Smoking withdrawal in smokers with and without posttraumatic stress disorder

Tobacco use, trauma exposure and PTSD: a systematic review

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

The effects of reduced nicotine content cigarettes on biomarkers of nicotine and toxicant exposure, smoking behavior and psychiatric symptoms in smokers with mood or anxiety disorders: A double-blind randomized trial

BACKGROUND

The U.S. Food and Drug Administration and the government of New Zealand have proposed a reduction of the nicotine content in cigarettes to very low levels. This study examined the potential effects of this regulation in smokers with affective disorders.

METHODS

In a randomized controlled parallel group trial conducted at two sites in the USA (Penn State University, Hershey, PA and Massachusetts General Hospital, Boston, MA) 188 adult smokers with a current (n = 118) or lifetime (n = 70) anxiety or unipolar mood disorder, not planning to quit in the next 6 months, were randomly assigned (1:1) to smoke either Usual Nicotine Content (UNC) (11.6 mg nicotine/cigarette) research cigarettes, or Reduced Nicotine Content (RNC) research cigarettes where the nicotine content per cigarette was progressively reduced to 0.2 mg in five steps over 18 weeks. Participants were then offered the choice to either receive assistance to quit smoking, receive free research cigarettes, or resume using their own cigarette brand during a 12-week follow-up period. Main outcomes were biomarkers of nicotine and toxicant exposure, smoking behavior and dependence and severity of psychiatric symptoms. The pre-registered primary outcome was plasma cotinine.

RESULTS

A total of 143 (76.1%) randomized participants completed the randomized phase of the trial, 69 (73.4%) in the RNC group and 74 (78.8%) in the UNC group. After switching to the lowest nicotine content cigarettes, compared to smokers in the UNC group, at the last randomized visit the RNC group had significantly lower plasma cotinine (metabolite of nicotine): difference between groups, -175.7, 95% CI [-218.3, -133.1] ng/ml. Urine NNAL (metabolite of NNK, a lung carcinogen), exhaled carbon-monoxide, cigarette consumption, and cigarette dependence were also significantly lower in the RNC group than the UNC group. No between-group differences were found on a range of other biomarkers (e.g. 8-isoprostanes) or health indicators (e.g. blood pressure), or on 5 different psychiatric questionnaires, including the Kessler K6 measure of psychological distress. At the end of the subsequent 12-week treatment choice phase, those randomized to the RNC group were more likely to have quit smoking, based on initial intent-to-treat sample, n = 188 (18.1% RNC v 4.3% UNC, p = 0.004).

CONCLUSION

Reducing nicotine content in cigarettes to very low levels reduces some toxicant exposures and cigarette addiction and increases smoking cessation in smokers with mood and/or anxiety disorders, without worsening mental health.

TRIAL REGISTRATION

TRN: NCT01928758, registered August 21, 2013.

Effectiveness of Mental Health Warnings on Tobacco Packaging in People With and Without Common Mental Health Conditions: An Online Randomised Experiment

Background

Health warning labels on tobacco packaging are a cost-effective means of health risk communication. However, while an extensive range of physical health risks are well-portrayed via current tobacco health warnings in the UK, there are none that currently portray the negative impact of smoking on mental health.

Aims

(i) develop novel mental health warning labels for tobacco packaging and (ii) test perceptions of these warnings in smokers and non-smokers, with and without mental health problems.

Methods

Six mental health warning labels were developed with a consultancy focus group. These warning labels were tested in an online randomised experiment, where respondents (N = 687) rated six Mental Health Warning Labels (MHWLs) and six Physical Health Warning Labels (PHWLs) on measures of perceived effectiveness, believability, arousal, valence, acceptability, reactance and novelty of information.

Results

MHWLs were perceived as low to moderately effective (mean = 4.02, SD = 2.40), but less effective than PHWLs (mean = 5.78, SD = 2.55, p < 0.001, η p 2 = 0.63). MHWLs were perceived as less believable, arousing, unpleasant, and acceptable than PHWLs. MHWLs evoked more reactance and were rated as more novel. Perceptions of MHWLs did not differ in people with and without mental health problems except for reactance and acceptability, but consistent with the PHWL literature, perceptions of MHWLs differed between non-smokers and smokers.

Conclusion

MHWLs could be an effective means to communicate novel information about the effects of smoking on mental health. MHWLs are perceived as less effective, believable, arousing, unpleasant, and acceptable than PHWLs, but MHWLs evoke more reactance and are rated as more novel.

Post-traumatic Stress Disorder and Risk Factors in Patients With Acute Myocardial Infarction After Emergency Percutaneous Coronary Intervention: A Longitudinal Study

This study aimed to investigate the status and risk factors of post-traumatic stress disorder (PTSD) in patients with acute myocardial infarction (AMI) after emergency percutaneous coronary intervention (PCI) in acute and convalescence phases. A longitudinal study design was used. Two questionnaire surveys were conducted in the acute stage of hospitalization, and 3 months after onset in patients. Logistic regression was used to analyze the risk factors for PTSD in AMI patients. The incidence of PTSD was 33.1 and 20.4% in acute and convalescent patients, respectively. The risk factors related to PTSD were door-to-balloon time (DTB) (≥92.6 min), left ventricular ejection fraction (LVEF) (<50%), smoking, anxiety, and depression. AMI patients after PCI had PTSD in the acute and convalescent stage. The findings indicate that tailored measures should be developed and carried out to prevent PTSD and improve the mental health of patients with AMI after undergoing PCI.

Tobacco Withdrawal Symptoms Before and After Nicotine Deprivation in Veteran Smokers with Posttraumatic Stress Disorder and with Major Depressive Disorder

INTRODUCTION

The high smoking prevalence amongst individuals with psychiatric disorders constitutes a major public health disparity. Negative reinforcement models of addiction posit that severe tobacco withdrawal symptoms, related to the affective vulnerabilities of these smokers, may thwart their quitting smoking successfully. However, relatively few studies have prospectively examined the effects of nicotine deprivation on withdrawal symptoms in these groups.

METHODS

This study compared the level of withdrawal symptoms both before and after nicotine deprivation in those diagnosed with posttraumatic stress disorder (PTSD) or major depressive disorder (MDD) and in those without psychiatric diagnoses. Participants were US veterans who smoked (≥10 cigarettes/day) and met diagnostic criteria for PTSD (n = 38), MDD (n = 43), or no psychiatric diagnosis ("controls" n = 44). Participants attended study visits before and during 48-hour nicotine deprivation to report tobacco withdrawal symptoms. Analyses evaluated withdrawal symptom levels (baseline and during nicotine deprivation) and the change in symptoms related to nicotine deprivation and compared (1) participants with a psychiatric diagnosis versus controls, and (2) participants with PTSD versus MDD.

RESULTS

Contrary to hypotheses, nicotine deprivation produced greater increases in most withdrawal symptoms amongst controls than in those with psychiatric diagnoses. Compared with controls, those with PTSD or MDD reported elevated symptom levels both before and after tobacco deprivation for most withdrawal symptoms.

CONCLUSIONS

These findings suggest that chronically high levels of distress and craving, rather than acute increases in withdrawal symptoms because of nicotine deprivation, may account for the quitting difficulties of those with comorbid conditions such as PTSD and MDD.

IMPLICATIONS

Severe tobacco withdrawal may account for the higher quitting difficulties of smokers with either posttraumatic stress disorder (PTSD) or major depressive disorder (MDD). Paradoxically, this study showed that individuals with no psychiatric diagnosis had greater increases in tobacco withdrawal severity because of nicotine deprivation than did those with either PTSD or MDD. Those with either PTSD or MDD showed high stable levels of withdrawal symptom severity both before and during two days of abstinence, suggesting that their quitting difficulties may be related to their chronically high levels of distress rather than nicotine deprivation per se.

The Impact of Co-occurring Post-traumatic Stress Disorder and Substance Use Disorders on Craving: A Systematic Review of the Literature

The frequent co-occurrence of post-traumatic stress disorder (PTSD) and substance use disorders (SUDs) leads to manifestations of both conditions that are more severe and more resistance to treatment than single disorders. One hypothesis to explain this synergy is the impact of intrusive memories on craving which, in turn, increases the risk of relapse among patients with substance use disorders. The aim of this systematic review is to examine this possibility by assessing the impact of PTSD and its symptoms on craving among dual disorder patients. Using PRISMA criteria, four databases were comprehensively searched up to June, 2021, in order to identify all candidate studies based on broad key words. Resulting studies were then selected if they examined the impact of PTSD or PTSD symptoms on craving, and if they used standardized assessments of PTSD, SUD, and craving. Twenty-seven articles matched the selection criteria and were included in this review. PTSD was found to be significantly associated with increased craving levels among patients with alcohol, cannabis, cocaine, tobacco, and other substance use disorders. Exposition to traumatic cues among dual disorder patients was also shown to trigger craving, with an additive effect on craving intensity when exposure to substance-related cues occurred. In addition, certain studies observed a correlation between PTSD symptom severity and craving intensity. Concerning mechanisms underlying these associations, some findings suggest that negative emotional states or emotion dysregulation may play a role in eliciting craving after traumatic exposure. Moreover, these studies suggest that PTSD symptoms may, independently of emotions, act as powerful cues that trigger craving. These findings argue for the need of dual disorder treatment programs that integrate PTSD-focused approaches and emotion regulation strategies, in addition to more traditional interventions for craving management.

Overexpression of corticotropin-releasing factor in the nucleus accumbens enhances the reinforcing effects of nicotine in intact female versus male and ovariectomized female rats

This study assessed the role of stress systems in the nucleus accumbens (NAc) in promoting sex differences in the reinforcing effects of nicotine. Intravenous self-administration (IVSA) of various doses of nicotine was compared following overexpression of corticotropin-releasing factor (CRF) in the NAc of female and male rats. Ovariectomized (OVX) females were also included to assess the role of ovarian hormones in promoting nicotine reinforcement. Rats received intra-NAc administration of an adeno-associated vector that overexpressed CRF (AAV2/5-CRF) or green fluorescent protein (AAV2/5-GFP). All rats were then given extended access (23 h/day) to an inactive and an active lever that delivered nicotine. Separate groups of rats received intra-NAc AAV2/5-CRF and saline IVSA. Rats were also allowed to nose-poke for food and water during IVSA testing. At the end of the study, the NAc was dissected and rt-qPCR methods were used to estimate CRF overexpression and changes in CRF receptors (CRFr1, CRFr2) and the CRF receptor internalizing protein, β-arrestin2 (Arrb2). Overexpression of CRF in the NAc increased nicotine IVSA to a larger extent in intact female versus male and OVX females. Food intake was increased to a larger extent in intact and OVX females as compared to males. The increase in CRF gene expression was similar across all groups; however, in females, overexpression of CRF resulted in a larger increase in CRFr1 and CRFr2 relative to males. In males, overexpression of CRF produced a larger increase in Arrb2 than females, suggesting greater CRF receptor internalization. Our results suggest that stress systems in the NAc promote the reinforcing effectiveness of nicotine in female rats in an ovarian hormone-dependent manner.

The Temporal Relationship Between Coping Self-Efficacy and Dissociation in Undergraduate Students

Dissociation is a lack of information integration resulting from a process that ranges on a continuum from normative experiences (e.g., daydreaming) to a pervasive traumatic response involving alterations and/or fragmentation in mental processes such as memory, emotion, and perception. Perceived coping self-efficacy (CSE) is a cognitive appraisal ability utilized to regulate internal and external stressors that arise from traumatic events, and is crucial for effective adaptation after extreme stress or trauma. Thus, CSE may be a critical component in decreasing dissociative experiences following a traumatic event. In the present study, 136 undergraduate students (M age = 22.36 years, SD = 6.27; 81% female, 69.1% Caucasian, 77.2% attended some college) completed self-report measures of trauma, dissociation, and coping self-efficacy. All measures were completed by the same participants at two different time points (Time 1 and Time 2) two months apart; all participants reported a history of exposure to at least one Criterion A traumatic event (according to the DSM-5) at Time 1. We hypothesized that CSE for posttraumatic coping demands at Time 2 would mediate the relationship between dissociation at Time 1 and dissociation at Time 2, and subsequently found evidence of significant mediation, 95% CI [.02, .18]. These findings suggest that initial levels of persistent dissociation negatively predict CSE, which in turn directly and negatively influence persistent dissociation at a later time point. This highlights how CSE may serve as a protective factor against persistent dissociation.

Contingency management and cognitive behavioral therapy for trauma-exposed smokers with and without posttraumatic stress disorder

INTRODUCTION

Trauma-exposed individuals with and without posttraumatic stress disorder (PTSD) are more likely to smoke and less successful in quit attempts than individuals without psychopathology. Contingency management (CM) techniques (i.e., incentives for abstinence) have demonstrable efficacy for smoking cessation in some populations with psychopathology, but have not been well tested in PTSD. This pilot study examined the feasibility of CM plus brief cognitive behavioral therapy (CBT) in promoting smoking cessation among trauma-exposed individuals with and without PTSD.

METHODS

Fifty trauma-exposed smokers (18 with PTSD) were asked to abstain from tobacco and nicotine replacement therapy for one month. During week one of cessation, CBT was provided daily and increasing CM stipends were paid for each continuous day of biochemically-verified abstinence; CM stipends were withheld in response to smoking lapses and reset to the initial payment level upon abstinence resumption. CBT and fixed payments for study visits were provided during the subsequent three weeks.

RESULTS

Of the 50 eligible participants who attended at least one pre-quit visit (49% female, 35% current PTSD), 43 (86%) attended the first post-quit study visit, 32 (64%) completed the first week of CM/CBT treatment, and 26 (52%) completed the study. Post-quit seven-day point prevalence abstinence rates for participants with and without PTSD, respectively, were similar: 39% vs. 38% (1 week), 33% vs. 28% (2 weeks), 22% vs. 19% (3 weeks), and 22% vs. 13% (4 weeks).

CONCLUSIONS

Use of CM + CBT to support tobacco abstinence is a promising intervention for trauma-exposed smokers with and without PTSD.

The clinical applications and practical relevance of human conditioning paradigms for posttraumatic stress disorder

The classical conditioning paradigm of fear learning has spawned a number of experimental variations for the explanation of posttraumatic stress disorder (PTSD) etiology. These paradigms include extinction learning and recall, fear inhibition, fear generalization, and conditioned avoidance. As such, each of these paradigms have significant applications for understanding the development, maintenance, treatment, and relapse of the fear-related features of PTSD. In the present review, we describe each of these conditioning-based paradigms with reference to the clinical applications, and supported by case examples from patients with severe PTSD symptoms. We also review the neurobiological models of conditioning and extinction in animals, psychiatrically healthy humans, and PTSD patients, and discuss the current balance of evidence suggesting a number of biological, behavioral, and cognitive mechanisms/moderators of the conditioning and extinction process in experimental and clinical contexts.

Posttraumatic stress disorder and cigarette smoking: A systematic review

BACKGROUND

Previous reviews of the PTSD and cigarette smoking literature showed high PTSD-smoking comorbidity and problematic smoking outcomes (Feldner et al., 2007, Clinical Psychology Review, 27, 14-45; Fu et al., 2007, Nicotine & Tobacco Research, 9, 1071-1084). However, past reviews also noted several prominent gaps in the literature, including a lack of etiological work examining underlying mechanisms and research on specialized PTSD-smoking treatments. The present review summarizes an extensive body of research conducted since the previous reviews targeting these areas of need.

METHODS

Literature searches identified 66 empirical studies specific to smoking and PTSD.

RESULTS

Smokers were approximately twice more likely to have PTSD than nonsmokers in the general population, and individuals with PTSD were approximately twice as likely to be current smokers. Smokers with PTSD evidenced more negative affect, trauma history, and comorbid psychiatric history, as well as quit attempts and higher relapse rates. PTSD symptoms were associated with expectations that smoking would reduce negative affect, which, in turn, was associated with increased smoking rate and nicotine dependence. Male sex was associated with nicotine dependence and PTSD avoidance, while the relationship between PTSD and smoking relapse due to withdrawal was stronger in females. Specialized, integrated PTSD and smoking cessation treatments showed promise in increasing quit success relative to standard care in randomized trials.

CONCLUSIONS

Rates of PTSD-smoking co-occurrence remain high. Notable gains have been made in relevant epidemiological and etiological research, although more work is needed in trauma-specific subpopulations. Several promising specialized treatments for comorbid smoking-PTSD have been developed and empirically tested but require replication.

Basolateral amygdala, nicotinic cholinergic receptors, and nicotine: Pharmacological effects and addiction in animal models and humans

The amygdala is involved in processing incoming information about rewarding stimuli and emotions that denote danger such as anxiety and fear. Bi-directional neural connections between basolateral amygdala (BLA) and brain regions such as nucleus accumbens, prefrontal cortex, hippocampus, and hindbrain regions regulate motivation, cognition, and responses to stress. Altered local regulation of BLA excitability is pivotal to the behavioral disturbances characteristic of posttraumatic stress disorder, and relapse to drug use induced by stress. Herein, we review the physiological regulation of BLA by cholinergic inputs, emphasizing the role of BLA nicotinic receptors. We review BLA-dependent effects of nicotine on cognition, motivated behaviors, and emotional states, including memory, taking and seeking drugs, and anxiety and fear in humans and animal models. The alterations in BLA activity observed in animal studies inform human behavioral and brain imaging research by enabling a more exact understanding of altered BLA function. Converging evidence indicates that cholinergic signaling from basal forebrain projections to local nicotinic receptors is an important physiological regulator of BLA and that nicotine alters BLA function. In essence, BLA is necessary for behavioral responses to stimuli that evoke anxiety and fear; reinstatement of cue-induced drug seeking; responding to second-order cues conditioned to abused drugs; reacquisition of amplified nicotine self-administration due to chronic stress during abstinence; and to promote responding for natural reward.

A two-site, two-arm, 34-week, double-blind, parallel-group, randomized controlled trial of reduced nicotine cigarettes in smokers with mood and/or anxiety disorders: trial design and protocol

BACKGROUND

The U.S. Food and Drug Administration can set standards for cigarettes that could include reducing their nicotine content. Such a standard should improve public health without causing unintended serious consequences for sub-populations. This study evaluates the effect of progressive nicotine reduction in cigarettes on smoking behavior, toxicant exposure, and psychiatric symptoms in smokers with comorbid mood and/or anxiety disorders using a two-site, two-arm, double-blind, parallel group, randomized controlled trial (RCT) in four phases over 34 weeks.

METHODS

Adult smokers (N = 200) of 5 or more cigarettes per day will be randomized across two sites (Penn State and Massachusetts General). Participants must have not had a quit attempt in the prior month, nor be planning to quit in the next 6 months, meet criteria for a current or lifetime unipolar mood and/or anxiety disorder based on the structured Mini-International Neuropsychiatric Interview, and must not have an unstable medical or psychiatric condition. After a week of smoking their own cigarettes, participants receive two weeks of Spectrum research cigarettes with usual nicotine content (11.6 mg). After this baseline period, participants will be randomly assigned to continue smoking Spectrum research cigarettes that contain either (a) Usual Nicotine Content (11.6 mg); or (b) Reduced Nicotine Content: the nicotine content per cigarette is progressively reduced from approximately 11.6 mg to 0.2 mg in five steps over 18 weeks. At the end of the randomization phase, participants will be offered the choice to either (a) quit smoking with assistance, (b) continue smoking free research cigarettes, or (c) return to purchasing their own cigarettes, for the final 12 weeks of the study. The primary outcome measure is blood cotinine; key secondary outcomes are: exhaled carbon monoxide, urinary total NNAL- 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and 1-hydroxypyrene, oxidative stress biomarkers including 8-isoprostanes, measures of psychiatric symptoms (e.g., depression, anxiety), smoking behavior and dependence (e.g., cigarette consumption, quit attempts), and health effects (e.g., blood pressure, respiratory symptoms).

DISCUSSION

Results from this study will inform FDA on the potential effects of regulating the nicotine content of cigarettes and help determine whether smokers with mood and/or anxiety disorders can safely transition to significantly reduced nicotine content cigarettes.

TRIAL REGISTRATION

TRN: NCT01928758 , registered August 21, 2013.

Smoking-induced affect modulation in nonwithdrawn smokers with posttraumatic stress disorder, depression, and in those with no psychiatric disorder

This research sought to determine whether smoking influences affect by means other than withdrawal reduction. Little previous evidence suggests such an effect. We surmised that such an effect would be especially apparent in posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), 2 disorders that are frequently comorbid with smoking and that involve dysregulated affect. Participants were U.S. veterans who were regular smokers (N = 159): 52 with PTSD (58% with comorbid MDD), 51 with MDD, and 56 controls with no psychiatric disorder. During 3 positive and 3 negative mood induction trials (scheduled over 2 sessions), nonwithdrawn participants smoked either a nicotine-containing cigarette (NIC+), a nicotine-free cigarette (NIC-), or held a pen. Positive and negative affect were each measured before and after mood induction. Results showed a significant 2-way interaction of Smoking Condition × Time on negative affect during the negative mood induction (F(6, 576) = 2.41, p = .03) in those with PTSD and controls. In these groups, both NIC+ and NIC-, relative to pen, produced lower negative affect ratings after the negative mood induction. There was also a 2-way interaction of Smoking Condition × Time on positive affect response to the positive mood induction among those with PTSD and controls (F(6, 564) = 3.17, p = .005) and among MDD and controls (F(6, 564) = 2.27, p = .036). Among all smokers, NIC+ enhanced the magnitude and duration of positive affect more than did NIC-. Results revealed affect modulation outside the context of withdrawal relief; such effects may motivate smoking among those with psychiatric diagnoses, and among smokers in general. (PsycINFO Database Record

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

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

Post-traumatic stress disorder symptoms, underlying affective vulnerabilities, and smoking for affect regulation

BACKGROUND AND OBJECTIVES

Post-traumatic stress disorder (PTSD) is overrepresented among cigarette smokers. It has been hypothesized that those with PTSD smoke to alleviate negative affect and counteract deficient positive affect commonly associated with the disorder; however, limited research has examined associations between PTSD symptoms, smoking motives, and affective vulnerability factors. In the current study, we examined (1) whether PTSD symptoms were associated with positive reinforcement and negative reinforcement smoking motives; and (2) whether two affective vulnerability factors implicated in PTSD-anxiety sensitivity and anhedonia-mediated relationships between PTSD symptoms and smoking motives.

METHODS

Data were drawn from a community sample of non-treatment-seeking smokers recruited without regard for trauma history (N = 342; 10+ cig/day). We used the Posttraumatic Stress Disorder Checklist-Civilian Version (PCL-C) to assess overall PTSD symptom severity as well as individual PTSD subfactors.

RESULTS

Overall, PTSD symptom severity was significantly associated with negative reinforcement, but not positive reinforcement, smoking motives. Variation in anxiety sensitivity significantly mediated the relation between PTSD symptom severity and negative reinforcement smoking motives, whereas anhedonia did not. Regarding PTSD subfactors, emotional numbing was the only PTSD subfactor associated with smoking rate, while re-experiencing symptoms were uniquely associated with both positive reinforcement and negative reinforcement smoking motives.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Findings suggest that anxiety sensitivity may be an important feature associated with PTSD that enhances motivation to smoke for negative reinforcement purposes. Smoking cessation interventions that alleviate anxiety sensitivity and enhance coping with negative affect may be useful for smokers with elevated PTSD symptoms.

PTSD and Risk of Incident Cardiovascular Disease in Aging Veterans

OBJECTIVES

To determine if late-life posttraumatic stress disorder (PTSD) is associated with cardiovascular disease in a sample of older veterans, and whether the association is independent of medical and psychiatric comorbities.

DESIGN

Retrospective cohort study conducted using the Department of Veterans Affairs (VA) National Patient Care Database (2000-2011).

SETTING

VA medical centers in the United States.

PARTICIPANTS

A total of 138,341 veterans 55 years and older without cardiovascular disease at study baseline (2000-2003).

MEASUREMENTS

PTSD and cardiovascular disease (as defined by diagnoses of: cerebrovascular disease [CVD], congestive heart failure [CHF], myocardial infarction [MI], and peripheral vascular disease [PVD]) were identified by ICD-9 codes during study baseline (2000-2003) and follow-up (2004-2011), respectively.

RESULTS

3% of veterans (N = 4,041) had a baseline diagnosis of PTSD. Unadjusted increased risk of incidence of CVD was 80%, CHF was 56%, MI was 82%, and PVD was 60% in veterans with PTSD compared with those without PTSD. After adjustment for demographics, medical comorbidities, substance use, and psychiatric comorbidities, veterans with late-life PTSD were at a 45% increased risk for incident CVD, 26% increased risk for incident CHF, 49% increased risk for incident MI, and 35% increased risk for PVD compared with veterans without late-life PTSD.

CONCLUSIONS

Findings highlight the longitudinal impact of PTSD on increasing the incidence of cardiovascular disease in older adults. This study implies the need for greater monitoring and treatment of PTSD in older persons, particularly older veterans, to assist in preventing adverse outcomes, such as cardiovascular disease, over the long term.

Cognitive Dysfunction, Affective States, and Vulnerability to Nicotine Addiction: A Multifactorial Perspective

Although smoking prevalence has declined in recent years, certain subpopulations continue to smoke at disproportionately high rates and show resistance to cessation treatments. Individuals showing cognitive and affective impairments, including emotional distress and deficits in attention, memory, and inhibitory control, particularly in the context of psychiatric conditions, such as attention-deficit hyperactivity disorder, schizophrenia, and mood disorders, are at higher risk for tobacco addiction. Nicotine has been shown to improve cognitive and emotional processing in some conditions, including during tobacco abstinence. Self-medication of cognitive deficits or negative affect has been proposed to underlie high rates of tobacco smoking among people with psychiatric disorders. However, pre-existing cognitive and mood disorders may also influence the development and maintenance of nicotine dependence, by biasing nicotine-induced alterations in information processing and associative learning, decision-making, and inhibitory control. Here, we discuss the potential forms of contribution of cognitive and affective deficits to nicotine addiction-related processes, by reviewing major clinical and preclinical studies investigating either the procognitive and therapeutic action of nicotine or the putative primary role of cognitive and emotional impairments in addiction-like features.

Early life adversity and/or posttraumatic stress disorder severity are associated with poor diet quality, including consumption of trans fatty acids, and fewer hours of resting or sleeping in a US middle-aged population: A cross-sectional and prospective study

BACKGROUND

Early life adversity (ELA) and post-traumatic stress disorder (PTSD) are associated with poorer psychological and physical health. Potential underlying mechanisms and mediators remain to be elucidated, and the lifestyle habits and characteristics of individuals with ELA and/or PTSD have not been fully explored. We investigated whether the presence of ELA and/or PTSD are associated with nutrition, physical activity, resting and sleeping and smoking.

METHODS

A cross-sectional sample of 151 males and females (age: 45.6±3.5 years, BMI: 30.0±7.1 kg/m(2)) underwent anthropometric measurements, as well as detailed questionnaires for dietary assessment, physical activity, resting and sleeping, smoking habits and psychosocial assessments. A prospective follow-up visit of 49 individuals was performed 2.5 years later and the same outcomes were assessed. ELA and PTSD were evaluated as predictors, in addition to a variable assessing the combined presence/severity of ELA-PTSD. Data were analyzed using analysis of covariance after adjusting for several socioeconomic, psychosocial and anthropometric characteristics.

RESULTS

Individuals with higher ELA or PTSD severity were found to have a poorer diet quality (DASH score: p=0.006 and p=0.003, respectively; aHEI-2010 score: ELA p=0.009), including further consumption of trans fatty acids (ELA p=0.003); the differences were significantly attenuated null after adjusting mainly for education or income and/or race. Further, individuals with higher ELA severity reported less hours of resting and sleeping (p=0.043) compared to those with zero/lower ELA severity, and the difference remained significant in the fully adjusted model indicating independence from potential confounders. When ELA and PTSD were combined, an additive effect was observed on resting and sleeping (p=0.001); results remained significant in the fully adjusted model. They also consumed more energy from trans fatty acids (p=0.017) tended to smoke more (p=0.008), and have less physical activity (PTSD p=0.024) compared to those with no or lower ELA and PTSD severity. Adjustments for sociodemographic factors and/or BMI rendered results of the above lifestyle parameters non-significant. The analysis of the prospective data showed similar trends to the cross-sectional analysis, further supporting the conclusions, although statistical significance of results was lower due to the lower number of participants.

CONCLUSION

Fewer hours of resting and sleeping and poorer diet quality are linked to ELA and/or PTSD, indicating that these pathways might underlie the development of several metabolic abnormalities in individuals with ELA and/or PTSD. Differences in terms of diet quality are significantly attenuated by race and/or education and/or income, whereas differences in other lifestyle habits of individuals with and without ELA and/or PTSD, such as physical activity, are mostly explained by confounding sociodemographic variables and/or body mass index.

Smoking cessation and reduction in people with chronic mental illness

The high prevalence of cigarette smoking and tobacco related morbidity and mortality in people with chronic mental illness is well documented. This review summarizes results from studies of smoking cessation treatments in people with schizophrenia, depression, anxiety disorders, and post-traumatic stress disorder. It also summarizes experimental studies aimed at identifying biopsychosocial mechanisms that underlie the high smoking rates seen in people with these disorders. Research indicates that smokers with chronic mental illness can quit with standard cessation approaches with minimal effects on psychiatric symptoms. Although some studies have noted high relapse rates, longer maintenance on pharmacotherapy reduces rates of relapse without untoward effects on psychiatric symptoms. Similar biopsychosocial mechanisms are thought to be involved in the initiation and persistence of smoking in patients with different disorders. An appreciation of these common factors may aid the development of novel tobacco treatments for people with chronic mental illness. Novel nicotine and tobacco products such as electronic cigarettes and very low nicotine content cigarettes may also be used to improve smoking cessation rates in people with chronic mental illness.

Nicotine Addiction and Psychiatric Disorders

Even though smoking rates have long been on the decline, nicotine addiction still affects 20% of the US population today. Moreover, nicotine dependence shows high comorbidity with many mental illnesses including, but are not limited to, attention deficit hyperactivity disorder, anxiety disorders, and depression. The reason for the high rates of smoking in patients with mental illnesses may relate to attempts to self-medicate with nicotine. While nicotine may alleviate the symptoms of mental disorders, nicotine abstinence has been shown to worsen the symptoms of these disorders. In this chapter, we review the studies from animal and human research examining the bidirectional relationship between nicotine and attention deficit hyperactivity disorder, anxiety disorders, and depression as well as studies examining the roles of specific subunits of nicotinic acetylcholine receptors (nAChRs) in the interaction between nicotine and these mental illnesses. The results of these studies suggest that activation, desensitization, and upregulation of nAChRs modulate the effects of nicotine on mental illnesses.

Nicotine modulation of fear memories and anxiety: Implications for learning and anxiety disorders

Anxiety disorders are a group of crippling mental diseases affecting millions of Americans with a 30% lifetime prevalence and costs associated with healthcare of $42.3 billion. While anxiety disorders show high levels of co-morbidity with smoking (45.3% vs. 22.5% in healthy individuals), they are also more common among the smoking population (22% vs. 11.1% in the non-smoking population). Moreover, there is clear evidence that smoking modulates symptom severity in patients with anxiety disorders. In order to better understand this relationship, several animal paradigms are used to model several key symptoms of anxiety disorders; these include fear conditioning and measures of anxiety. Studies clearly demonstrate that nicotine mediates acquisition and extinction of fear as well as anxiety through the modulation of specific subtypes of nicotinic acetylcholine receptors (nAChRs) in brain regions involved in emotion processing such as the hippocampus. However, the direction of nicotine's effects on these behaviors is determined by several factors that include the length of administration, hippocampus-dependency of the fear learning task, and source of anxiety (novelty-driven vs. social anxiety). Overall, the studies reviewed here suggest that nicotine alters behaviors related to fear and anxiety and that nicotine contributes to the development, maintenance, and reoccurrence of anxiety disorders.

Predicted Impact of Nicotine Reduction on Smokers with Affective Disorders

OBJECTIVES

In 2009 the FDA acquired the authority to reduce the nicotine content in cigarettes if appropriate for public health, prompting research to evaluate the implications of this policy scientifically. Studies in non-psychiatric populations show that reducing the nicotine content of cigarettes to non-addictive levels reduces smoking rates and nicotine dependence. However, few studies have examined this hypothesis in vulnerable populations.

METHODS

In this narrative review we examined the extant literature on the effects of nicotine reduction or cessation on symptoms of withdrawal, as well as psychiatric symptoms, among those with affective disorders.

RESULTS

Following initial withdrawal from nicotine, smokers with affective disorders experience more severe mood disruption than smokers without these disorders. Use of very low nicotine content (VLNC) cigarettes during abstinence may help mitigate the mood-disrupting effects of initial abstinence. Once the initial effects of nicotine withdrawal on mood have passed, longer-term abstinence is associated with psychiatric improvement rather than worsening.

CONCLUSIONS

These findings suggest that if a national nicotine reduction policy were to be implemented, smokers with affective disorders would need additional support to overcome initial withdrawal but that long-term outcomes would likely be positive.

Resilient but addicted: The impact of resilience on the relationship between smoking withdrawal and PTSD

Nicotine use is common among people with posttraumatic stress disorder (PTSD). Resilience, which is reflected in one's ability to cope with stress, has been shown to be associated with lower cigarette smoking and posttraumatic stress symptoms, but relationships among these three variables have not been examined. This study investigates the relationships of resilience and nicotine withdrawal with each other and in relation to PTSD symptoms. Participants were 118 cigarette smokers with PTSD seeking treatment for PTSD and nicotine use. Data were randomly cross-sectionally sampled from three time points: week 0, week 12, and week 27 of the study. Hierarchical multiple regression analyses revealed main effects of both resilience and nicotine withdrawal symptoms on PTSD severity, controlling for the sampled time point, negative affect, and expired carbon monoxide concentration. Consistent with prior research, PTSD severity was higher among individuals who were less resilient and for those who had greater nicotine withdrawal. There was an interaction between resilience and nicotine withdrawal on self-reported PTSD severity, such that greater resilience was associated with lower PTSD severity only among participants with low nicotine withdrawal symptoms. Among individuals with high nicotine withdrawal, PTSD severity was high, regardless of resilience level. These results suggest that resilience is a protective factor for PTSD severity for those with low levels of nicotine withdrawal, but at high levels of nicotine withdrawal, the protective function of resilience is mitigated.

The Relationship between Anxiety Sensitivity and Posttraumatic Stress Disorder: What is the Impact of Nicotine Withdrawal?

OBJECTIVES

Anxiety sensitivity (AS) is related to the development and maintenance of posttraumatic stress disorder (PTSD) among cigarette smokers, and is also implicated in the amplification of acute nicotine withdrawal symptoms. The present study sought to examine the role of nicotine withdrawal in moderating the association between AS and PTSD symptom severity among a sample of treatment-seeking smokers with PTSD.

METHOD

Participants (n = 117) were enrolled in a randomized controlled trial for the treatment of PTSD and nicotine dependence. Cross-sectional data were randomly sampled from three different study time points. A series of multiple regression models were tested.

RESULTS

Results revealed main effects of both AS and withdrawal severity on PTSD severity after controlling for gender, assessment time-point, negative affectivity, and biochemically verified smoking (expired carbon monoxide). The interaction of AS and withdrawal was also significant, and appeared to be specific to PTSD avoidance and hyperarousal symptoms. However, contrary to expectations, the association between AS and PTSD symptoms was only significant at relatively lower levels of nicotine withdrawal.

CONCLUSIONS

These findings highlight the complex interplay between AS, nicotine withdrawal, and their synergistic effect in terms of the exacerbation of PTSD symptomology.

Cigarette smoking and 9/11-related posttraumatic stress disorder among World Trade Center Health Registry enrollees, 2003-12

OBJECTIVE

Numerous studies have observed higher rates of smoking among adults with mental health conditions. We examined posttraumatic stress disorder (PTSD) and smoking over a 7-9year period among adults with firsthand exposure to the 9/11 attacks enrolled in the World Trade Center Health Registry.

METHOD

Data were collected at three waves: W1 (2003-04), W2 (2006-07), and W3 (2011-12). Enrollees aged ≥25 at W1 and who completed all three waves (n=34,458) were categorized by smoker-type: non-smoker, non-daily (smoked some days in last 30days), light (1-10 cigarettes per day (CPD)), or heavy (11+ CPD). Enrollees who smoked at W1 but not W3 were considered to have quit. PTSD was defined as a score of ≥44 on the PTSD Checklist-Civilian Version.

RESULTS

Smoking declined significantly from W1 (12.6%) to W3 (9.2%). Smoking prevalence was higher among enrollees with PTSD. In multivariable models, odds of quitting were 25-39% lower among heavy, light, and non-daily smokers with PTSD compared to those without.

CONCLUSION

PTSD was associated with reduced odds of quitting regardless of smoker-type. Disaster-exposed smokers with PTSD are likely in need of more supportive services in order to abstain from smoking.

Post-traumatic stress disorder symptoms mediate the relationship between trauma exposure and smoking status in college students

The present study examined the relationship between trauma exposure and smoking status and the extent to which post-traumatic stress disorder symptoms mediated this relationship in a sample of 329 college students who experienced a prior traumatic event. Participants experienced an average of 2.2 prior traumas, and approximately 15% (n = 49) were smokers. Bootstrapping analyses revealed that after controlling for age, gender and time since trauma, post-traumatic stress disorder symptoms served as a pathway through which trauma exposure increased the risk of smoking [BC 95% CI (0.02, 0.18)]. Results appeared to be due largely to the influence of hyperarousal symptoms [BC 95% CI (0.05, 0.22)]. Comprehensive interventions for undergraduate smokers may be improved by attending to the impact of prior trauma and mental health needs.

Cigarette Cravings, Impulsivity, and the Brain

Craving is a core feature of tobacco use disorder as well as a significant predictor of smoking relapse. Studies have shown that appetitive smoking-related stimuli (e.g., someone smoking) trigger significant cravings in smokers impede their self-control capacities and promote drug seeking behavior. In this review, we begin by an overview of functional magnetic resonance imaging (fMRI) studies investigating the neural correlates of smokers to appetitive smoking cues. The literature reveals a complex and vastly distributed neuronal network underlying smokers' craving response that recruits regions involved in self-referential processing, planning/regulatory processes, emotional responding, attentional biases, and automatic conducts. We then selectively review important factors contributing to the heterogeneity of results that significantly limit the implications of these findings, namely between- (abstinence, smoking expectancies, and self-regulation) and within-studies factors (severity of smoking dependence, sex-differences, motivation to quit, and genetic factors). Remarkably, we found that little to no attention has been devoted to examine the influence of personality traits on the neural correlates of cigarette cravings in fMRI studies. Impulsivity has been linked with craving and relapse in substance and tobacco use, which prompted our research team to examine the influence of impulsivity on cigarette cravings in an fMRI study. We found that the influence of impulsivity on cigarette cravings was mediated by fronto-cingulate mechanisms. Given the high prevalence of cigarette smoking in several psychiatric disorders that are characterized by significant levels of impulsivity, we conclude by identifying psychiatric patients as a target population whose tobacco-smoking habits deserve further behavioral and neuro-imaging investigation.

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

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

Reduced nicotine product standards for combustible tobacco: building an empirical basis for effective regulation

INTRODUCTION

Both the Tobacco Control Act in the U.S. and Article 9 of the Framework Convention on Tobacco Control enable governments to directly address the addictiveness of combustible tobacco by reducing nicotine through product standards. Although nicotine may have some harmful effects, the detrimental health effects of smoked tobacco are primarily due to non-nicotine constituents. Hence, the health effects of nicotine reduction would likely be determined by changes in behavior that result in changes in smoke exposure.

METHODS

Herein, we review the current evidence on nicotine reduction and discuss some of the challenges in establishing the empirical basis for regulatory decisions.

RESULTS

To date, research suggests that very low nicotine content cigarettes produce a desirable set of outcomes, including reduced exposure to nicotine, reduced smoking, and reduced dependence, without significant safety concerns. However, much is still unknown, including the effects of gradual versus abrupt changes in nicotine content, effects in vulnerable populations, and impact on youth.

DISCUSSION

A coordinated effort must be made to provide the best possible scientific basis for regulatory decisions. The outcome of this effort may provide the foundation for a novel approach to tobacco control that dramatically reduces the devastating health consequences of smoked tobacco.

Do ethnicity and gender moderate the influence of posttraumatic stress disorder on time to smoking lapse?

BACKGROUND

Following a smoking cessation attempt, smokers with posttraumatic stress disorder (PTSD) experience smoking relapse at a higher and faster rate. Black ethnicity and female gender are also associated with lower success rates following smoking cessation. No study to date has prospectively examined how ethnicity and gender may moderate the effect of PTSD on smoking relapse. It was hypothesized that female gender and Black ethnicity would significantly predict early lapse after quitting; further, it was predicted that ethnicity and gender would moderate the effect of PTSD on relapse rate.

METHODS

Smokers with PTSD (n=48) and without PTSD (n=56) completed ecological momentary assessment (EMA) the week after a quit date, and self-initiated EMA entries after smoking lapse. Smoking abstinence was biologically verified. The sample included Black (62%) and White (38%) participants, and was 50% female. Study hypotheses were tested with Cox proportional hazards regression modeling time to first smoking lapse.

RESULTS

Study results confirmed the main hypothesis, with a significant PTSD × Ethnicity interaction emerging. The effect of PTSD on smoking relapse was significant for White participants but not for Black participants. No significant gender moderation was found.

CONCLUSION

Taken together, study results support previous research, and suggest that the relationship between smoking and PTSD is stronger for White smokers than for minorities. This study has significant implications for research in smoking and mental disease, as well as for smoking cessation treatments for Black smokers.

Posttraumatic stress disorder and cardiovascular disease

Posttraumatic stress disorder (PTSD) is an anxiety disorder initiated by exposure to a traumatic event and characterized by intrusive thoughts about the event, attempts to avoid reminders of the event, and physiological hyperarousal. In a number of large prospective observational studies, PTSD has been associated with incident cardiovascular disease (CVD) and mortality. Also, in recent years, a number of studies have shown that cardiovascular events can themselves cause PTSD in more than 1 in 8 patients with acute coronary syndrome. Further, a few small studies suggest that PTSD secondary to an acute CVD event then places patients at increased risk for subsequent CVD events and mortality. In this article, we review the evidence for a link between PTSD and CVD, and discuss potential mechanisms for that association as well as future directions for research.

Pharmacy considerations in tobacco cessation for patients suffering from posttraumatic stress disorder

Multiple studies have associated post traumatic stress disorder (PTSD) with variable and high rates of smoking documented in different populations. This article will cover the neurobiology behind tobacco use, and its implications in those with PTSD. Discussion on cessation programs (e.g., effectiveness, drug interactions), and controversy over the use of varenicline will also be discussed.

Predictors of lapse in first week of smoking abstinence in PTSD and non-PTSD smokers

INTRODUCTION

Retrospective research suggests smokers with posttraumatic stress disorder (PTSD) lapse more quickly after their quit date. Ecological momentary assessment (EMA) research is needed to confirm the presence of early smoking lapse in PTSD and form conceptualizations that inform intervention.

METHODS

Smokers with (n = 55) and without (n = 52) PTSD completed alarm-prompted EMA of situational and psychiatric variables the week before and after a quit date, and self-initiated EMA following smoking lapses. Blood samples at baseline and on the quit date allowed assessment of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEA(S)).

RESULTS

PTSD was related to shorter time to lapse (hazard ratio [HR] = 1.677, 95% CI: 1.106-2.544). Increased smoking abstinence self-efficacy was related to longer time to lapse (HR = 0.608, 95% CI: 0.430-0.860). Analyses of participants' real-time reports revealed that smokers with PTSD were more likely to attribute first-time lapses to negative affect ( = 5.412, p = .020), and trauma reminders (Fisher's exact p = .003**). Finally, the quit date decrease in DHEA(S) was related to shorter time to lapse (HR = 1.009, 95% CI: 1.000-1.018, p < .05).

CONCLUSIONS

Results provide evidence of shorter time to first smoking lapse in PTSD, and add to evidence that early lapse occasions are more strongly related to trauma reminders, negative affect, and cravings in smokers with PTSD.