-2011 National Health Study for a New Generation of US Veterans. On the basis of a stratified random sample of 60 000 OEF/OIF veterans, we sought responses to a 72-item questionnaire via mail, telephone, or Internet. Cigarette smoking status was based on self-reported cigarette use in the past year. We used multinomial logistic regression to evaluate associations between smoking status and sociodemographic, military, and health characteristics.

RESULTS

Among 19 911 veterans who provided information on cigarette smoking, 5581 were current smokers (weighted percentage: 32.5%, 95% confidence interval [CI]: 31.7-33.2). Current smokers were more likely than nonsmokers or former smokers to be younger, to have less education or income, to be separated/divorced or never married/single, and to have served on active duty or in the army. Comparing current smokers and nonsmokers, some significant associations from adjusted analyses included the following: having a Mental Component Summary score (a measure of overall mental health) above the mean of the US population relative to below the mean (adjusted odds ratio [aOR] = 0.81, 95% CI: 0.73-0.90); having physician-diagnosed depression (aOR = 1.52, 95% CI: 1.33-1.74), respiratory conditions (aOR = 1.16, 95% CI: 1.04-1.30), or repeated seizures/blackouts/convulsions (aOR = 1.80, 95% CI: 1.22-2.67); heavy alcohol use vs never use (aOR = 5.49, 95% CI: 4.57-6.59); a poor vs excellent perception of overall health (aOR = 3.79, 95% CI: 2.60-5.52); and being deployed vs nondeployed (aOR = 0.87, 95% CI: 0.78-0.96). Using health care services from the VA protected against current smoking.

CONCLUSION

Mental and physical health, substance use, and military service characteristics shape cigarette-smoking patterns in OEF/OIF veterans.

Multicomponent smoking cessation treatment including mobile contingency management in homeless veterans

INTRODUCTION

Smoking rates are 80% among persons who are homeless, and these smokers have decreased odds of quitting smoking. Little is known about relapse rates among homeless smokers. More information is needed regarding both quit rates and innovative methods to treat smoking cessation among homeless smokers. Web-based contingency management (CM) approaches have been found helpful in reducing smoking among other difficult-to-treat smoker populations but have been generally limited by the need for computers or frequent clinic-based carbon monoxide (CO) monitoring. This open pilot study builds on a web-based CM approach by evaluating a smartphone-based application for CM named mobile CM (mCM). The study was conducted from January 1, 2013-April 15, 2014.

METHOD

Following a 1-week training period, 20 homeless veteran smokers (≥ 10 cigarettes daily for 1 year or more and a CO baseline level ≥ 10 ppm) participated in a multicomponent smoking cessation intervention including 4 weeks of mCM. All smokers received 4 smoking cessation counseling sessions, nicotine replacement, and bupropion (if medically eligible). Participants could earn up to $815 ($480 for mCM, $100 for CO readings showing abstinence [ie, 6 ppm or less] at posttreatment and follow-up, and $35 for equipment return).

RESULTS

Mean compensation for the mCM component was $286 of a possible $480. Video transmission compliance was high during the 1-week training (97%) and the 4-week treatment period (87%). Bioverified 7-day point prevalence abstinence was 50% at 4 weeks. Follow-up bioverified single assessment point prevalence abstinence was 55% at 3 months and 45% at 6 months.

CONCLUSIONS

Results of this open pilot study suggest that mCM may be a useful adjunctive smoking cessation treatment component for reducing smoking among homeless veterans.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01789710.

Accounting for Posttraumatic Stress Disorder Symptom Severity With Pre- and Posttrauma Measures: A Longitudinal Study of Older Adults

Using data from a longitudinal study of community-dwelling older adults, we analyzed the most extensive set of known correlates of PTSD symptoms obtained from a single sample to examine the measures' independent and combined utility in accounting for PTSD symptom severity. Fifteen measures identified as PTSD risk factors in published meta-analyses and 12 theoretically and empirically supported individual difference and health-related measures were included. Individual difference measures assessed after the trauma, including insecure attachment and factors related to the current trauma memory, such as self-rated severity, event centrality, frequency of involuntary recall, and physical reactions to the memory, accounted for symptom severity better than measures of pre-trauma factors. In an analysis restricted to prospective measures assessed before the trauma, the total variance explained decreased from 56% to 16%. Results support a model of PTSD in which characteristics of the current trauma memory promote the development and maintenance of PTSD symptoms.

Health care expenditures attributable to smoking in military veterans

INTRODUCTION

The health effects of cigarette smoking have been estimated to account for between 6%-8% of U.S. health care expenditures. We estimated Veterans Health Administration (VHA) health care costs attributable to cigarette smoking.

METHODS

VHA survey and administrative data provided the number of Veteran enrollees, current and former smoking prevalence, and the cost of 4 types of care for groups defined by age, gender, and region. Cost and smoking status could not be linked at the enrollee level, so we used smoking attributable fractions estimated in sample of U.S. residents where the linkage could be made.

RESULTS

The 7.7 million Veterans enrolled in VHA received $40.2 billion in VHA provided health services in 2010. We estimated that $2.7 billion in VHA costs were attributable to the health effects of smoking. This was 7.6% of the $35.3 billion spent on the types of care for which smoking-attributable fractions could be determined. The fraction of inpatient costs that was attributable to smoking (11.4%) was greater than the fraction of ambulatory care cost attributable to smoking (5.3%). More cost was attributable to current smokers ($1.7 billion) than to former smokers ($983 million).

CONCLUSIONS

The fraction of VHA costs attributable to smoking is similar to that of other health care systems. Smoking among Veterans is slowly decreasing, but prevalence remains high in Veterans with psychiatric and substance use disorders, and in younger and female Veterans. VHA has adopted a number of smoking cessation programs that have the potential for reducing future smoking-attributable costs.

The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans: a meta-analysis

Literature on posttraumatic stress disorder (PTSD) prevalence among Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans report estimates ranging from 1.4% to 60%. A more precise estimate is necessary for projecting healthcare needs and informing public policy. This meta-analysis examined 33 studies published between 2007 and 2013 involving 4,945,897 OEF/OIF veterans, and PTSD prevalence was estimated at 23%. Publication year and percentage of Caucasian participants and formerly active duty participants explained significant variability in prevalence across studies. PTSD remains a concern for a substantial percentage of OEF/OIF veterans. To date, most studies have estimated prevalence among OEF/OIF veterans using VA medical chart review. Thus, results generalize primarily to the prevalence of PTSD in medical records of OEF/OIF veterans who use VA services. Additional research is needed with randomly selected, representative samples administered diagnostic interviews. Significant financial and mental health resources are needed to promote recovery from PTSD.

Surveying treatment preferences in U.S. Iraq-Afghanistan Veterans with PTSD symptoms: a step toward veteran-centered care

This study examined health care barriers and preferences among a self-selected sample of returning U.S. veterans drawn from a representative, randomly selected frame surveyed about posttraumatic stress disorder (PTSD) symptomatology and mental health utilization in the prior year. Comparisons between treated (n = 160) and untreated (n = 119) veterans reporting PTSD symptoms were conducted for measures of barriers and preferences, along with logistic models regressing mental health utilization on clusters derived from these measures. Reported barriers corroborated prior research findings as negative beliefs about treatment and stigma were strongly endorsed, but only privacy concerns were associated with lower service utilization (B = -0.408, SE = 0.142; p = .004). The most endorsed preference (91.0%) was for assistance with benefits, trailed by help for physical problems, and particular PTSD symptoms. Help-seeking veterans reported stronger preferences for multiple interventions, and desire for services for families (B = 0.468, SE = 0.219; p = .033) and specific PTSD symptoms (B = 0.659, SE = 0.302; p = .029) were associated with increased utilization. Outcomes of the study suggested PTSD severity drove help-seeking in this cohort. Results also support the integration of medical and mental health services, as well as coordination of health and benefits services. Finally, the study suggested that outreach about privacy protections and treatment options could well improve engagement in treatment.

Posttraumatic stress symptoms and tobacco abstinence effects in a non-clinical sample: evaluating the mediating role of negative affect reduction smoking expectancies

The relation between posttraumatic stress symptoms and smoking is well documented but poorly understood. The present investigation sought to evaluate the impact of posttraumatic stress symptoms on subjective and behavioral tobacco abstinence effects both directly and indirectly through negative affect reduction smoking outcome expectancies. Participants included 275 (68.7% male; Mage =43.9, 10+ cig/day) adult non-treatment seeking smokers, who attended two counterbalanced laboratory sessions (16 h of smoking deprivation vs ad libitum smoking), during which they completed self-report measures of withdrawal symptoms and mood followed by a smoking lapse task in which they could earn money for delaying smoking and purchase cigarettes to smoke. Results supported a mediational pathway whereby higher baseline symptoms of posttraumatic stress predicted greater endorsement of expectancies that smoking will effectively reduce negative affect, which in turn predicted greater abstinence-provoked exacerbations in nicotine withdrawal symptoms and negative affect. Posttraumatic stress symptoms also predicted number of cigarettes purchased independent of negative affect reduction expectancies, but did not predict delaying smoking for money. Findings highlight tobacco abstinence effects as a putative mechanism underlying posttraumatic stress disorder (PTSD)-smoking comorbidity, indicate an important mediating role of beliefs for smoking-induced negative affect reduction, and shed light on integrated treatment approaches for these two conditions.

Combined ecological momentary assessment and global positioning system tracking to assess smoking behavior: a proof of concept study

OBJECTIVE

Ecological momentary assessment (EMA) methods have provided a rich assessment of the contextual factors associated with a wide range of behaviors including alcohol use, eating, physical activity, and smoking. Despite this rich database, this information has not been linked to specific locations in space. Such location information, which can now be easily acquired from global positioning system (GPS) tracking devices, could provide unique information regarding the space-time distribution of behaviors and new insights into their determinants. In a proof of concept study, we assessed the acceptability and feasibility of acquiring and combining EMA and GPS data from adult smokers with attention deficit hyperactivity disorder (ADHD).

METHODS

Participants were adults with ADHD who were enrolled in a larger EMA study on smoking and psychiatric symptoms. Among those enrolled in the latter study who were approached to participate (N = 11), 10 consented, provided daily EMA entries, and carried a GPS device with them during a 7-day assessment period to assess aspects of their smoking behavior.

RESULTS

The majority of those eligible to participate were willing to carry a GPS device and signed the consent (10 out of 11, 91%). Of the 10 who consented, 7 participants provided EMA entries and carried the GPS device with them daily for at least 70% of the sampling period. Data are presented on the spatial distribution of smoking episodes and ADHD symptoms on a subset of the sample to demonstrate applications of GPS data.

CONCLUSIONS

We conclude by discussing how EMA and GPS might be used to study the ecology of smoking and make recommendations for future research and analysis.