Menstrual cycle phase at quit date predicts smoking status in an NRT treatment trial: a retrospective analysis

Coordinating smoking cessation treatment with menstrual cycle phase to improve quit outcomes (MC-NRT): study protocol for a randomized controlled trial

BACKGROUND

Women experience greater difficulty achieving smoking abstinence compared to men. Recent evidence suggests that hormonal fluctuations during different phases of the menstrual cycle can contribute to lower smoking abstinence rates following a quit attempt among women. However, these findings are limited by small sample sizes and variability among targeted smoking quit dates. This clinical trial aims to clarify whether targeting the quit date to the follicular or luteal phase of the menstrual cycle can improve smoking abstinence.

METHODS

Participants will enroll in an online smoking cessation program providing nicotine replacement therapy (NRT) and behavioral support. We will randomize 1200 eligible individuals to set a target quit date: (1) during the mid-luteal phase, (2) during the mid-follicular phase, or (3) 15-30 days after enrollment with no regard to the menstrual cycle phase (usual practice). Participants will receive a 6-week supply of combination NRT consisting of a nicotine patch plus their choice of nicotine gum or lozenge. Participants will be instructed to start using NRT on their target quit date. Optional behavioral support will consist of a free downloadable app and brief videos focusing on building a quit plan, coping with cravings, and relapse prevention, delivered via e-mail. Smoking status will be assessed via dried blood spot analysis of cotinine concentration at 7 days, 6 weeks, and 6 months post-target quit date.

DISCUSSION

We aim to overcome the limitations of previous studies by recruiting a large sample of participants and assigning target quit dates to the middle of both the follicular and luteal phases. The results of the trial can further elucidate the effects of the menstrual cycle on smoking cessation outcomes and whether it is beneficial to combine menstrual cycle phase timing strategies with accessible and low-cost NRT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05515354. Registered on August 23, 2022.

The importance of translationally evaluating steroid hormone contributions to substance use

Clinically, women appear to be more susceptible to certain aspects of substance use disorders (SUDs). The steroid hormones 17β-estradiol (E2) and progesterone (Pg) have been linked to women-specific drug behaviors. Here, we review clinical and preclinical studies investigating how cycling ovarian hormones affect nicotine-, cocaine-, and opioid-related behaviors. We also highlight gaps in the literature regarding how synthetic steroid hormone use may influence drug-related behaviors. In addition, we explore how E2 and Pg are known to interact in brain reward pathways and provide evidence of how these interactions may influence drug-related behaviors. The synthesis of this review demonstrates the critical need to study women-specific factors that may influence aspects of SUDs, which may play important roles in addiction processes in a sex-specific fashion. It is important to understand factors that impact women's health and may be key to moving the field forward toward more efficacious and individualized treatment strategies.

The association between hormonal contraceptive use and smoking, negative affect, and cessation attempts in college females

Exogenous and endogenous female hormones influence nicotine use and cessation, potentially through mechanisms such as anxiety and negative affect. In the present study, college females using all types of hormonal contraceptives (HC) were compared to those not using HC to determine the potential influence on current smoking, negative affect, and current and past cessation attempts. Differences between progestin-only and combination HC were also examined. Of the 1,431 participants, 53.2% (n = 761) reported current HC use, and 12.3% (n = 176) of participants endorsed current smoking. Women currently using HC were significantly more likely to smoke (13.5%; n = 103) compared to women not using HC (10.9%; n = 73), p = .04. There was a significant main effect of HC use being associated with lower anxiety levels (p = .005), as well as a significant HC use by smoking status interaction, such that women who smoke using HC reported the lowest levels of anxiety among participants (p = .01). Participants using HC were more likely to be making a current attempt to quit smoking than those not using HC (p = .04) and were more likely to have made past quit attempts (p = .04). No significant differences were observed across women using progestin-only, combined estrogen and progestin, and women not using HC. These findings provide evidence that exogenous hormones may be an advantageous treatment target and that they warrant additional study.

Ovarian Hormones Regulate Nicotine Consumption and Accumbens Glutamatergic Plasticity in Female Rats

Women report greater cigarette cravings during the menstrual cycle phase with higher circulating levels of 17β-estradiol (E2), which is metabolized to estrone (E1). Both E2 and E1 bind to estrogen receptors (ERs), which have been highly studied in the breast, uterus, and ovary. Recent studies have found that ERs are also located on GABAergic medium spiny neurons (MSNs) within the nucleus accumbens core (NAcore). Glutamatergic plasticity in NAcore MSNs is altered following nicotine use; however, it is unknown whether estrogens impact this neurobiological consequence. To test the effect of estrogen on nicotine use, we ovariectomized (OVX) female rats that then underwent nicotine self-administration acquisition and compared them to ovary-intact (sham) rats. The OVX animals then received either sesame oil (vehicle), E2, or E1+E2 supplementation for 4 or 20 d before nicotine sessions. While both ovary-intact and OVX females readily discriminated levers, OVX females consumed less nicotine than sham females. Further, neither E2 nor E1+E2 increased nicotine consumption back to sham levels following OVX, regardless of the duration of the treatment. OVX also rendered NAcore MSNs in a potentiated state following nicotine self-administration, which was reversed by 4 d of systemic E2 treatment. Finally, we found that E2 and E1+E2 increased ERα mRNA in the NAcore, but nicotine suppressed this regardless of hormone treatment. Together, these results show that estrogens regulate nicotine neurobiology, but additional factors may be required to restore nicotine consumption to ovary-intact levels.

Establishing preclinical withdrawal syndrome symptomatology following heroin self-administration in male and female rats

Opioid use disorder (OUD) is a significant health problem, and understanding mechanisms of various aspects of OUD including drug use and withdrawal is important. Preclinical models provide an ideal opportunity to evaluate mechanisms underlying opioid withdrawal. Current models are limited by their reliance upon forced opioid administration, focus on the acute (and not protracted) syndrome, and exclusion of females. In this study, male and female rats self-administered heroin (maintenance dose of 12.5 μg/kg/infusion) and opioid withdrawal after abrupt discontinuation was measured. In Phase 1, acute withdrawal symptoms were rated in male and female rats at 0, 16, 48, and 72 hr after the last self-administration session. Total somatic signs increased until 48 hr (predominantly in females), and heroin intake positively correlated with total somatic signs at the 48 and 72 hr timepoints. Measures of hyperactivity and anxiety-like behavior increased by 16 and 48 hr, respectively. In Phase 2, symptoms were assessed at baseline, acute, and protracted (168 and 312 hr after self-administration) timepoints in a subset of male and female rats from Phase 1. The total number of somatic signs did not differ across timepoints, though females displayed significantly higher body temperature at all timepoints compared with males, indicating sex-specific protracted withdrawal symptomatology. These data provide a thorough characterization of rodent opioid withdrawal symptomatology after self-administration and abrupt discontinuation that serve as a foundation for future studies designed to mimic the human experience, and demonstrate the importance of characterizing acute and protracted withdrawal with sex-specificity in preclinical models of opioid self-administration. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A systematic review of the effect of ovarian sex hormones on stimulant use in females

Stimulant use disorder is associated with significant global health burden. Despite evidence for sex differences in the development and maintenance of stimulant use disorder, few studies have focused on mechanisms underpinning distinct trajectories in females versus males, including the effect of the ovarian sex hormones estrogen and progesterone. This review aimed to identify and synthesise the existing preclinical and clinical literature on the effect of ovarian sex hormones on stimulant consumption in females. A systematic search of peer-reviewed literature identified 1593 articles, screened using the following inclusion criteria: (1) adult female humans or animals, (2) using stimulant drugs, (3) ovarian sex hormones were administered exogenously OR were measured in a validated manner and (4) with stimulant consumption as an outcome measure. A total of 50 studies (3 clinical and 47 preclinical) met inclusion criteria. High-estrogen (low progesterone) phases of the menstrual/estrus cycle were associated with increased stimulant use in preclinical studies, while there were no clinical studies examining estrogen and stimulant consumption. Consistent preclinical evidence supported progesterone use reducing stimulant consumption, which was also identified in one clinical study. The review was limited by inconsistent data reporting across studies and different protocols across preclinical laboratory paradigms. Importantly, almost all studies examined cocaine use, with impact on methamphetamine use a significant gap in the existing evidence. Given the safety and tolerability profile of progesterone, further research is urgently needed to address this gap, to explore the potential therapeutic utility of progesterone as a treatment for stimulant use disorder.

Natural and synthetic estrogens specifically alter nicotine demand and cue-induced nicotine seeking in female rats

Women have more difficulty maintaining smoking cessation than men, and experience greater withdrawal symptomatology as well as higher prevalence of relapse. Further, currently available treatments for smoking cessation, such as the nicotine patch and varenicline, have been shown to be less effective in women. Fluctuations in ovarian hormones across the menstrual cycle can affect craving and smoking relapse propensity. In addition, many women who smoke use some form of oral contraceptives, which most often contain ethinyl estradiol (EE), a synthetic, orally bio-available estrogen that is currently prescribed to women chronically and has been shown to alter smoking reward in women. The current study examined the impact of 17β-estradiol (E2), the prominent endogenous form of the steroid hormone estrogen, as well as EE, on nicotine self-administration, demand, and reinstatement following ovariectomy (OVX) or sham surgery. OVX vehicle-treated female rats consumed less nicotine, had lower intensity of demand, and reinstated less compared to sham vehicle-treated female rats. OVX-E2 and OVX-EE treatment groups showed a rebound of nicotine intake later in training, and Q₀ levels of consumption were partially rescued in both groups. Further, E2 but not EE reversed the abolishment of reinstated nicotine seeking induced by OVX. Taken together, these results demonstrate that natural and synthetic estrogens play a critical role in mediating the neurobehavioral effects of nicotine, and future studies are essential for our understanding of how synthetic hormones contained within oral contraceptives interact with smoking.

Recent Insights into the Nutritional Antioxidant Therapy in Prevention and Treatment of Diabetic Vascular Complications - A comprehensive Review

Diabetes mellitus (DM) and DM-induced vascular complications are a significant global healthcare problem causing a decrease in patient quality of life. The main reason for the disability and mortality of patients is rapidly progressing micro- and macroangiopathies. Currently, free radical oxidation is recognized as one of the main mechanisms in the development of DM and associated complications. Under normal physiological conditions, the level of free radicals and antioxidant defense capabilities is balanced. However, imbalance occurs between the antioxidant defense system and pro-oxidants during chronic hyperglycemia and may invoke formation of excess free radicals, leading to activation of lipid peroxidation and accumulation of highly toxic products of free radical oxidation. This is accompanied by varying degrees of insulin deficiency and insulin resistance in DM patients. Simultaneously with the activation of free radical generation, a decrease in the activity of antioxidant defense factors (superoxide dismutase, catalase, glutathione peroxidase, glutathione reductase, vitamins C and E) and an acceleration of diabetic complications is seen. Therefore, we hypothesize that antioxidants may play a positive role in the treatment of DM patients to prevent DM-induced vascular complications. However this has not been sufficiently studied. In this review, we discuss recent insights into the potential underlying mechanisms of oxidative stress induced diabetic complications, and implications of antioxidants in mitigation of DM-induced vascular complications.

Interactions between reproductive transitions during aging and addiction: promoting translational crosstalk between different fields of research

Discovery of neural mechanisms underlying neuropsychiatric disorders within the aging and addiction fields has been a main focus of the National Institutes of Health. However, there is a dearth of knowledge regarding the biological interactions of aging and addiction, which may have important influences on progression of disease and treatment outcomes in aging individuals with a history of chronic drug use. Thus, there is a large gap in these fields of research, which has slowed progress in understanding and treating substance use disorders (SUDs) as well as age-related diseases, specifically in women who experience precipitous reproductive cycle transitions during aging. The goal of this review is to highlight overlap of SUDs and age-related processes with a specific focus on menopause and smoking, and identify critical gaps. We have narrowed the focus of the review to smoking, as the majority of findings on hormonal and aging influences on drug use have come from this area of research. Further, we highlight female-specific issues such as transitional menopause and exogenous estrogen use. These issues may impact drug use cessation as well as outcomes with aging and age-related neurodegenerative diseases in women. We first review clinical studies for smoking, normal aging, and pathological aging, and discuss the few aging-related studies taking smoking history into account. Conversely, we highlight the dearth of clinical smoking studies taking age as a biological variable into account. Preclinical and clinical literature show that aging, age-related pathological brain disease, and addiction engage overlapping neural mechanisms. We hypothesize that these putative drivers interact in meaningful ways that may exacerbate disease and hinder successful treatment outcomes in such comorbid populations. We highlight areas where preclinical studies are needed to uncover neural mechanisms in aging and addiction processes. Collectively, this review highlights the need for crosstalk between different fields of research to address medical complexities of older adults, and specifically women, who smoke.

Interactions of neuroimmune signaling and glutamate plasticity in addiction

Chronic use of drugs of abuse affects neuroimmune signaling; however, there are still many open questions regarding the interactions between neuroimmune mechanisms and substance use disorders (SUDs). Further, chronic use of drugs of abuse can induce glutamatergic changes in the brain, but the relationship between the glutamate system and neuroimmune signaling in addiction is not well understood. Therefore, the purpose of this review is to bring into focus the role of neuroimmune signaling and its interactions with the glutamate system following chronic drug use, and how this may guide pharmacotherapeutic treatment strategies for SUDs. In this review, we first describe neuroimmune mechanisms that may be linked to aberrant glutamate signaling in addiction. We focus specifically on the nuclear factor-kappa B (NF-κB) pathway, a potentially important neuroimmune mechanism that may be a key player in driving drug-seeking behavior. We highlight the importance of astroglial-microglial crosstalk, and how this interacts with known glutamatergic dysregulations in addiction. Then, we describe the importance of studying non-neuronal cells with unprecedented precision because understanding structure-function relationships in these cells is critical in understanding their role in addiction neurobiology. Here we propose a working model of neuroimmune-glutamate interactions that underlie drug use motivation, which we argue may aid strategies for small molecule drug development to treat substance use disorders. Together, the synthesis of this review shows that interactions between glutamate and neuroimmune signaling may play an important and understudied role in addiction processes and may be critical in developing more efficacious pharmacotherapies to treat SUDs.

Effectiveness of transdermal nicotine patch in premenopausal female smokers is moderated by within-subject severity of negative affect and physical symptoms

RATIONALE

Nicotine patches may be less effective in female compared with male smokers. However, it is unknown if negative affect and physical symptoms influence transdermal nicotine patch-related effects on smoking behaviors.

METHODS

Eighty-one acutely tobacco-abstinent premenopausal female smokers attended three counter-balanced experimental sessions across the menstrual cycle (early follicular, late follicular, and mid-luteal) and were randomized to patch condition (nicotine [21 mg] vs. placebo [0 mg] transdermal patch). Negative affect and physical symptoms were assessed prior to patch administration. The patch was removed 5 h post-administration, and participants completed a smoking reinstatement task. Multilevel linear models tested associations of patch condition, negative affect and physical symptoms, and their interaction on smoking behavior.

RESULTS

There was a significant patch condition × Negative Affect and Pain symptoms interaction on the number of cigarettes smoked (p < 0.05). When Negative Affect and Pain were lower-than-usual, females administered a nicotine patch smoked significantly fewer cigarettes than females administered a placebo patch (p < .05), but there were no significant patch differences when Negative Affect and Pain were higher-than-usual. There was also a significant patch condition × Negative Affect interaction on time delay. The effects of patch condition on time delay to smoking were greater during sessions in which Negative Affect was higher-than-usual.

CONCLUSIONS

Results suggest that among female smokers transdermal nicotine patch effectiveness may interact with negative affect and pain. Understanding and considering female-specific factors that may impact the efficacy of one of the most commonly used cessation medications is important for improving smoking cessation in female smokers.

Feasibility and acceptability of testing a menstrual-cycle timed smoking cessation intervention for women of reproductive age (Project Phase): Protocol of a pilot randomized controlled trial

BACKGROUND

Compared to men, women have unique barriers to smoking cessation and are less likely to utilize quitline services. While current clinical recommendations have called for sex/gender-specific smoking cessation protocols, quitlines have not been expanded protocols to address the unique needs of women. Menstrual cycles (and/or ovarian hormones) influence quit outcomes in women. This paper presents the study design and protocol for a randomized control trial (Project Phase) designed to test the feasibility and acceptability of utilizing menstrual cycle timing to improve quit outcomes in women of reproductive age.

METHODS/DESIGN

Participants include treatment-seeking women (n = 116), between the ages of 18-40 with regular and naturally-occurring menstrual cycles. Eligible participants are randomized to either the mid-Follicular Phase (FP) or Standard Care (SC-control) group. Counseling includes six weekly telephone sessions with four weeks of nicotine replacement therapy. The timing and frequency of sessions is identical to both conditions, with the exception of the quit day (week 3 of counseling). In addition to providing education on menstrual cycle and quitting, quit day for FP participants is set within 6-8 days post onset of menses; the SC group quit day is set for Week 3 of counseling regardless of their menstrual cycle phase. Dried blood spots will be used to bioverify menstrual cycle phase and smoking status.

DISCUSSION

If feasible and acceptable, our behavioral counseling intervention that times the quit day to the mid-follicular phase of the menstrual may increase quit outcomes among women of reproductive age and has potential for dissemination across quitlines nationally.

N-acetylcysteine yields sex-specific efficacy for cue-induced reinstatement of nicotine seeking

Women report greater craving during certain phases of the menstrual cycle. As well, research indicates that pharmacotherapies for smoking may be less efficacious in women compared with men, which may be due to interactions with natural fluctuations in ovarian hormone levels. N-Acetylcysteine (NAC) is a glutamatergic compound that has shown some efficacy in treating substance use disorders and aids in the prevention of relapse. However, it is unclear whether NAC has sex-specific effectiveness for nicotine relapse treatment. Given that NAC has shown promise to reduce nicotine reinstatement in preclinical models using male rats, the exploration of potential sex differences in the efficacy of NAC is warranted. Using a rat model, we first investigated the ability of NAC treatment (100 mg/kg, ip) during nicotine withdrawal with extinction training to reduce cue-induced nicotine seeking in male and female rats. Next, we assessed whether NAC's effects were estrous cycle-dependent for female rats. Results show that following NAC treatment during extinction, reinstatement of nicotine seeking was significantly decreased in males but not females, indicating a sex-specific effect of NAC. Furthermore, for females, both vehicle- and NAC-treated groups significantly reinstated nicotine-seeking behavior compared with extinction, regardless of estrous cycle phase. These results suggest that NAC is inefficacious in reducing nicotine relapse in females regardless of estrous cycle phase at the dose evaluated here. These collective findings could have important clinical implications for use and efficacy of NAC as a pharmacotherapy for freely cycling women smokers.

Subjective response to intranasal nicotine administration in oral contraceptive users and naturally-cycling women

INTRODUCTION

Approximately half of premenopausal women who smoke cigarettes also use hormonal contraceptives, with most using oral contraceptives (OCs). While research on the effects of endogenous hormones on smoking-related outcomes continues to expand, little is known about the influence of OCs on similar outcomes. We sought to explore differences in the subjective response to nicotine by OC use after stratifying by testing condition (e.g., smoking status).

METHODS

Participants were regular (≥5 cigarettes/day) smokers, classified into OC and naturally cycling (NC) groups. All participants completed four total lab sessions by smoking status (ad libitum smoking, acute smoking abstinence) and anticipated progesterone level (low progesterone week (LPW), high progesterone week (HPW)). Each lab session included self-administration of intranasal nicotine (Time 0 min), assessment of subjective response via the Subjective State Scale (-30 and + 5 min).

RESULTS

Compared to the NC group (n = 28), the OC group (n = 14) was younger (26.2 ± 1.1 versus 24.2 ± 1.1; p < 0.001) and had a lower Fagerström Test for Nicotine Dependence score (3.4 ± 0.5 versus 2.6 ± 0.5; p = 0.011). Progesterone-to-estradiol ratios varied significantly by group at three of the four time points (p < 0.05). During ad libitum smoking, the OC group had significantly lower craving after nicotine administration than the NC group (1.93 ± 0.33 versus 2.89 ± 0.23; p = 0.024). No other significant differences in subjective response were identified.

CONCLUSIONS

Despite significantly different hormone levels, group differences in subjective response to nicotine were relatively few. Additional research is needed to elucidate the mechanisms involved in these observations, as well as explore how they may influence cessation in women.

Exogenous progesterone for smoking cessation in men and women: a pilot double-blind, placebo-controlled randomized clinical trial

BACKGROUND AND AIMS

In some clinical studies men and women have been found to differ in their ability to quit smoking, perhaps as a result of progesterone. The primary aim of this study was to provide a preliminary test of whether progesterone (PRO), compared with placebo (PBO), was more effective for smoking cessation in men and women.

DESIGN

Pilot double-blind, placebo-controlled randomized clinical trial.

SETTING

Minneapolis/St Paul metro area, Minnesota, USA.

PARTICIPANTS

A total of 216 participants were randomized, including 113 men (18-60 years; PRO = 56, PBO = 57) and 103 women (18-50 years, pre-menopausal with self-reported regular menstrual cycles; PRO = 51, PBO = 52).

INTERVENTION

Participants were randomized (1 : 1 within sex group) to either PRO (200 mg twice daily) or PBO. Participants were assigned a quit date approximately 7 days after starting medication (luteal phase for women) and were followed for 12 weeks to assess relapse.

MEASUREMENTS

The primary outcome was self-reported 7-day point prevalence abstinence (PPA) at week 4. Secondary outcomes included 7-day PPA at weeks 8 and 12, prolonged abstinence, continuous abstinence, urine cotinine < 50 ng/ml, expired carbon monoxide ≤ 5 parts per million (p.p.m.) and days to relapse.

FINDINGS

There was a significant difference in 7-day PPA at week 4 among women [PRO: 18 (35.3%) versus PBO: 9 (17.3%), odds ratio (OR) = 2.61, 95% confidence interval (CI) = 1.04, 6.54, P = 0.041], but not among men [PRO: 13 (23.2%) versus PBO: 12 (21.1%), 1.13 (0.47, 2.76), P = 0.782]. There was some evidence that PRO delayed relapse in women (days to relapse; PRO: 20.5 ± 29.6 versus PBO: 14.3 ± 26.8, P = 0.03) but not in men (PRO: 13.4 ± 25.9 versus PBO: 13.3 ± 23.8, P = 0.69).

CONCLUSIONS

Oral micronized progesterone may aid smoking cessation in women.

Non-Opioid Neurotransmitter Systems that Contribute to the Opioid Withdrawal Syndrome: A Review of Preclinical and Human Evidence

Opioid misuse and abuse is a major international public health issue. Opioid use disorder (OUD) is largely maintained by a desire to suppress aversive opioid withdrawal symptoms. Opioid withdrawal in patients seeking abstinence from illicit or prescribed opioids is often managed by provision of a μ-opioid agonist/partial agonist in combination with concomitant medications. Concomitant medications are administered based on their ability to treat specific symptoms rather than a mechanistic understanding of the opioid withdrawal syndrome; however, their use has not been statistically associated with improved treatment outcomes. Understanding the central and/or peripheral mechanisms that underlie individual withdrawal symptom expression in humans will help promote medication development for opioid withdrawal management. To support focused examination of mechanistically supported concomitant medications, this review summarizes evidence from preclinical (N = 68) and human (N = 30) studies that administered drugs acting on the dopamine, serotonin, cannabinoid, orexin/hypocretin, and glutamate systems and reported outcomes related to opioid withdrawal. These studies provide evidence that each of these systems contribute to opioid withdrawal severity. The Food and Drug Administration has approved medications acting on these respective systems for other indications and research in this area could support the repurposing of these medications to enhance opioid withdrawal treatment. These data support a focused examination of mechanistically informed concomitant medications to help reduce opioid withdrawal severity and enhance the continuum of care available for persons with OUD.

Menstrual cycle phase modulates responses to smoking cues in the putamen: Preliminary evidence for a novel target

BACKGROUND

The preclinical literature identifies the ventral striatum (VS) as a key player in drug-conditioned responses, guiding hypotheses examining neural substrates involved in human drug cue reactivity, including the study of sex differences. Men show a replicable response that includes the VS, while women's responses have been weaker and variable. New evidence suggests that the hormonal milieu modulates women's responses to drug cues in the dorsal striatum (DS), specifically, in the putamen. Here we tested the hypothesis that the hormonal milieu affects neural responses to smoking cues (SCs) in the putamen in women cigarette smokers.

METHODS

We re-examined our three previous neuroimaging studies of the influence of sex and menstrual cycle (MC) phase effects on SC neuroactivity, incorporating the DS as a region of interest.

RESULTS

As previously shown, men exhibited increased ventral medial prefrontal cortex (vmPFC) and VS/V pallidum responses, and women showed increased vmPFC responses that were greater in women during the follicular phase (high estradiol), compared to the luteal phase (high progesterone). Reducing the statistical threshold within luteal phase women revealed select deactivation of the putamen.

CONCLUSIONS

These preliminary findings shed light upon factors that may modulate drug cue reactivity in women, specifically the influence of hormones on DS responses. Emerging literature suggests that manipulating the hormonal milieu may open a fundamental window into sex-specific treatment targets. More rigorous study of the brain substrates involved in drug cue reactivity and other reward-related behavior that may be influenced by sex and the hormonal milieu is imperative.

Addiction and Dopamine: Sex Differences and Insights from Studies of Smoking

Mesolimbic dopaminergic function influences addiction through effects on reinforcement learning, decision-making, and impulsivity. This review covers sex differences in dopaminergic neurochemistry, their hormonal and genetic determinants, and how differences in dopaminergic tone interact with sex and/or ovarian hormone status to affect cognitive functions. Findings from research on cigarette smoking reveal sex differences in striatal and midbrain dopamine D2-type receptor availability and striatal dopamine release that suggest mechanisms of nicotine dependence, and stronger subjective responses to nicotine and efficacy of nicotine replacement therapies in male smokers than in their female counterparts. Opportunities exist to extend such efforts in studies of how sex and hormone status influence other addictions.

Use of hormonal contraceptives and smoking cessation: A preliminary report

Although endogenous sex hormones influence smoking-related outcomes, little is known about the effect of exogenous sex hormones. Therefore, the goal of this preliminary study was to examine differences in withdrawal symptoms and cessation between women using hormonal contraceptives (HC), women not using hormonal contraceptives (no-HC) and men. Utilizing data from two recently completed smoking cessation randomized clinical trials, we selected participants who were between the ages of 18-35years old. Participants were classified based on use of hormonal contraceptives and gender, then matched based on pharmacotherapy randomization assignment and baseline cigarettes per day. Participants provided self-reported assessments on withdrawal, craving and negative affect, and smoking status was assessed for 52weeks after quit date. Participants (N=130) were 28.7±0.4years old and smoked 16.8±0.6 cigarettes/day. Compared to both no-HC and men, the HC group had significantly greater withdrawal one week prior to the quit date, on the quit date and one week after the quit date. During the first week of attempted abstinence, craving declined in HC and in men, but increased in no-HC. At end of treatment, the HC group was at 3.73 times higher odds of being abstinent compared to men (95% confidence interval: 1.12-12.40). There were no group differences in abstinence rates at Week 26 or 52. These data suggest that HC users may experience more adverse levels of withdrawal, though may be more likely to achieve short-term abstinence. Future research is needed to replicate our observations and explore mechanisms of action.

Brain substrates of early (4h) cigarette abstinence: Identification of treatment targets

INTRODUCTION

Research indicates that overnight nicotine abstinence disrupts neural activity in the mesocorticolimbic reward network; however, less is known about the time course of abstinence-induced brain changes. To examine the potential neural effects of early abstinence, we used arterial spin labeling perfusion fMRI, to measure regional cerebral blood flow (rCBF) changes in the resting brain induced by 4h of nicotine abstinence.

METHODS

In a repeated measures design, 5min of resting perfusion fMRI data were acquired in awake nicotine-dependent individuals (eyes open) during 'smoking as usual' (SMK) and following 4h of monitored nicotine abstinence (ABS) conditions (N=20). Conditions were compared using a paired t test in SPM8. Craving was assessed prior to each condition.

RESULTS

Compared to SMK, ABS significantly increased craving and reduced rCBF in select regions, including the hippocampus and ventral striatum (cluster corr, α=0.01, 943 contiguous voxels). The magnitude of the abstinence-induced change in rCBF correlated with the magnitude of the change in craving across conditions in select regions, including the medial and lateral orbitofrontal cortices and the anterior ventral insula (r values ranging from 0.59-0.74).

CONCLUSIONS

Results show that as few as 4h of abstinence can reduce resting rCBF in multiple nodes of the brain's mesocorticolimbic network, disrupting neural processing. Identifying early withdrawal treatment targets has far-reaching implications, which include thwarting relapse proclivities. Results parallel those of the extant human literature and are in agreement with an extensive preclinical literature showing compromised mesolimbic dopaminergic function and impairments in reward function during nicotine withdrawal.

Differences in mood and cortisol by menstrual phase during acute smoking abstinence: A within-subject comparison

There is evidence that smoking-cessation success differs by menstrual phase and sex hormone levels; however, the biological mechanisms underlying these differences are not clear. One possibility is that variation in cortisol throughout the menstrual cycle and early smoking abstinence may be partly responsible. The goal of this secondary-data analysis was to conduct a within-subject examination of the effects of menstrual phase and smoking abstinence on salivary cortisol and mood. Data are from a controlled crossover trial, in which participants completed 2 testing weeks during their follicular and luteal phases. During each testing week, they smoked ad libitum during the first 2 days and then abstained from smoking during the next 4 days. Salivary cortisol and self-reported mood were collected 5 times on the day before abstinence (D0) and the first (D1) and third (D3) days of abstinence. Participants (n = 125) were, on average (mean ± SE), 29.4 ± 0.6 years old and smoked 12.6 ± 0.5 cigarettes/day. Whereas salivary cortisol varied significantly by time of day (p < .0001) and smoking abstinence (D0 to D1: β = -0.06 ± 0.02 log[ng/ml], p = .0074 and D3: β = -0.05 ± 0.02 log[ng/ml], p = .0117). no significant differences by menstrual phase were observed. Craving increased from D0 to D1 during the follicular phase but decreased in the luteal phase (+0.31 vs. -0.15, β = 0.46 ± 0.19, p = .0162). This work builds on prior observations in demonstrating a decrease in cortisol in acute smoking abstinence and menstrual phase differences in craving. The results provide further evidence that cortisol levels do not vary by menstrual phase in the first few days of abstinence. (PsycINFO Database Record

Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG

Tobacco smoking is the world's leading cause of premature death and disability. Global targets to reduce premature deaths by 25% by 2025 will require a substantial increase in the number of smokers making a quit attempt, and a significant improvement in the success rates of those attempts in low, middle and high income countries. In many countries the only place where the majority of smokers can access support to quit is primary care. There is strong evidence of cost-effective interventions in primary care yet many opportunities to put these into practice are missed. This paper revises the approach proposed by the International Primary Care Respiratory Group published in 2008 in this journal to reflect important new evidence and the global variation in primary-care experience and knowledge of smoking cessation. Specific for primary care, that advocates for a holistic, bio-psycho-social approach to most problems, the starting point is to approach tobacco dependence as an eminently treatable condition. We offer a hierarchy of interventions depending on time and available resources. We present an equitable approach to behavioural and drug interventions. This includes an update to the evidence on behaviour change, gender difference, comparative information on numbers needed to treat, drug safety and availability of drugs, including the relatively cheap drug cytisine, and a summary of new approaches such as harm reduction. This paper also extends the guidance on special populations such as people with long-term conditions including tuberculosis, human immunodeficiency virus, cardiovascular disease and respiratory disease, pregnant women, children and adolescents, and people with serious mental illness. We use expert clinical opinion where the research evidence is insufficient or inconclusive. The paper describes trends in the use of waterpipes and cannabis smoking and offers guidance to primary-care clinicians on what to do faced with uncertain evidence. Throughout, it recognises that clinical decisions should be tailored to the individual's circumstances and attitudes and be influenced by the availability and affordability of drugs and specialist services. Finally it argues that the role of the International Primary Care Respiratory Group is to improve the confidence as well as the competence of primary care and, therefore, makes recommendations about clinical education and evaluation. We also advocate for an update to the WHO Model List of Essential Medicines to optimise each primary-care intervention. This International Primary Care Respiratory Group statement has been endorsed by the Member Organisations of World Organization of Family Doctors Europe.

Progesterone and Postpartum Smoking Relapse: A Pilot Double-Blind Placebo-Controlled Randomized Trial

INTRODUCTION

Pregnancy is a strong motivator to quit smoking, yet postpartum relapse rates are high. Growing evidence suggests a role of sex hormones in drug abuse behavior and given the precipitous drop in sex hormones at delivery, they may play a role in postpartum relapse. This pilot study evaluates the feasibility and potential role of exogenous progesterone in postpartum smoking relapse.

METHODS

This 12-week double-blind placebo-controlled randomized pilot trial randomized 46 abstinent postpartum women to active progesterone (PRO; 200mg twice a day) versus placebo (PBO) for 4 weeks. Participants were followed for relapse for 12 weeks. Main study outcomes include abstinence (point prevalence), feasibility (compliance per number of clinic visits attended, pill counts and Electronic Data Capture [EDC] completed) and self-reported acceptability. Safety was also measured by depressive symptom scores, adverse events, and breastfeeding.

RESULTS

Overall retention rate was 87% at week 12. At week 4, abstinence rates were 75% in the PRO group and 68.2% in the PBO group (p = .75). Medication adherence was 68% and clinic visit attendance was 80%, with no differences by randomization. Depressive symptom scores, adverse events, and breastfeeding did not vary by randomization.

CONCLUSIONS

Although the study was not powered to evaluate abstinence rates, we did observe a higher prevalence of abstinence at week 4 in the PRO group. Further, exogenous progesterone was well tolerated and did not adversely affect depressive symptoms or breastfeeding. Thus, the results of this pilot study indicate further investigation into progesterone as a postpartum relapse prevention strategy is warranted.

IMPLICATIONS

This innovative pilot trial determined the feasibility of delivering exogenous progesterone as a potential prevention of postpartum smoking relapse. We observed high retention and moderate adherence rates, as well as high acceptability among participants. Further, though not statistically significant, more women in the treatment group remained abstinent from smoking during follow-up. This project adds to the growing body of literature on the role of sex hormones in smoking relapse and also provides support for a fully powered clinical trial.

How to study sex differences in addiction using animal models

The importance of studying sex as a biological variable in biomedical research is becoming increasingly apparent. There is a particular need in preclinical studies of addiction to include both sexes, as female animals are often excluded from studies, leaving large gaps in our knowledge of not only sex differences and potential prevention and treatment strategies but also with regard to the basic neurobiology of addiction. This review focuses on methodology that has been developed in preclinical studies to examine sex differences in the behavioral aspects and neurobiological mechanisms related to addiction across the full range of the addiction process, including initiation (acquisition), maintenance, escalation, withdrawal, relapse to drug seeking and treatment. This review also discusses strategic and technical issues that need to be considered when comparing females and males, including the role of ovarian hormones and how sex differences interact with other major vulnerability factors in addiction, such as impulsivity, compulsivity and age (adolescent versus adult). Novel treatments for addiction are also discussed, such as competing non-drug rewards, repurposed medications such as progesterone and treatment combinations. Practical aspects of conducting research comparing female and male animals are also considered. Making sex differences a point of examination requires additional effort and consideration; however, such studies are necessary given mounting evidence demonstrating that the addiction process occurs differently in males and females. These studies should lead to a better understanding of individual differences in the development of addiction and effective treatments for males and females.

Sex and menstrual cycle effects on chronic oral cocaine self-administration in rhesus monkeys: Effects of a nondrug alternative reward

BACKGROUND

In previous studies, female monkeys self-administered more oral phencyclidine (PCP) than males, and PCP intake differed by phase of menstrual cycle.

OBJECTIVES

The purpose of this study was to examine sex and hormonal influences on oral cocaine self-administration in male and female rhesus monkeys in the follicular vs. luteal phases of the menstrual cycle, with concurrent access to an alternative nondrug reward, saccharin (SACC) vs. water.

MATERIALS AND METHODS

Concurrent access to cocaine (0.2, 0.4, and 0.8 mg/ml) and SACC or water was available from two drinking spouts under concurrent fixed-ratio (FR) 2, 4, and 8 schedules during daily 3-h sessions.

RESULTS

Cocaine deliveries were similar in males and females in the females' luteal phase, but cocaine deliveries were higher in females during the follicular phase than the luteal phase and compared to males. When SACC was available, cocaine deliveries were reduced in females in the follicular phase of the cycle, and cocaine intake (mg/kg) was reduced in males and in females' follicular and luteal phases.

CONCLUSIONS

Access to concurrent SACC (vs. water) reduced cocaine intake (mg/kg) in males and in females during both menstrual phases, and the magnitude of the reduction in cocaine intake was greatest during the females' follicular phase. Thus, a nondrug alternative reward, SACC, is a viable alternative treatment for reducing cocaine's rewarding effects on male and female monkeys, and reductions in cocaine seeking were optimal in the females' luteal phase.

Gender-related Differences in Food Craving and Obesity

Food craving is often defined as a strong desire to eat. Much work has shown that it consistently and prospectively predicts eating and weight-related outcomes, contributing to the growing obesity epidemic. Although there are clear gender differences in the prevalence and health consequences of obesity, relatively little recent work has investigated gender differences in craving, or any sex-hormone-based differences as they relate to phases of the menstrual cycle. Here, we propose that gender-related differences in food craving contribute to gender-related differences in obesity. Drawing on findings in the addiction literature, we highlight ways to incorporate gender-based differences in food craving into treatment approaches, potentially improving the efficacy of obesity and weight loss treatment. Overall, this review aims to emphasize the importance of investigating gender differences in food craving, with a view towards informing the development of more effective treatments for obesity and weight loss.

Sympathetic arousal increases a negative memory bias in young women with low sex hormone levels

Emotionally arousing events are typically better attended to and remembered than neutral ones. Current theories propose that arousal-induced increases in norepinephrine during encoding bias attention and memory in favor of affectively salient stimuli. Here, we tested this hypothesis by manipulating levels of physiological arousal prior to encoding and examining how it influenced memory for emotionally salient images, particularly those that are negative rather than positive in valence. We also tested whether sex steroid hormones interact with noradrenergic activity to influence these emotional memory biases in women. Healthy naturally cycling women and women on hormonal contraception completed one of the following physiological arousal manipulations prior to viewing a series of negative, positive and neutral images: (1) immediate handgrip arousal-isometric handgrip immediately prior to encoding, (2) residual handgrip arousal-isometric handgrip 15min prior to encoding, or (3) no handgrip. Sympathetic arousal was measured throughout the session via pupil diameter changes. Levels of 17β-estradiol and progesterone were measured via salivary samples. Memory performance was assessed approximately 10min after encoding using a surprise free recall test. The results indicated that handgrip successfully increased sympathetic arousal compared to the control task. Under immediate handgrip arousal, women showed enhanced memory for negative images over positive images; this pattern was not observed in women assigned to the residual and no-handgrip arousal conditions. Additionally, under immediate handgrip arousal, both high estradiol and progesterone levels attenuated the memory bias for negative over positive images. Follow-up hierarchical linear models revealed consistent effects when accounting for trial-by-trial variability in normative International Affective Picture System valence and arousal ratings. These findings suggest that heightened sympathetic arousal interacts with estradiol and progesterone levels during encoding to increase the mnemonic advantage of negative over positive emotional material.

Associations between adrenocortical activity and nicotine response in female smokers by menstrual phase

Previous research suggests that menstrual phase may influence smoking-related symptomatology. The present study analyzes the relationship between menstrual phase and salivary cortisol with subjective responses to nicotine among female smokers during ad libitum smoking. We hypothesize higher cortisol levels would be associated with increased positive and decreased negative subjective responses to nicotine. We also expected that these associations would vary by menstrual phase. Females aged 18-40 who smoke at least five cigarettes/day, reported regular menstrual cycles and did not use exogenous hormones or psychotropic medications were enrolled into a controlled cross-over trial. Participants completed identical data collection procedures during follicular (F) and luteal (L) phases; including self-collected salivary cortisol samples and completion of a nicotine response lab session involving administration of nicotine nasal spray and monitoring of subjective response to nicotine via the Subjective State Scale and Visual Analog Scale. Participants (n = 116) were 29.1 ± 6.9 years old and smoked an average of 12.3 ± 5.5 cigarettes daily. During F phase, higher morning cortisol was associated with decreased negative affect (r = -0.21, p = 0.03), withdrawal (r = -0.30, p < 0.01) and increased relaxation (r = 0.24, p = 0.02) after administration of nicotine nasal spray. Conversely, during L phase, higher morning cortisol was associated with a decrease in head rush (r = -0.26, p = 0.01) and urge to smoke (r = -0.21, p = 0.04) after administration of nicotine nasal spray. Similar associations between greater diurnal cortisol variation and response to nicotine were seen. These observations indicate that cortisol may have a phase-specific association with some subjective responses to nicotine in female smokers. Additional research should explore how these relationships may influence smoking cessation efforts.

Increasing progesterone levels are associated with smoking abstinence among free-cycling women smokers who receive brief pharmacotherapy

INTRODUCTION

Preclinical and human laboratory research suggests that (a) progesterone may decrease drug reward, craving, and smoking behavior, and (b) estradiol may enhance drug reward and smoking behavior. A modest majority of treatment research examining the relationship between menstrual cycle phase and outcomes suggests that the luteal menstrual phase, with its uniquely higher progesterone levels, is associated with better cessation outcomes. However, no studies to date have examined the effects of naturally occurring variation in progesterone and estradiol levels on medication-assisted smoking cessation. The present study sought to fill this notable gap in the treatment literature.

METHODS

Weekly plasma progesterone and estradiol levels were obtained from nicotine-dependent female smokers enrolled in a 4-week cessation trial. Participants (N = 108) were randomized to receive a 4-week course of either varenicline (VAR) tablets and placebo patches or placebo tablets and nicotine patches. Plasma samples were obtained 1 week before their cessation attempt and weekly during medication administration. Abstinence was assessed weekly.

RESULTS

Weekly hormone data replicated commonly observed menstrual cycle patterns of progesterone and estradiol levels. Importantly, increases in progesterone level were associated with a 23% increase in the odds for being abstinent within each week of treatment. This effect was driven primarily by nicotine patch-treated versus VAR-treated females.

CONCLUSIONS

This study was the first to identify an association between progesterone level (increasing) and abstinence outcomes in free-cycling women smokers who participated in a medication-based treatment. Furthermore, the potential benefits of progesterone may vary across different pharmacotherapies. Implications of these findings for smoking cessation intervention are discussed.

Systematic and meta-analytic review of research examining the impact of menstrual cycle phase and ovarian hormones on smoking and cessation

INTRODUCTION

To determine the effect of ovarian hormones on smoking, we conducted a systematic review of menstrual cycle effects on smoking (i.e., ad lib smoking, smoking topography, and subjective effects) and cessation-related behaviors (i.e., cessation, withdrawal, tonic craving, and cue-induced craving).

METHODS

Thirty-six papers were identified on MEDLINE that included a menstrual-related search term (e.g., menstrual cycle, ovarian hormones), a smoking-related search term (e.g., smoking, nicotine), and met all inclusion criteria. Thirty-two studies examined menstrual phase, 1 study measured hormone levels, and 3 studies administered progesterone.

RESULTS

Sufficient data were available to conduct meta-analyses for only 2 of the 7 variables: withdrawal and tonic craving. Women reported greater withdrawal during the luteal phase than during the follicular phase, and there was a nonsignificant trend for greater tonic craving in the luteal phase. Progesterone administration was associated with decreased positive and increased negative subjective effects of nicotine. Studies of menstrual phase effects on the other outcome variables were either small in number or yielded mixed outcomes.

CONCLUSIONS

The impact of menstrual cycle phase on smoking behavior and cessation is complicated, and insufficient research is available upon which to conduct meta-analyses on most smoking outcomes. Future progress will require collecting ovarian hormone levels to more precisely quantify the impact of dynamic changes in hormone levels through the cycle on smoking behavior. Clarifying the relationship between hormones and smoking-particularly related to quitting, relapse, and medication response-could determine the best type and timing of interventions to improve quit rates for women.

Profile of women who carried out smoking cessation treatment: a systematic review

OBJECTIVE Analyze the profile of women, in health services, who carry out treatment for smoking cessation. METHODS Systematic review that used the following sources of information: Cummulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Biblioteca Virtual em Saúde (BVS), Scopus and Web of Science. We included quantitative studies that addressed the characterization of women, in health services, who carried out treatment for smoking cessation, resulting in 12 articles for analysis. The assessment of the methodological quality of the studies was performed using the instrument MAStARI from Joanna Briggs Institute. RESULTS The predominant profile of women who carried out treatment for smoking cessation in health services was composed of white, married, employed, and highly level educated women. Women who carried out the treatment for smoking cessation in specialized services had a more advanced age, were white, were married and had a diagnosis of depression. The quality level of most studies was moderate. CONCLUSIONS The profile of women who carry out treatment for smoking cessation, either in general or specialized health services, is composed of white, married, and highly level educated women. Publications about smoking women are scarce and the lack of Brazilian studies characterizing the profile of women who start treatment for smoking cessation shows the need for studies that explore this subject.

The multidimensional impact of total laryngectomy on women

Based on society's expectations of what defines the norms for what is deemed "masculine" and "feminine", and a propensity for society's members to adhere to these expectations, women may face a unique set of circumstances and pressures following surgical treatment for laryngeal cancer. This is primarily due to the changes that occur to women's physical, psychological, and social functioning when dealing with cancer diagnosis and treatment outcomes. Because of concerns related to physical disfigurement, acoustic and perceptual changes to one's voice, and threat of the psychological sequelae associated with total laryngectomy (TL) (or, the surgical removal of one's voicebox and surrounding structures), there is an increased potential for violation of social expectations that cross these areas of functioning. As such, efforts that seek to better understand the potentially differential impact of TL on women and identify the specific needs they may have leading up to and after such treatment pursuant to contemporary societal expectations are warranted. Thus, this paper provides an examination of the potentially differential impact of TL on women. In addressing this position, this paper examines the unique challenges women may face postlaryngectomy through the framework of the International Classification of Functioning, Disability, and Health (ICF). Through the use of the ICF, this paper will provide an expanded perspective related to the interactions between body functioning, active participation in daily activities, and contextual factors that may act as facilitators or barriers to women's societal reintegration secondary to TL.

LEARNING OUTCOMES

Readers will be able to describe the multiple factors that may contribute to the differential impact of total laryngectomy (TL) on women. More specifically, readers will gain an understanding about women's physical, psychological, and social functioning secondary to TL. This paper also provides readers with exposure to the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) framework. This framework provides readers with an expanded perspective related to the interactions between body functioning, active participation in daily activities, and contextual factors that may act as either facilitators or barriers to the societal reintegration of women secondary to TL.

Subjective response to nicotine by menstrual phase

INTRODUCTION

The luteal menstrual phase might be a favorable time for smoking cessation when non-nicotine interventions (e.g. counseling, bupropion) are used, whereas the follicular menstrual phase appears favorable when nicotine interventions are used. Thus, there may be an interaction between menstrual phase and response to nicotine. We sought to examine the role of menstrual phase on response to nicotine during acute smoking abstinence.

METHODS

In this controlled cross-over trial, women completed two identical experimental sessions (follicular [F] vs. luteal [L] phase) after four days of biochemically-verified smoking abstinence. During the sessions, nicotine nasal spray was administered, and participants provided a series of subjective assessments.

RESULTS

Participants (n=140) were 29.7±6.6years old and smoked 12.6±5.8 cigarettes per day. Compared to the F phase, the L phase was associated with a greater increase in stimulation (7.2±2.2 vs. 14.4±2.3, p=0.01, respectively) and greater decrease in urge to smoke (-13.6±2.3 vs. -21.1±2.5, p=0.02, respectively) after the first dose of nicotine. No other significant differences were observed.

CONCLUSIONS

Out of 13 total measures examined at two different time points, we observed only two significant menstrual phase differences in the subjective response to nicotine. Therefore, these data do not provide strong evidence for a menstrual phase difference in the subjective response to nicotine. Additional research is needed to confirm this relationship and explore how non-nicotine smoking reinforcements (such as sensory sensations) may vary by menstrual phase.

Gender differences in medication use and cigarette smoking cessation: results from the International Tobacco Control Four Country Survey

INTRODUCTION

There is conflicting evidence for gender differences in smoking cessation, and there has been little research on gender differences in smoking cessation medication (SCM) use and effectiveness. Using longitudinal data from the International Tobacco Control Four Country Surveys (ITC-4) conducted in the United Kingdom, the United States, Canada, and Australia, we examined gender differences in the incidence of quit attempts, reasons for quitting, use of SCMs, reasons for discontinuing use of SCMs, and rates of smoking cessation.

METHODS

Data were analyzed from adult smokers participating in the ITC-4, annual waves 2006-2011 (n = 7,825), as well as a subsample of smokers (n = 1,079) who made quit attempts within 2 months of survey. Adjusted modeling utilized generalized estimating equations.

RESULTS

There were no gender differences in the likelihood of desire to quit, plans to quit, or quit attempts between survey waves. Among quit attempters, women had 31% lower odds of successfully quitting (OR = 0.69; 95% CI = 0.51, 0.94). Stratified by medication use, quit success was lower among women who did not use any SCMs (OR = 0.59; 95% CI = 0.39, 0.90), and it was no different from men when medications were used (OR = 0.73; 95% CI = 0.46, 1.16). In particular, self-selected use of nicotine patch and varenicline contributed to successful quitting among women.

CONCLUSIONS

Women may have more difficulty quitting than men, and SCMs use may help attenuate this difference.

Ovarian hormones and borderline personality disorder features: Preliminary evidence for interactive effects of estradiol and progesterone

Cyclical fluctuations in the ovarian hormones 17β-estradiol (E2; estrogen) and progesterone (P4) predict emotions, cognitive processes, and behaviors relevant to Borderline Personality Disorder (BPD); however, there are individual differences in sensitivity to normal hormone shifts. This study examined associations of naturally occurring hormonal changes with concurrent BPD feature expression. Forty women sampled for a flat distribution of the PAI-BOR (n=10 where T<50, n=10 where 50<T<60, n=10 where 60<T<70, and n=10 where T>70) provided four weekly saliva samples and psychological assessments. Across most outcomes (e.g., BPD features, felt rejection, anger rumination, negative urgency) P4 deviation (from one's person mean) moderated the effect of current E2 deviation (from one's person mean) among women high (+1 SD) in trait BPD features such that E2 deviation was negatively associated with symptoms only when P4 was higher-than-usual. Cyclical hormone changes (e.g., higher P4 in the luteal phase; E2 fluctuations at ovulation and in the luteal phase) may impact BPD feature expression among at-risk women.

Influence of menstrual cycle phase on neural and craving responses to appetitive smoking cues in naturally cycling females

INTRODUCTION

Functional magnetic resonance imaging (fMRI) has been used extensively in an attempt to understand brain vulnerabilities that mediate maladaptive responses to drug cues. Using perfusion fMRI, we have consistently shown reward-related activation (medial orbitofrontal cortex/ventral striatum) to smoking cues (SCs). Because preclinical and clinical studies generally show that progesterone may reduce reward and craving, we hypothesized that females in the follicular phase of the cycle (FPs; when progesterone levels are low) would have greater reward-related neural responses to SCs compared with females in the luteal phase (LPs).

METHODS

Sated cigarette-dependent premenopausal naturally cycling females underwent pseudo-continuous arterial spin-labeled perfusion fMRI during exposure to 10-min audio visual clips of appetitive SCs and non-SCs. Brain responses to SCs relative to non-SCs were examined among females grouped according to menstrual cycle (MC) phase at the time of scanning (22 FPs, 15 LPs). Craving scores were acquired pre- and post-SC exposure.

RESULTS

FPs showed increased neural responses to SCs compared with non-SCs in the medial orbitofrontal cortex (p ≤ .05 corrected), whereas LPs did not. FPs reported SC-elicited craving (p ≤ .005), whereas LPs did not. Within FPs, SC-induced craving correlated with increased neural responses in the anterior insula (r = 0.73, p < .0001).

CONCLUSIONS

FPs may be more vulnerable to relapse during appetitive SC exposure than LPs. Because the influence of MC phase on drug cue neural activity has not been examined, these results contribute to our knowledge of the neurobiological underpinnings of responses to drug cues, and they highlight the importance of monitoring menstrual cycle phase in all areas of addiction research.

Allopregnanolone association with psychophysiological and cognitive functions during acute smoking abstinence in premenopausal women

Nicotine response may predict susceptibility to smoking relapse. Allopregnanolone, a neuroactive steroid metabolized from progesterone, has been shown to be associated with several symptoms of nicotine response. We sought to explore the association between allopregnanolone and response to nicotine during acute smoking abstinence in premenopausal women. Participants completed 2 nicotine-response laboratory sessions, 1 in their follicular (low allopregnanolone) and 1 in their luteal (high allopregnanolone) menstrual phase, on the fourth day of biochemically confirmed smoking abstinence. During the laboratory sessions, participants self-administered a nicotine nasal spray and completed a timed series of cardiovascular, cognitive, and subjective assessments of response to nicotine. The relationships of allopregnanolone with baseline values and change scores of outcome measures were assessed using covariance pattern modeling. Study participants (N = 77) had a mean age of 29.9 (SD = 6.8) years and smoked an average of 12.2 (SD = 4.9) cigarettes per day. Allopregnanolone concentration measured before nicotine administration was positively associated with systolic (β = 0.85, p = .04) and diastolic blood pressure (β = 1.19, p < .001) and self-report of physical symptoms (β = 0.58, p < .001), dizziness (β = 0.88, p < .01), jitteriness (β = 0.90, p = .04), and pleasantness (β = 2.05, p = .04). Allopregnanolone also had significant positive associations with change in cognition following nicotine nasal spray administration, specifically discriminability as a measure of attention (β = 1.15, p = .05) and response bias as a measure of impulsivity (β = 0.13, p = .02). These data suggest that allopregnanolone may be related to cardiovascular and subjective physical state during acute smoking abstinence, as well as cognitive response to nicotine.

Comparison of two isometric handgrip protocols on sympathetic arousal in women

Isometric handgrip is commonly used in stress research because the task reliably increases sympathetic arousal. Various handgrip protocols have been used; they vary in handgrip strength, duration of grip, and the number of cycles of handgrip and rest. However, most protocols require the calibration of a maximum voluntary contraction (MVC) prior to the handgrip task, which is not always convenient (i.e., in a functional magnetic resonance imaging study). Here, we wanted to test whether two handgrip protocols with different strength, duration and cycle protocols would reliably elicit sympathetic arousal in the absence of calibrating an MVC. Sixty-two healthy naturally cycling women and women on hormonal contraception participated in one of the two isometric handgrip protocols using a hand therapy ball of medium resistance. Women completed one of the following handgrip protocols: 1) 30% of a perceived maximum voluntary contraction for 3 min or 2) 3 cycles of maximum voluntary contraction for 18s with a one minute rest in between. All handgrip blocks were counterbalanced with a control condition. Sympathetic arousal was measured throughout the session via pupil diameter changes and salivary alpha-amylase. Results indicate that in the absence of calibrating an MVC, the handgrip tasks elicited different changes in sympathetic arousal. Pupil dilation responses increased significantly in the handgrip versus control blocks only in participants in the 18-s protocol. Additionally, more participants exhibited a salivary alpha-amylase response to the handgrip block in the 18-s condition compared to the 3-min condition. Thus, these results suggest that neuroimaging and behavioral studies with isometric handgrip should be able to successfully induce sympathetic nervous activity with the 18-s paradigm, regardless of the handgrip device and the ability to calibrate an MVC.

Menstrual cycle phase effects in the gender dimorphic stress cue reactivity of smokers

INTRODUCTION

We previously reported that female smokers evidence greater subjective craving and stress/emotional reactivity to personalized stress cues than males. The present study employed the same dataset to assess whether females in the follicular versus luteal phase of the menstrual cycle accounted for the gender differences.

METHODS

Two objective criteria, onset of menses and luteinizing hormone surge (evaluated via home testing kits), were used to determine whether female smokers were in either the follicular (n = 22) or the luteal (n = 15) phase of their menstrual cycle, respectively. The females and a sample of male smokers (n = 53) were then administered a laboratory-based cue reactivity paradigm that involved assessment of craving, stress, and emotional reactivity in response to counterbalanced presentations of both a personalized stress script and neutral/relaxed script.

RESULTS

While there were no significant differences between females in the follicular versus luteal phase on any outcome measure, females in the luteal menstrual phase reported greater craving than males whereas females in the follicular phase reported greater stress and arousal than males and perceived the stress cues as more emotionally aversive than males.

CONCLUSIONS

This preliminary investigation suggests that gender differences in craving versus affective responding to stress cues may, in part, be explained variation by menstrual cycle phase. Study limitations and implications of the findings for future research and treatment are briefly discussed.

Consideration of sex in clinical trials of transdermal nicotine patch: a systematic review

Transdermal nicotine patch (TNP) is 1 of the most commonly used smoking cessation treatments; however, the efficacy of TNP by sex is not yet clear. The purpose of the current review was to synthesize how sex has been considered in published clinical trials of TNP for smoking cessation. The specific aims of the study were to examine the inclusion of sex in analyses of cessation outcomes, TNP-related variables (compliance, side effects), and quit-related variables (withdrawal, cravings); to review the consideration of sex-related variables (menstrual cycle phase, pregnancy); and to identify needs for future research. Potential articles published through December 31, 2013 were identified through a MEDLINE search of the terms "clinical trial," "nicotine patch," and "smoking cessation." Forty-two studies used all 3 terms and met the inclusion criteria. Approximately half of the studies reported that they considered sex in smoking cessation outcomes, with 15 studies finding no difference by sex and 7 studies finding better outcomes for men versus women. Only 5 studies reported data on outcomes by sex in their publications. No studies reported analysis of TNP compliance or withdrawal by sex. In the 1 study that examined side effects by sex, more women than men reported discontinuing TNP because of skin irritation. No study examined the association of cessation outcomes with menstrual cycle phase. There is a need to include sex in research on TNP, as well as other pharmacological and behavioral smoking treatments, to clarify the picture of treatment efficacy for women compared with men.

Smoking- and menstrual-related symptomatology during short-term smoking abstinence by menstrual phase and depressive symptoms

Menstrual phase and depressive symptoms are known to minimize quit attempts in women. Therefore, the influence of these factors on smoking- and menstrual-related symptomatology during acute smoking cessation was investigated in a controlled cross-over lab-study. Participants (n=147) completed two six-day testing weeks during their menstrual cycle with testing order randomly assigned (follicular vs. luteal). The testing week consisted of two days of ad libitum smoking followed by four days of biochemically verified smoking abstinence. Daily symptomatology measures were collected. Out of the 11 total symptoms investigated, six were significantly associated with menstrual phase and nine were significantly associated with level of depressive symptoms. Two significant interactions were noted indicating that there may be a stronger association between depressive symptoms with negative affect and premenstrual pain during the follicular phase compared to the luteal phase. Overall, these observations suggest that during acute smoking abstinence in premenopausal smokers, there is an association between depressive symptoms and symptomatology whereas menstrual phase appears to have less of an effect. Further study is needed to determine the effect of these observations on smoking cessation outcomes, as well as to define the mechanism of menstrual phase and depressive symptoms on smoking-related symptomatology.

Subjective, physiological, and cognitive responses to intravenous nicotine: effects of sex and menstrual cycle phase

Nicotine dependence is a serious public health concern. Optimal treatment of nicotine dependence will require greater understanding of the mechanisms that contribute to the maintenance of smoking behaviors. A growing literature indicates sex and menstrual phase differences in responses to nicotine. The aim of this study was to assess sex and menstrual phase influences on a broad range of measures of nicotine response including subjective drug effects, cognition, physiological responses, and symptoms of withdrawal, craving, and affect. Using a well-established intravenous nicotine paradigm and biochemical confirmation of overnight abstinence and menstrual cycle phase, analyses were performed to compare sex (age 18-50 years; 115 male and 45 female) and menstrual cycle phase (29 follicular and 16 luteal) effects. Females had diminished subjective drug effects of, but greater physiological responses to, nicotine administration. Luteal-phase females showed diminished subjective drug effects and better cognition relative to follicular-phase women. These findings offer candidate mechanisms through which the luteal phase, wherein progesterone is dominant relative to estradiol, may be protective against vulnerability to smoking.

Neural correlates of attentional bias for smoking cues: modulation by variance in the dopamine transporter gene

Cigarette-dependent smokers automatically and involuntarily orient attention toward smoking cues (SCs). This attentional bias is clinically significant, as it may contribute to relapse. Thus, identifying neural and genetic correlates of attentional bias is critical for improving interventions. Our previous studies show that the dopamine transporter (DAT) SLC6A3 genotype exerts profound effects on limbic responses to SCs. One potential mechanism underlying these effects is greater attentional bias for SCs. Here, we explored associations between attentional bias for SCs and neural responses to SCs among 'sated' smokers genotyped for the SLC6A3 polymorphism. Pseudo-continuous arterial spin-labeled perfusion functional magnetic resonance imaging images were acquired during SC exposure in 35 smokers genotyped for the SLC6A3 variable number of tandem repeats polymorphism (n = 16, 9-repeats; n = 19, 10/10-repeats). Participants completed a visual dot-probe attentional bias task, which contained pictures of smoking and non-smoking pictures, to examine whether genetic variation in DAT influences attentional bias and to investigate relationships between attentional bias and neural responses to SCs. Although attentional bias to smoking pictures was not significantly different between 9-repeats and 10/10-repeats, 9-repeats showed a positive correlation between attentional bias and increased SC-induced brain activity in the amygdala, whereas 10/10-repeats showed an inverse correlation in the medial orbitofrontal cortex (mOFC). In group comparisons, 9-repeats exhibited positive correlations between attentional bias and SCs in the mOFC and amygdala, relative to 10/10-repeats. Findings suggest that genetic variation in the DAT gene influences brain responses associated with attentional bias; thus, providing additional support for a SC-vulnerable endophenotype.

Women and Smoking: The Effect of Gender on the Epidemiology, Health Effects, and Cessation of Smoking

Smoking is still the leading cause of premature morbidity and mortality. This paper examines new research on gender differences and the epidemiology of smoking, smoking-related morbidity and mortality, and factors that affect smoking cessation. The rate of decline in the prevalence of smoking has been slowing, especially among adolescent girls. New research suggests that, compared with men, women may be more susceptible to smoking-related morbidity and mortality. Gender-related barriers to smoking cessation include weight gain, sex hormones, and mood. Furthermore, the sensory aspects of smoking may have more of an effect on smoking treatment for women than for men. We discuss new studies that examine smoking-cessation interventions that may be particularly beneficial for women, including exercise (as an adjunct intervention), very low nicotine content cigarettes, and a variety of pharmacotherapy. Further research is needed to identify and target the gender-specific needs of smokers.

Menstrual phase, depressive symptoms, and allopregnanolone during short-term smoking cessation

Preclinical literature indicates that allopregnanolone (ALLO), a neuroactive steroid metabolized from progesterone, may protect against drug abuse behaviors. It is important to understand how ALLO varies during smoking changes in clinical samples with depressive symptoms (DS) given they are at high risk of smoking relapse. The purpose of this article is to characterize changes in ALLO by menstrual phase during short-term smoking cessation among women with and without DS. At screening, study participants (n = 84) were classified as either having past or current DS (n = 48) or not (n = 36). In a controlled crossover trial design, participants completed 2 testing weeks in the follicular (F; low ALLO) and luteal (L; high ALLO) menstrual phases. During each testing week, blood samples were collected during ad libitum smoking and on the fourth day of biochemically verified smoking abstinence. Participants were, on average, 30.1 ± 6.7 years old, smoked 12.6 ± 5.7 cigarettes per day, and most (73%) were White. The change in ALLO during short-term smoking cessation varied significantly by menstrual phase such that it decreased by 10% in the follicular phase and increased by 31% in the luteal phase. There were no significant differences in ALLO levels by DS group. In premenopausal women, ALLO levels varied by menstrual phase and smoking status, but not DS. Given that other research has indicated L phase is associated with improved smoking cessation outcomes, an increase in ALLO during short-term cessation in the L phase may protect against relapse whereas a decrease in ALLO, as observed in the F phase, may increase risk for relapse.

Sex differences in negative affect and lapse behavior during acute tobacco abstinence: a laboratory study

Heightened negative affect during acute tobacco abstinence in women relative to men could be an important factor underlying sex differences in smoking motivation. However, little controlled experimental work addresses this hypothesis. The current study investigated sex differences in withdrawal-related negative affect, time to start smoking on a lab analogue smoking lapse task, and the interrelation between sex, withdrawal-related negative affect, and smoking lapse behavior. Following a baseline session, current smokers (women: n = 68, men: n = 131) attended two counterbalanced lab sessions (16 hours smoking abstinence and ad libitum smoking) during which they completed self-report measures of mood and withdrawal symptoms followed by a laboratory analogue smoking lapse task. In this task participants are monetarily rewarded for delaying smoking. Performance on this task serves as an analogue model of smoking lapse behavior by measuring smoker's capability to resist temptation to smoke under conditions where abstinence is advantageous. Females showed greater abstinence induced increases in composite negative affect as well as several particular negative affect states (i.e., POMS Anger, Anxiety, Depression, and Confusion, ps < .05) but no differences in abstinence induced changes in other forms of affect or craving. Females also exhibited marginally greater abstinence induced decreases in their willingness to delay smoking for money (p = .10), which was mediated by abstinence induced increases in anger (p < .05). These results suggest that differential sensitivity to abstinence induced negative affect, particularly anger, could underlie sex specific smoking patterns. Negative affect during tobacco abstinence may be an important factor for understanding and treating nicotine addiction in women.

Sex and menstrual cycle phase at encoding influence emotional memory for gist and detail

Sex influences on emotional memory have received increasing interest over the past decade. However, only a subset of this previous work explored the influence of sex on memory for central information (gist) and peripheral detail in emotional versus neutral contexts. Here we examined the influence of sex and menstrual cycle phase at encoding on memory for either an emotional or neutral story, specifically with respect to the retention of gist and peripheral detail. Healthy naturally cycling women and men viewed a brief, narrated, three-phase story containing neutral or emotionally arousing elements. One week later, participants received a surprise free recall test for story elements. The results indicate that naturally cycling women in the luteal (high hormone) phase of the menstrual cycle at encoding show enhanced memory for peripheral details, but not gist, when in the emotional compared with neutral stories (p<.05). In contrast, naturally cycling women in the follicular (low hormone) phase of the menstrual cycle at encoding did not show enhanced memory for gist or peripheral details in the emotional compared with neutral stories. Men show enhanced memory for gist, but not peripheral details, in the emotional versus neutral stories (p<.05). In addition, these sex influences on memory cannot be attributed to differences in attention or arousal; luteal women, follicular women, and men performed similarly on measures of attention (fixation time percentage) and arousal (pupil diameter changes) during the most arousing phase of the emotional story. These findings suggest that sex and menstrual cycle phase at encoding influence long term memory for different types of emotional information.

Increased impulsive choice for saccharin during PCP withdrawal in female monkeys: influence of menstrual cycle phase

BACKGROUND

In previous studies with male and female rhesus monkeys, withdrawal of access to oral phencyclidine (PCP) self-administration reduced responding for food under a high fixed-ratio (FR) schedule more in males than females, and with a delay discounting (DD) task with saccharin (SACC) as the reinforcer impulsive choice for SACC increased during PCP withdrawal more in males than females.

OBJECTIVES

The goal of the present study was to examine the effect of PCP (0.25 or 0.5 mg/ml) withdrawal on impulsive choice for SACC in females during the follicular and luteal phases of the menstrual cycle.

MATERIALS AND METHODS

In component 1, PCP and water were available from two drinking spouts for 1.5 h sessions under concurrent FR 16 schedules. In component 2, a SACC solution was available for 45 min under a DD schedule. Monkeys had a choice of one immediate SACC delivery (0.6 ml) or six delayed SACC deliveries, and the delay was increased by 1 s after a response on the delayed lever and decreased by 1 s after a response on the immediate lever. There was then a 10-day water substitution phase, or PCP withdrawal, that occurred during the mid-follicular phase (days 7-11) or the late luteal phase (days 24-28) of the menstrual cycle. Access to PCP and concurrent water was then restored, and the PCP withdrawal procedure was repeated over several follicular and luteal menstrual phases.

RESULTS

PCP deliveries were higher during the luteal (vs follicular) phase. Impulsive choice was greater during the luteal (vs follicular) phase during withdrawal of the higher PCP concentration.

CONCLUSIONS

PCP withdrawal was associated with elevated impulsive choice for SACC, especially in the luteal (vs follicular) phase of the menstrual cycle in female monkeys.