Are occasional smokers a heterogeneous group? An exploratory study

Determinants of tobacco use transitions in smoker nursing students in Catalonia: A prospective longitudinal study

INTRODUCTION

The use of emerging tobacco and nicotine products affects tobacco use behaviors among college students. Thus, we aimed to examine transitions in tobacco use patterns and identify their predictors among smokers in a cohort of nursing students in Catalonia (Spain).

METHODS

We conducted a prospective longitudinal study of Catalan nursing students between 2015-2016 and 2018-2019. We examined transitions in tobacco use patterns between baseline and follow-up among smokers from: 1) daily to non-daily smoking, 2) non-daily to daily smoking, 3) cigarette-only use to poly-tobacco use, 4) poly-tobacco use to cigarette-only use, 5) between products, 6) reducing consumption by ≥5 cigarettes per day (CPD); and 7) quitting smoking. We applied a Generalized Linear Model with a log link (Poisson regression) and robust variance to identify predictors of reducing cigarette consumption by ≥5 CPD and quitting smoking, obtaining both crude and adjusted (APR) prevalence ratios and their 95% confidence intervals (CIs).

RESULTS

Among daily smokers at baseline, 12.1% transitioned to non-daily smoking at follow-up, while 36.2% of non-daily smokers shifted to daily smoking. Among cigarette-only users, 14.2% transitioned to poly-tobacco use, while 48.4% of poly-tobacco users switched to exclusive cigarette use. Among all smokers (daily and non-daily smokers), 60.8% reduced their cigarette consumption by ≥5 CPD and 28.3% quit smoking. Being a non-daily smoker (APR=0.33; 95% CI 0.19-0.55) and having lower nicotine dependence (APR=0.78; 95% CI 0.64-0.96) were inversely associated with reducing cigarette consumption, while being a non-daily smoker (APR=1.19; 95% CI: 1.08-1.31) was directly associated with quitting smoking.

CONCLUSIONS

Nursing students who smoked experienced diverse transitions in tobacco use patterns over time. Evidence-based tobacco use preventive and cessation interventions are needed to tackle tobacco use among future nurses.

Feature-level analysis of a smoking cessation smartphone app that uses a positive psychology approach (Preprint)

Background

Smoking cessation smartphone apps have emerged as highly accessible tools to support smoking cessation efforts. It is unknown how specific app features contribute to user engagement over time and relate to smoking outcomes.

Objective

To provide a feature-level analysis of the Smiling Instead of Smoking app (version 2) and to link feature use to subsequent smoking cessation.

Methods

Nondaily smokers (N=100) used the app for a period of 49 days (1 week before quitting and 6 weeks after quitting). Participants self-reported 30-day point-prevalence abstinence at the end of this period and at a 6-month follow up (the survey response rate was 94% and 89% at these points, respectively). Self-reported 30-day point prevalence abstinence rates were 40% at the end of treatment and 56% at the 6-month follow up. The app engaged users in both positive psychology content and traditional behavioral smoking cessation content. The app sent push notifications to prompt participants to complete prescribed content (ie, a “happiness exercise” every day and a “behavioral challenge” to use the app’s smoking cessation tools on 15 out of 49 days). Actions that participants took within the app were timestamped and recorded.

Results

Participants used the app on 24.7 (SD 13.8) days out of the 49 prescribed days, interacting with the happiness content on more days than the smoking content (23.8, SD 13.8 days vs 17.8, SD 10.3 days; t₉₉=9.28 [2-tailed]; P<.001). The prescribed content was frequently completed (45% of happiness exercises; 57% of behavioral challenges) and ad libitum tools were used on ≤7 days. Most participants used each ad libitum smoking cessation tool at least once, with higher use of personalized content (≥92% used “strategies,” “cigarette log,” “smoke alarms,” and “personal reasons”) than purely didactic content (79% viewed “benefits of quitting smoking”). The number of days participants used the app significantly predicted 30-day point-prevalence abstinence at the end of treatment (odds ratio [OR] 1.05, 95% CI 1.02-1.09; P=.002) and at the 6-month follow up (OR 1.04, 95% CI 1.008-1.07; P=.01). The number of days participants engaged with the happiness content significantly predicted smoking abstinence at the end of treatment (OR 1.05, 95% CI 1.02-1.08; P=.002) and at the 6-month follow up (OR 1.04, 95% CI 1.007-1.07; P=.02). This effect was not significant for the number of days participants engaged with the smoking cessation content of the app, either at the end of treatment (OR 1.04, 95% CI 0.996-1.08, P=.08) or at the 6-month follow up (OR 1.02, 95% CI 0.98-1.06; P=.29).

Conclusions

Greater app usage predicted greater odds of self-reported 30-day point-prevalence abstinence at both the end of treatment and over the long term, suggesting that the app had a therapeutic benefit. Positive psychology content and prescriptive clarity may promote sustained app engagement over time.

Trial Registration

ClinicalTrials.gov NCT03951766; https://clinicaltrials.gov/ct2/show/NCT03951766

Beyond abstinence and relapse II: momentary relationships between stress, craving, and lapse within clusters of patients with similar patterns of drug use

RATIONALE

Given that many patients being treated for opioid-use disorder continue to use drugs, identifying clusters of patients who share similar patterns of use might provide insight into the disorder, the processes that affect it, and ways that treatment can be personalized.

OBJECTIVES AND METHODS

We applied hierarchical clustering to identify patterns of opioid and cocaine use in 309 participants being treated with methadone or buprenorphine (in a buprenorphine-naloxone formulation) for up to 16 weeks. A smartphone app was used to assess stress and craving at three random times per day over the course of the study.

RESULTS

Five basic patterns of use were identified: frequent opioid use, frequent cocaine use, frequent dual use (opioids and cocaine), sporadic use, and infrequent use. These patterns were differentially associated with medication (methadone vs. buprenorphine), race, age, drug-use history, drug-related problems prior to the study, stress-coping strategies, specific triggers of use events, and levels of cue exposure, craving, and negative mood. Craving tended to increase before use in all except those who used sporadically. Craving was sharply higher during the 90 min following moderate-to-severe stress in those with frequent use, but only moderately higher in those with infrequent or sporadic use.

CONCLUSIONS

People who share similar patterns of drug-use during treatment also tend to share similarities with respect to psychological processes that surround instances of use, such as stress-induced craving. Cluster analysis combined with smartphone-based experience sampling provides an effective strategy for studying how drug use is related to personal and environmental factors.

Racial/ethnic differences in daily, nondaily, and menthol cigarette use and smoking quit ratios in the United States: 2002 to 2016

In the United States (US), racial/ethnic groups differ in cigarette smoking behaviors. We examined changes in cigarette prevalence and quit ratios over 15 years by racial/ethnic group (Non-Hispanic (NH) White, NH Black, Hispanic, NH Other). Data were drawn from the 2002-2016 National Survey on Drug Use and Health (NSDUH) public use data files and analyzed in 2018. Linear time trends of the prevalence of daily, nondaily, and menthol cigarette use and quit ratios (i.e., proportion of former smokers among lifetime smokers) were assessed using logistic regression models. 19.35% of NH White persons were daily smokers in 2016; this prevalence was significantly higher than all other groups (NH Black 10.99%, Hispanic 6.81%, NH Other 9.10%). Menthol use was significantly more common among NH Black individuals than all other groups in every year from 2002 to 2016 (2016: NH Black 23.38%, NH White 14.52%, Hispanic 10.49%, NH Other 8.97%). From 2002 to 2016, daily and nondaily smoking decreased significantly among all groups. The rate of decline of nondaily smoking was more rapid among Hispanic than NH White individuals while the rate of menthol smoking decline was more rapid among NH White than among Hispanic individuals. The quit ratio did not change significantly from 2002 to 2016 among NH Black individuals (31% to 35%) in contrast to a significant increase among NH White (2002, 45%; 2016, 50%) and Hispanic (2002, 33%; 2016, 41%) individuals. Further progress in tobacco control for vulnerable groups may need to include innovative strategies to address these concerning trends.

Factors associated with changing cigarette consumption patterns among low-intensity smokers: Longitudinal findings across four waves (2008-2012) of ITC Mexico Survey

Background

Light and intermittent smoking has become increasingly prevalent as smokers shift to lower consumption in response to tobacco control policies. We examined changes in cigarette consumption patterns over a four-year period and determined which factors were associated with smoking transitions.

Methods

We used data from a cohort of smokers from the 2008–2012 ITC Mexico Survey administrations to investigate transitions from non-daily (ND; n = 669), daily light (DL; ≤5 cigarettes per day (cpd); n = 643), and daily heavy (DH; >5 cpd; n = 761) smoking patterns. To identify which factors (i.e., sociodemographic measures, perceived addiction, quit behavior, social norms) were associated with smoking transitions, we stratified on smoking status at time t (ND, DL, DH) and used multinomial (ND, DL) and binomial (DH) logistic regression to examine transitions (quitting/reducing or increasing versus same level for ND and DL, quitting/reducing versus same level for DH).

Results

ND smokers were more likely to quit at follow-up than DL or DH smokers. DH smokers who reduced their consumption to ND were more likely to quit eventually compared to those who continued as DH. Smokers who perceived themselves as addicted had lower odds of quitting/reducing smoking consumption at follow-up compared to smokers who did not, regardless of smoking status at the prior survey. Quit attempts and quit intentions were also associated with quitting/reducing consumption.

Conclusions

Reducing consumption may eventually lead to cessation, even for heavier smokers. The findings that perceived addiction and quit behavior were important predictors of changing consumption for all groups may offer insights into potential interventions.

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Smoking transitions were evaluated in a cohort of Mexican smokers.

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The cohort consisted mostly of understudied light and intermittent smokers (LITS).

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Reductions in smoking intensity were found to facilitate smoking cessation.

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Greater perceived addiction inhibited cessation for smokers at all levels of intensity.

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LITS patterns warrant attention as number of low-intensity smokers worldwide grows.

Smokers' Understandings of Addiction to Nicotine and Tobacco: A Systematic Review and Interpretive Synthesis of Quantitative and Qualitative Research

Background

Despite the centrality of addiction in academic accounts of smoking, there is little research on smokers' beliefs about addiction to smoking, and the role of nicotine in tobacco dependence. Smokers' perspectives on nicotine's role in addiction are important given the increasing prevalence of nontobacco nicotine products such as e-cigarettes. We conducted a systematic review of studies investigating smokers' understandings and lay beliefs about addiction to smoking and nicotine.

Method

We searched PubMed, Embase, CINAHL, and PsycINFO for studies investigating lay beliefs about addiction to smoking. Twenty-two quantitative and 24 qualitative studies met inclusion criteria. Critical interpretive synthesis was used to analyze the results.

Results

Very few studies asked about addiction to nicotine. Quantitative studies that asked about addiction to smoking showed that most smokers believe that cigarettes are an addictive product, and that they are addicted to smoking. Across qualitative studies, nicotine was not often mentioned by participants. Addiction to smoking was most often characterized as a feeling of "need" for cigarettes resulting from an interplay between physical, mental, and social processes. Overall, we found that understandings of smoking were more consistent with the biopsychosocial model of addiction than with more recent models that emphasize the biological aspects of addiction.

Conclusion

Researchers should not treat perceptions of addiction to smoking interchangeably with perceptions of addiction to nicotine. More research on lay beliefs about nicotine is required, particularly considering the increasing use of e-cigarettes and their potential for long-term nicotine maintenance for harm reduction.

Implications

Quantitative studies show that most smokers believe that smoking is addictive and that they are addicted. A feeling of "need" for cigarettes was central to qualitative accounts of addiction, but nicotine was not often discussed. Overall, smokers' understandings of addiction reflect a biopsychosocial model rather than a neurobiological one. Given the growing market for e-cigarettes and therapeutic nicotine, more research is required on lay beliefs about nicotine and addiction.

Nondaily Cigarette Smoking Is Increasing Among People With Common Mental Health and Substance Use Problems in the United States: Data From Representative Samples of US Adults, 2005-2014

OBJECTIVE

The current study estimated trends in the prevalence of daily and nondaily cigarette smoking among United States adults with any common mental health or substance use problem (MHSUP), compared to US adults without MHSUP, from 2005 to 2014.

METHODS

Data were drawn from the years 2005 to 2014 from the public use data files for the annually conducted National Survey on Drug Use and Health. Linear time trends of current, daily, and nondaily cigarette smoking among adults (age 18 years and older) with and without MHSUP were assessed using logistic regression models with continuous year as the predictor.

RESULTS

In 2014, the prevalence of current cigarette smoking among those with MHSUP was more than twice that of those without MHSUP. Nondaily cigarette smoking increased significantly from 2005 to 2014 among those with MHSUP (P = .001) in contrast to a decline in nondaily cigarette smoking among those without MHSUP (P < .01). The rate of change differed significantly (P < .001). Daily cigarette smoking declined significantly from 2005 to 2014 among those with and without MHSUP (P values < .001).

CONCLUSIONS

The prevalence of nondaily cigarette smoking is increasing among US adults with common mental health and substance use problems, while it continues to decline among those without these vulnerabilities. The disparity in prevalence of daily cigarette smoking between those with and without MHSUP remains substantial. Conclusions about how to reach the tobacco endgame may need to be reconsidered to develop targeted tobacco control public health approaches that address common MHSUP.

Depression Among Non-Daily Smokers Compared to Daily Smokers and Never-Smokers in the United States: An Emerging Problem

INTRODUCTION

Depression is strongly associated with daily smoking. Yet, little is known about the association between depression and non-daily smoking. The aim of this study was to investigate the prevalence of past-year depression and changes in past-year depression over time among non-daily smokers, compared to daily smokers and never-smokers, overall and stratified by age, gender, income, nicotine dependence, and cigarettes per day.

METHODS

Data were drawn from the National Household Survey on Drug Use (NSDUH), an annual cross-sectional study of persons aged 12 and over (total study population N = 496 805). The prevalence of past-year depression was examined annually among non-daily smokers, daily smokers, and never-smokers from 2005 to 2013 using linear trend analyses.

RESULTS

Past-year depression was common among 10.10% of non-daily smokers, common among 10.78% of daily smokers, and 5.51% of never-smokers in 2013. The prevalence of depression increased from 2005 to 2013 among non-daily smokers (9.06% vs. 10.10%; p = .034) while there was no significant change in depression over time among daily smokers. Increases in depression among non-daily smokers occurred for both men and women and appear most pronounced youth, those smoking fewer cigarettes, and those without nicotine dependence.

CONCLUSIONS

The prevalence of depression among non-daily smokers was equivalent to daily smokers and nearly twice that among nonsmokers. Depression appears to be increasing over time in non-daily smokers especially among youth, those who smoke less, and those without nicotine dependence. More work on the mental health of non-daily smokers is needed as this is an increasing and understudied group.

IMPLICATIONS

This is the first study to investigate changes in the prevalence of depression among non-daily smokers compared to daily smokers and never-smokers over the past decade in a nationally representative sample of the United States. The results suggest an increase in depression among non-daily smokers over time that did not similarly occur for daily smokers. Further, there were several subgroups of non-daily smokers among whom depression has increased more rapidly. This study suggests the need for more information about the relationship between depression and non-daily smoking including the impact of depression on quit attempts and outcomes.

Tobacco outlet density and converted versus native non-daily cigarette use in a national US sample

OBJECTIVE

Investigate whether non-daily smokers' (NDS) cigarette price and purchase preferences, recent cessation attempts, and current intentions to quit are associated with the density of the retail cigarette product landscape surrounding their residential address.

PARTICIPANTS

Cross-sectional assessment of N=904 converted NDS (CNDS). who previously smoked every day, and N=297 native NDS (NNDS) who only smoked non-daily, drawn from a national panel.

OUTCOME MEASURES

Kernel density estimation was used to generate a nationwide probability surface of tobacco outlets linked to participants' residential ZIP code. Hierarchically nested log-linear models were compared to evaluate associations between outlet density, non-daily use patterns, price sensitivity and quit intentions.

RESULTS

Overall, NDS in ZIP codes with greater outlet density were less likely than NDS in ZIP codes with lower outlet density to hold 6-month quit intentions when they also reported that price affected use patterns (G2=66.1, p<0.001) and purchase locations (G2=85.2, p<0.001). CNDS were more likely than NNDS to reside in ZIP codes with higher outlet density (G2=322.0, p<0.001). Compared with CNDS in ZIP codes with lower outlet density, CNDS in high-density ZIP codes were more likely to report that price influenced the amount they smoke (G2=43.9, p<0.001), and were more likely to look for better prices (G2=59.3, p<0.001). NDS residing in high-density ZIP codes were not more likely to report that price affected their cigarette brand choice compared with those in ZIP codes with lower density.

CONCLUSIONS

This paper provides initial evidence that the point-of-sale cigarette environment may be differentially associated with the maintenance of CNDS versus NNDS patterns. Future research should investigate how tobacco control efforts can be optimised to both promote cessation and curb the rising tide of non-daily smoking in the USA.

Use of and reasons for using multiple other tobacco products in daily and nondaily smokers: Associations with cigarette consumption and nicotine dependence

BACKGROUND

Use of other tobacco products (OTPs) among smokers is increasing. Little is known about types of OTP used and the reasons for use, and how OTP use and reasons for use correlate with smoking patterns and nicotine dependence in daily and nondaily smokers. This paper addresses these gaps in the literature.

METHODS

656 daily smokers and 203 nondaily smokers provided information on their use of different OTPs (hookah, e-cigarettes, chew/snuff, snus, cigars, dissolvables), and reasons for using OTPs (e.g., "to cut down on smoking"), as well as their cigarette consumption and nicotine dependence. Logistic regression models assessed the association of smoking status with OTP use (ever and current) and reasons for use. Within each smoking group, separate logistic regression models examined the associations of OTP use and reasons for use with cigarette consumption and nicotine dependence.

RESULTS

Compared to daily smokers, nondaily smokers were more likely to use hookah and cigars, less likely to use dissolvables, and less likely to endorse using OTPs to reduce their smoking. Among non-daily smokers, nicotine dependence was associated with a higher likelihood of current OTP use (OR=1.04 [95% CI 1.01-1.07]; p<0.05), whereas cigarette consumption was not.

CONCLUSIONS

Results suggest OTP use in nondaily smokers does not correlate with less frequent smoking, but may correlate with higher nicotine dependence. Use of combustible OTPs among nondaily smokers may offset any potential benefits achieved through less frequent cigarette consumption. Providers should explicitly address OTP use when discussing cigarette cessation and reduction.

Smoking transitions in a sample of Hispanic daily light and intermittent smokers

Few studies have documented the differences between daily light (DLS; ≤10 cigarettes per day) and intermittent (ITS; nondaily) smokers. The primary aim of this study was to assess the potential transitions (i.e., increased/stayed at same level) between baseline and a 3month follow-up of Hispanic DLS and ITS who were randomly assigned to a control group of a brief cessation intervention. Additionally, potential nicotine addiction differences between groups of smokers (e.g., ITS who became DLS vs. those who did not change) were assessed. Participants were 190 Hispanic DLS/ITS (who represent a subsample from a larger dataset, n=370) with complete data (53.7% female; Mage=38.6years, SD=15.1; range=18-74years) randomized to the control arm of a brief cessation intervention. Participants completed sociodemographics, tobacco use history, and the Fagerström Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker and Fagerström, 1991). The majority of participants remained DLS (41.1%) or ITS (21.6%). ANCOVA findings indicated significant group differences regarding FTND scores (F [5114]=6.93, p<0.001). Those who remained DLS had significantly higher FTND scores than those who remained ITS and those who converted from ITS to DLS. Within these DLS/ITS who were randomized to a control group, smoking transitions primarily remained stable over time, particularly among DLS (who demonstrated higher nicotine dependence), suggesting the need for low level cessation interventions to continue and include a focus on dependence symptoms.

Assessing 30-day quantity-frequency of U.S. adolescent cigarette smoking as a predictor of adult smoking 14 years later

BACKGROUND

To improve measures of monthly tobacco cigarette smoking among non-daily smokers, predictive of future non-daily monthly and daily smoking.

METHODS

Data from United States National Longitudinal Study of Adolescent to Adult Health, tracking adolescents, ages 12-21, over 14 years were analyzed. At baseline, 6501 adolescents were assessed; 5114 individuals provided data at waves 1 and 4. Baseline past 30-day non-daily smokers were classified using quantity-frequency measures: cigarettes smoked/day by number of days smoked in the past 30 days.

RESULTS

Three categories of past 30-day non-daily smokers emerged using cigarettes/month (low:1-5, moderate: 6-60, high: 61+) and predicted past 30-day smoking at follow-up (low: 44.5%, moderate: 60.0%, high: 77.0%, versus 74.2% daily smokers; rτ=-0.2319, p<0.001). Two categories of non-smokers plus low, moderate and high categories of non-daily smokers made up a five-category non-daily smoking index (NDSI). High NDSI (61+ cigs/mo.) and daily smokers were equally likely to be smoking 14 years later (High NDSI OR=0.97, 95% CI=0.53-1.80 [daily as reference]). Low (1-5 cigs/mo.) and moderate (6-60 cigs/mo.) NDSI were distinctly different from high NDSI, but similar to one another (OR=0.21, 95% CI=0.15-0.29 and OR=0.22, 95% CI=0.14-0.34, respectively) when estimating future monthly smoking. Among those smoking at both waves, wave 1 non-daily smokers, overall, were less likely than wave 1 daily smokers to be smoking daily 14 years later.

CONCLUSIONS

Non-daily smokers smoking over three packs/month were as likely as daily smokers to be smoking 14-years later. Lower levels of non-daily smoking (at ages 12-21) predicted lower likelihood of future monthly smoking. In terms of surveillance and cessation interventions, high NDSI smokers might be treated similar to daily smokers.

Correlates of Converted and Native Nondaily Smoking

OBJECTIVES

Nondaily smokers represent a growing proportion of current smokers in the United States. However, little is known about which characteristics are important in distinguishing between nondaily smokers who are former daily smokers (converted nondaily) and nondaily smokers who never smoked daily (native nondaily). This study contrasts converted and native nondaily smokers on demographic, psychosocial, tobacco-related characteristics and quit intentions and behaviors in a tri-ethnic sample (Blacks, Whites, and Latinos) of smokers.

METHODS

Smokers were recruited for a web-based survey using an online panel survey company. Participants were 1,201 nondaily smokers (904 converted nondaily smokers and 297 native nondaily smokers). A multivariable logistic regression was conducted to assess the associations between demographic, smoking-related, and psychosocial variables with converted versus native nondaily smoking.

RESULTS

Logistic regression indicated that number of years smoking, years as a nondaily smoker, number of days smoked in a month, smoking dependence, identity as a smoker, and number of smoking cessation methods used were correlates of being converted nondaily smokers versus native nondaily smokers.

CONCLUSIONS

Clinicians and researchers should consider characteristic variations in nondaily smokers when designing and implementing intervention efforts targeting this smoking population.

Effect of graphic cigarette warnings on smoking intentions in young adults

INTRODUCTION

Graphic warnings (GWs) on cigarette packs are widely used internationally and perhaps will be in the US but their impact is not well understood. This study tested support for competing hypotheses in different subgroups of young adults defined by their history of cigarette smoking and individual difference variables (e.g., psychological reactance). One hypothesis predicted adaptive responding (GWs would lower smoking-related intentions) and another predicted defensive responding (GWs would raise smoking-related intentions).

METHODS

Participants were an online sample of 1,169 Americans ages 18-24, who were randomly assigned either to view nine GWs designed by the FDA or to a no-label control. Both the intention to smoke in the future and the intention to quit smoking (among smokers) were assessed before and after message exposure.

RESULTS

GWs lowered intention to smoke in the future among those with a moderate lifetime smoking history (between 1 and 100 cigarettes), and they increased intention to quit smoking among those with a heavy lifetime smoking history (more than 100 cigarettes). Both effects were limited to individuals who had smoked in some but not all of the prior 30 days (i.e., occasional smokers). No evidence of defensive "boomerang effects" on intention was observed in any subgroup.

CONCLUSION

Graphic warnings can reduce interest in smoking among occasional smokers, a finding that supports the adaptive-change hypothesis. GWs that target occasional smokers might be more effective at reducing cigarette smoking in young adults.

Psychosocial and behavioral characteristics among subgroups of nondaily college student smokers

Nondaily smoking is becoming common in young adults and there appear to be different characteristics associated with past month smoking frequency among nondaily smokers. The present study examines behavioral and psychosocial correlates of smoking among subgroups of nondaily college student smokers (N = 80; 18–25 years of age) attending a large, public university. Nondaily smokers were categorized based on the frequency of days smoked in the past month and were divided into two subgroups: 1–5 days and 6–29 days. A quarter of nondaily smokers considered themselves as a smoker and significantly more 6–29 nondaily smokers were identified as a smoker and smoked more cigarettes per day (CPD). Almost half (45%) of nondaily smokers have attempted to quit smoking completely and 71% of the 6–29 nondaily smokers reported significantly higher quit attempts. The 6–29 nondaily smokers had significantly higher perceived risk related to smoking. Self-efficacy to abstain from smoking was significantly higher for 1–5 nondaily smokers. These results suggest heterogeneity among subgroups of nondaily college student smokers exists in a number of behavioral and psychosocial factors. Prevention and cessation strategies may be improved by considering frequency of nondaily smoking and targeting subgroups differently.

Transitions in smoking status over time in a population-based panel study of smokers

INTRODUCTION

Few studies have examined the transitions of smokers in the general population through multiple periods of daily, occasional smoking, or abstinence over time. Transitions from daily to occasional smoking are particularly of interest as these may be steps toward cessation.

METHODS

The Ontario Tobacco Survey panel study followed 4,355 baseline smokers, semiannually for up to 3 years. Probabilities of all possible changes in smoking status more than 6 months were estimated using 13,000 repeated measures observations generated from sets of 3 consecutive interviews (n = 9,932 daily smokers, 1,245 occasion smokers, and 1,823 abstinent for at least 30 days, at Time 1).

RESULTS

For initial daily smokers, an estimated 83% remained daily smokers more than 2 follow-ups. The majority of those who had been abstinent for 30 days at 1 interview, were also former smokers at the following interview. In contrast, occasional smoking status was unstable and future smoking status was dependent upon smoking history and subjective dependence. Among daily smokers who became occasional smokers 6 months later, an estimated 20% became a former smoker, at the next interview, but 50% returned to daily smoking. Daily, turned occasional smokers who rebounded back to daily smoking were more likely to describe themselves as addicted at Time 1. Continuing occasional smokers were somewhat less likely to intend to quit, or have tried, despite considering themselves less addicted.

CONCLUSIONS

Reducing to occasional smoking can be a stepping stone toward cessation but entails a greater risk of return to daily smoking, compared with complete abstinence.

Implicit and explicit reward learning in chronic nicotine use

BACKGROUND

Chronic tobacco use is related to specific neurobiological alterations in the dopaminergic brain reward system that can be termed "reward deficiency syndrome" in dependent nicotine consumers. The close linkage of dopaminergic activity and reward learning led us to expect implicit and explicit reward learning deficits in dependent compared to non-smokers. Smokers who maintain a less regular, occasional use may also, to a lesser extent, show implicit reward learning deficits. The purpose of our study was to examine the behavioral effects of the neurobiological alterations on reward related learning. We also tested whether any deficits observed in an abstinent state are also present in a satiated state.

METHODS

In two studies, we examined implicit and explicit reward learning in smokers. Participants were administered a probabilistic implicit reward learning task, and an explicit reward- and punishment-based trial-and-error learning task. In Study 1, we compared dependent, occasional, and non-smokers, and in Study 2 satiated and abstinent smokers.

RESULTS

In Study 1, chronic and occasional smokers showed impairments in both, implicit and explicit reward learning tasks. In Study 2, satiated smokers did not perform better than abstinent smokers.

CONCLUSIONS

The results support the hypothesis of reward learning deficits. These deficits are not limited to explicit but extend to implicit reward learning and cannot be explained by tobacco withdrawal.

Smoking in context: a multilevel analysis of 49,088 communities in Canada

BACKGROUND

The extent to which the prevalence of smoking in Canada varies across geographic areas independently of individual characteristics has not been quantified.

PURPOSE

To estimate the extent and potential sources of geographic variation in smoking among communities, health regions, and provinces/territories in Canada.

METHODS

Data are from the Canadian Community Health Surveys conducted between 2001 and 2008 (n=461,709). Current cigarette smoking among adults (aged ≥18 years) was the primary outcome. Individual-level markers of SES were education, household income, and occupation. Contextual variables potentially related to smoking considered were provincial cigarette taxes, workplace smoking bans, and collective family norms discouraging smoking in communities. A multilevel logistic regression analysis was conducted to model variation in smoking at the geographic scale of communities, health regions, and provinces.

RESULTS

Overall, the contribution of geography as a percentage of the total variation in smoking was 8.4%, with 2.4% attributable to provinces, 1.2% attributable to health regions, and 4.8% attributable to communities after adjusting for age, gender and survey period. In models that accounted for socioeconomic and demographic characteristics in addition to age and gender, the contribution of geography to the total variation in smoking was attenuated to 4.1%; with 2.0% at the province level, 0.4% at the health region level, and 1.7% at the community level. Within provinces/territories, the community variation in smoking ranged from 2.4% in Prince Edward Island to 9.1% in British Columbia. Nationally, 71% of community and 21% of provincial differences in smoking were explained by individual, socioeconomic, and demographic factors alone; the inclusion of contextual covariates explained an additional 27% of the variation among communities. Collective family norms discouraging smoking in a community was the strongest contextual predictor of individual smoking; provincial cigarette taxes and workplace bans were only modestly related to individual smoking behavior.

CONCLUSIONS

Geographic variation in smoking remained after accounting for individual, socioeconomic, and demographic characteristics, suggesting the importance of place, at the level of provinces and communities in Canada. Remaining community variation in smoking was largely attenuated after accounting for collective family norms discouraging smoking. Area-level influences such as the social and/or environmental conditions of provinces and communities may be important sources of variation in smoking and therefore need to be considered if rates of smoking are to be modified.

Smoking motives of daily and non-daily smokers: a profile analysis

BACKGROUND

Non-daily or intermittent smoking is becoming common, but little is known about smoking patterns of intermittent smokers (ITS). This study assesses differences in the profile of smoking motives of non-daily, ITS and daily smokers (DS).

METHODS

Participants were 218 DS and 252 ITS (152 converted ITS [CITS], who previously smoked daily, and 80 native ITS [NITS] who did not), not currently quitting, recruited by advertisement. ITS were defined as smoking 4-27 days per month; DS as smoking daily, 5-30 cigarettes per day. Participants completed the Wisconsin Inventory of Smoking Dependence Motives (WISDM), yielding scores for 13 different motives. The within-profile standard deviation expressed profile scatter (differentiation among motives), and profile shape was assessed on scores standardized for within-profile mean and standard deviation.

RESULTS

There was no difference between ITS and DS on profile scatter. ITS and DS differed in the shape of the standardized score profile, with DS scoring higher on Tolerance, Craving, Automaticity, Loss of Control and Behavioral Choice motives, and ITS scoring higher on Cue Exposure, Weight Control, and Positive Reinforcement motives. CITS did not differ from NITS in profile scatter or profile shape.

CONCLUSION

ITS differ from DS in the relative importance of motives, with ITS emphasizing motives associated with acute, situational smoking, and DS emphasizing dependence-related motives. Among ITS, history of daily smoking did not influence the profile of motives.

Neuroadaptation in nicotine addiction: update on the sensitization-homeostasis model

The role of neuronal plasticity in supporting the addictive state has generated much research and some conceptual theories. One such theory, the sensitization-homeostasis (SH) model, postulates that nicotine suppresses craving circuits, and this triggers the development of homeostatic adaptations that autonomously support craving. Based on clinical studies, the SH model predicts the existence of three distinct forms of neuroplasticity that are responsible for withdrawal, tolerance and the resolution of withdrawal. Over the past decade, many controversial aspects of the SH model have become well established by the literature, while some details have been disproven. Here we update the model based on new studies showing that nicotine dependence develops through a set sequence of symptoms in all smokers, and that the latency to withdrawal, the time it takes for withdrawal symptoms to appear during abstinence, is initially very long but shortens by several orders of magnitude over time. We conclude by outlining directions for future research based on the updated model, and commenting on how new experimental studies can gain from the framework put forth in the SH model.

Characteristics and smoking patterns of intermittent smokers

Current models of smoking and dependence assume a need to smoke at regular intervals to maintain nicotine levels, yet about 25% of adult smokers do not smoke daily. This subset of intermittent smokers (ITS) has gone largely unexamined. In this study, we describe the demographics, smoking history, and smoking behavior of ITS (n = 282; 50.2% male) in comparison to daily smokers (DS; n = 233; 60.7% male). Within ITS, we also compare "converted" ITS (CITS), who had previously smoked daily, with "native" ITS (NITS). On average, ITS were 34.66 years of age, and had smoked 42,850 cigarettes in the course of an average of 18 years of smoking. They smoked an average of 4.38 days per week, consuming 4.39 cigarettes a day on smoking days, and demonstrated considerable day-to-day variability in cigarette consumption. Almost half of ITS had Fagerstrom Test of Nicotine Dependence scores of 0, indicating no dependence. Compared to DS, ITS were more likely to cite alcohol drinking, socializing, and being with other smokers as common contexts for smoking, and they also more often cited being angry or stressed. Data suggested that ITS' behavior was not explained by use of other nicotine products nor by economic constraints on smoking, nor by differences in psychological adjustment. Within ITS, CITS were heavier, more frequent, and more dependent smokers. In many respects, CITS were intermediate between NITS and DS. ITS show distinct patterns of smoking behavior that are not well explained by current models of nicotine dependence.

Adult current smoking: differences in definitions and prevalence estimates--NHIS and NSDUH, 2008

OBJECTIVES

To compare prevalence estimates and assess issues related to the measurement of adult cigarette smoking in the National Health Interview Survey (NHIS) and the National Survey on Drug Use and Health (NSDUH).

METHODS

2008 data on current cigarette smoking and current daily cigarette smoking among adults ≥18 years were compared. The standard NHIS current smoking definition, which screens for lifetime smoking ≥100 cigarettes, was used. For NSDUH, both the standard current smoking definition, which does not screen, and a modified definition applying the NHIS current smoking definition (i.e., with screen) were used.

RESULTS

NSDUH consistently yielded higher current cigarette smoking estimates than NHIS and lower daily smoking estimates. However, with use of the modified NSDUH current smoking definition, a notable number of subpopulation estimates became comparable between surveys. Younger adults and racial/ethnic minorities were most impacted by the lifetime smoking screen, with Hispanics being the most sensitive to differences in smoking variable definitions among all subgroups.

CONCLUSIONS

Differences in current cigarette smoking definitions appear to have a greater impact on smoking estimates in some sub-populations than others. Survey mode differences may also limit intersurvey comparisons and trend analyses. Investigators are cautioned to use data most appropriate for their specific research questions.

Occasional smoking in college: who, what, when and why?

INTRODUCTION

The majority of college students who smoke do so on an occasional basis and generally do not define themselves as smokers. This represents a considerable challenge for public health efforts to prevent escalation of use and to promote cessation. Strengthening such efforts will require further examination of the motivations behind occasional smoking within this vulnerable group.

METHODS

Based within a priori identified content areas, we conducted eight focus groups of occasional smokers (N=53) at two demographically diverse colleges in the southeastern U.S.

RESULTS

Few participants self-identified as a smoker and few had immediate desire to quit. Most identified extrinsic motivations for future quitting, including college graduation and parenthood. Although participants acknowledged smoking-related health risks, they minimized them as being personally irrelevant. Participants highlighted social (i.e., alcohol and other smokers) and stress-related smoking triggers. They also described how they carefully managed the situations in which they would, and would not smoke in order to preserve their identity.

CONCLUSIONS

College students who smoke occasionally appear to engage in impression management, taking effort to shape their personal image to not appear as a smoker. They use smoking mainly as a social engagement tool, but also to alleviate negative emotions. They express minimal desire to quit and believe they are immune to the health risks of smoking. Public health messages should address this common pattern of smoking among young adults differently than regular smoking patterns by highlighting the social, emotional, and health consequences of occasional smoking before nicotine dependence has fully developed.

Smoking cessation behavior among intermittent smokers versus daily smokers

Nondaily intermittent smokers (ITS) are common, but their cessation behavior remains elusive. We examined cessation of native-ITS (n = 2040), converted-ITS (n = 1808), and daily smokers (DS; n = 25 344). All ITS were more likely than were DS to make a quit attempt (native-ITS adjusted odds ratio [AOR] = 1.60, 95% confidence interval [CI] = 1.42, 1.80; converted-ITS AOR = 3.33, 95% CI = 2.93, 3.78). Native-ITS (18%) and converted-ITS (27%) were more likely than were DS (13%) to quit smoking (native-ITS AOR = 1.34, 95% CI = 1.07, 1.67; converted-ITS AOR = 2.36, 95% CI = 2.01, 2.78), but the low cessation rates of ITS challenge their nonaddicted status.