Effects of abstinence in adolescent tobacco smokers: withdrawal symptoms, urge, affect, and cue reactivity

The Independent Contribution of Positive and Negative Metacognitions About Smoking to Urge to Smoke, Withdrawal Symptoms and Dependence in Smoking-Dependent Men

Previous research has indicated that various factors, such as psychological distress, distress intolerance, anhedonia, impulsivity and smoking metacognitions, have been individually linked to the urge to smoke, withdrawal symptoms and dependence. However, these factors have not been collectively examined to determine whether smoking metacognitions independently and significantly contribute to these outcomes. Therefore, the aim of this study was to investigate the impact of distress intolerance, anhedonia, impulsivity and smoking metacognitions on the urge to smoke, withdrawal symptoms and dependency in men who are dependent on smoking. A total of 300 smoking-dependent men completed psychological scales and smoking-related measures. The findings of the study indicated that positive metacognitions about emotion regulation significantly predicted the urge to smoke, even when accounting for other significant predictors such as the number of daily cigarettes smoked, psychological distress, anhedonia and impulsivity. Furthermore, positive metacognitions about cognitive regulation were found to be a significant predictor of withdrawal symptoms, independent of other significant predictors such as psychological distress and the urge to smoke. Smoking dependence was predicted by negative metacognitions about uncontrollability beyond other significant predictors, including the number of daily cigarettes smoked and distress intolerance. These results highlight the role of metacognitions about smoking in both short- and long-term clinical outcomes related to smoking. Consequently, addressing such beliefs during treatment for smoking dependence should be an important therapeutic goal.

Smoking-Specific Risk Factors in Early Adulthood That Mediate Risk of Daily Smoking by Age 29 for Children with ADHD

OBJECTIVE

To test whether smoking-specific risk factors in early adulthood mediate prediction to daily smoking from childhood ADHD.

METHODS

Participants were 237 with and 164 without childhood ADHD. A smoking risk profile score comprising smoking-specific factors measured between ages 18 to 25 (e.g., craving severity) and age of initiation was tested as mediator of the association between childhood ADHD and age 29 daily smoking.

RESULTS

Childhood ADHD predicted age 29 smoking (β = -.15, p = .019), 35% of ADHD versus 17% of nonADHD, and the profile score (β = -.07, p = .004), which in turn mediated prediction to age 29 daily smoking (β = -.03; p = .007). When tested individually, three profile variables (# cigarettes/day, difficulty concentrating during abstinence, and nicotine dependence) were significant mediators (ps = 0.005-0.038), above and beyond early adult smoking, ADHD persistence, and delinquency.

CONCLUSIONS

These behavioral smoking characteristics help explain later daily cigarette smoking for adults with ADHD histories and may need to be targeted in intervention.

ASRS Questionnaire and Tobacco Use: Not Just a Cigarette. A Screening Study in an Italian Young Adult Sample

Young adults exhibit greater sensitivity than adults to nicotine reinforcement, and Attention Deficit Hyperactivity Disorder (ADHD) increases the risk for early-onset smoking. We investigated the correlation between ADHD Self-Report Scale (ASRS) scores and smoking, evaluated the prevalence of ADHD symptomatology (not diagnoses) in smokers and non-smokers and its comorbidity with benzodiazepine and gambling addictions. A total of 389 young adults from 14 schools in Northern Italy fill out a survey and the Adult ADHD Self-Report Scale (ASRS). A total of 15.2% of subjects tested positive at the ASRS, which correlated with smoking; moreover, smokers had twice the probability of testing positive at the ASRS. ADHD symptomatology, especially when comorbid with tobacco abuse, is an important condition to monitor because early nicotine exposure could be a gateway for other addictive behaviors.

Severity of negative mood and anxiety symptoms occurring during acute abstinence from tobacco: A systematic review and meta-analysis

This review was conducted with the following goals: To quantify the severity of mood and anxiety symptoms emerging during acute abstinence from tobacco (1). To explore sex differences related to the experience of specific symptoms (2). To investigate the early time course of symptoms (3). A meta-analysis was performed from 28 studies assessing mood and anxiety symptoms during the earliest phases of tobacco abstinence (up to 24 hrs post-quit) conducted from 1999 to 2019. Results revealed a significant (p < 0.0001) increase in 'anxiety', 'anger/irritability', 'depressed mood /sadness', and composite negative affect ('NA') in the 24 hours following smoking cessation. The largest effect size was detected for 'anxiety' (0.63). A qualitative analysis was performed to investigate sex differences and the time course of the specific symptoms. Results indicated that female smokers may experience worse mood symptoms compared to male smokers and that these symptoms may emerge within 3 hrs post-quit. Smoking cessation programs should implement sex-tailored interventions in order to improve their effectiveness, while future research should focus on alternative methods of nicotine administration.

Differences in Magnitude of Cue Reactivity Across Durations of Smoking History: A Meta-analysis

BACKGROUND

Cue-elicited craving may vary due to duration of smoking history, increasing as more years of smoking strengthen associations between nicotine intake and cues. However, research on this relationship is virtually absent. This project assessed the relationship between cue reactivity and years of smoking.

METHODS

Data from 53 studies (68 effect sizes) were analyzed. Eligible studies were those measuring self-reported craving following cue exposure in nontreatment seeking smokers and reporting mean years smoking. Preliminary subgroup analyses identified methodological factors influencing cue-reactivity effect sizes; primary meta-regression analysis assessed differences across years smoking; exploratory analyses assessed potential for ceiling effects.

RESULTS

Effect sizes varied due to abstinence requirement and cue presentation modality, but not dependence severity. Unexpectedly, meta-regression analysis revealed a decline in effect sizes across years smoking. Exploratory analyses suggested declines may have been due to a ceiling effect in craving measurement for those with longer smoking histories-more experienced smokers reported higher levels of craving at baseline or following neutral cue exposure, but all reported similar levels of craving after smoking cue exposure.

CONCLUSIONS

Methodological factors and duration of smoking history influenced measurement of cue reactivity. Highlighted were important relationships between years smoking and magnitude of cue reactivity, depending on use of baseline or neutral cue comparisons. Further research is needed to assess differences in cue reactivity due to duration of smoking history using participant-level data, directly testing for ceiling effects. In addition, cue-reactivity studies are needed across young adults to assess onset of associations between nicotine intake and cues.

IMPLICATIONS

This meta-analysis project contributes to the cue-reactivity literature by reporting on the previously ignored relationship between duration of smoking history and magnitude of cue-elicited craving. Results suggest that declines in cue-reactivity effect sizes across years of smoking may have been due to study-level methodological factors, but not due to differences in sample-level dependence severity. Cue-reactivity effect sizes were stable across years of smoking in studies using a neutral cue comparison but declined sharply in studies when baseline assessment (typically coupled with an abstinence requirement) was used.

PhenX: Host: Biobehavioral measures for tobacco regulatory research

A working group (WG) of experts from diverse fields related to nicotine and tobacco addiction was constituted to identify constructs and measures for the PhenX (Phenotypes and eXposures) Tobacco Regulatory Research (TRR) Host: Biobehavioral Collection with potential relevance to users of both conventional and newer tobacco products. This paper describes the methods and results the WG used to identify, select, approve and place measures in the PhenX TRR Collection. The WG recognised 13 constructs of importance to guide their categorisation of measures already in the PhenX Toolkit ('complementary measures') and to identify novel or improved measures of special relevance to tobacco regulatory science. In addition to the 22 complementary measures of relevance to tobacco use already in the PhenX Toolkit, the WG identified and recommended nine additional Host: Biobehavioral measures characterising the use, exposure and health outcomes of tobacco products for application to TRR. Of these, five were self-administered or interviewer-administered measures: amount, type and frequency of recent tobacco use; flavor preference in e-cigarette users (adult and youth); pregnancy status and tobacco use; pregnancy status-mother and baby health and withdrawal from tobacco use. The remaining four measures were laboratory-based: cotinine in serum, expired carbon monoxide, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol in urine and cue reactivity. Although a number of validated tools are now available in the Host: Biobehavioral Collection, several gaps were identified, including a need to develop and test the identified measures in adolescent samples and to develop or identify measures of nicotine dependence, tolerance and withdrawal associated with newer non-combusted tobacco products.

Pain characteristics and nicotine deprivation as predictors of performance during a laboratory paradigm of smoking cessation

Although smokers with co-occurring pain report expectations for experiencing greater nicotine withdrawal and difficulty quitting, limited work has examined the role of pain in cessation-related outcomes. The goal of this study was to examine clinically relevant pain characteristics (pain persistence, pain intensity, pain-related disability) as predictors of withdrawal and smoking lapse/relapse outcomes using a laboratory paradigm of cessation. Participants (N = 120 daily cigarette smokers; 48% male; M_age = 36.17, SD = 12.16; M_{Cigarettes Per Day} = 20.51, SD = 6.99) were randomized to either nondeprived or 12-hr nicotine deprivation conditions prior to an experimental study visit. Upon arrival to the laboratory, participants completed measures of pain characteristics and nicotine withdrawal symptoms. Primary outcomes included nicotine withdrawal scores and analogues of smoking lapse (latency to initiating smoking) and relapse (number of cigarettes smoked). We hypothesized that smokers with greater pain persistence, pain intensity, and pain-related disability would endorse more severe nicotine withdrawal and greater lapse/relapse behavior, and that these positive associations would be stronger among those who were nicotine deprived. Results indicated that, above and beyond the effect of nicotine deprivation, persistent pain predicted more severe nicotine withdrawal, and that greater pain-related disability predicted quicker latency to lapse during the laboratory paradigm. Contrary to expectation, nicotine deprivation did not moderate effects of pain characteristics on withdrawal or lapse/relapse outcomes. Clinical implications include that different pain processes may influence different cessation outcomes, and that smokers in pain may benefit from the provision of pharmacological aids to better control withdrawal symptoms. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The Impact of Nicotine Dose on the Reinforcing Value of Cigarettes in Adolescents

Objectives

The FDA is considering the implementation of a national nicotine reduction policy for cigarettes, and such a policy may reduce the reinforcing efficacy of cigarettes and ultimately reduce tobacco dependence. However, it is not yet known how different levels of nicotine may affect the reinforcing efficacy of cigarettes in adolescents. We aimed to determine how reduced nicotine content may affect adolescents' demand for cigarettes using the cigarette purchase task (CPT).

Methods

Adolescent daily smokers (ages 15-19, n = 50) completed a CPT for their usual brand cigarette and for each dose of SPECTRUM research cigarettes (15.8, 5.2, 1.3, 0.4 mg nicotine/g tobacco) during four laboratory sessions. We conducted repeated measures ANOVAs to evaluate the effect of nicotine dose on five demand indices derived from the CPT.

Results

Tests revealed significantly higher demand for usual brand than each research cigarette dose (all p's < .01); dose did not significantly affect any measure when usual brand was excluded.

Conclusions

These results demonstrate the potential utility of the CPT for comparing the reinforcing efficacy of cigarettes varying in nicotine content in adolescents, and indicate a significantly reduced reinforcing efficacy of all research cigarettes relative to usual brand.

Adolescent smokers' response to reducing the nicotine content of cigarettes: Acute effects on withdrawal symptoms and subjective evaluations

BACKGROUND

Mandating a reduction in the nicotine content of cigarettes to a minimally addictive level could dramatically reduce smoking rates in the US. However, little is known about the effects of reduced nicotine content cigarettes in adolescents.

METHODS

Following overnight abstinence, adolescent daily smokers (ages 15-19, n = 50) reported on their craving, withdrawal, and positive and negative affect pre- and post- ad lib smoking of one cigarette containing varying nicotine content (15.8, 5.2, 1.3 and 0.4 mg/g of tobacco) in the laboratory and reported their subjective evaluations of each cigarette. Carbon monoxide (CO) boost from pre- to post-cigarette was calculated to determine if lower-nicotine cigarettes led to differential acute changes in toxicant exposure.

RESULTS

All four nicotine cigarette types significantly reduced abstinence-induced craving, withdrawal, and negative affect (all p's < .05). Mixed models evaluating the effect of nicotine content, with nicotine dependence level and gender included as covariates, revealed a significant effect of nicotine content on craving and subjective evaluations: higher nicotine content resulted in greater reductions in craving and increases in both positive and negative subjective evaluations. There were no significant effects of nicotine dose on withdrawal symptoms, negative affect, or CO boost.

CONCLUSIONS

These results suggest that lower nicotine cigarettes might result in reduced abuse liability compared to higher nicotine content cigarettes due to reduced positive subjective effects, while still reducing withdrawal, in adolescents. These results highlight the potential feasibility of this policy approach and support continued research on how a nicotine reduction policy may affect adolescent smoking patterns.

Abstinence-induced withdrawal severity among adolescent smokers with and without ADHD: disentangling effects of nicotine and smoking reinstatement

RATIONALE

Individuals with attention deficit hyperactivity disorder (ADHD) start smoking earlier, are more likely to progress to nicotine dependence, and have a more difficult time quitting smoking compared to their non-ADHD peers. Little is known about the underlying behavioral mechanisms associated with this increased risk, particularly at the adolescent stage.

OBJECTIVE

This study aimed to assess the effects of overnight nicotine abstinence and smoking reinstatement on subjective withdrawal states in adolescent smokers with and without ADHD.

METHODS

Adolescent daily smokers (27 with ADHD and 17 without ADHD) completed three experimental sessions: (1) a placebo patch followed by smoking a nicotine cigarette, (2) placebo patch followed by smoking a nicotine-free cigarette, and (3) nicotine patch followed by smoking a nicotine-free cigarette. Subjects abstained overnight before each session, and patches were administered 45 min before smoking. The primary outcome measure was a smoking withdrawal symptom questionnaire.

RESULTS

ADHD smokers experienced greater difficulty concentrating and impatience/restlessness during abstinence than non-ADHD smokers. Smoking a cigarette improved abstinence-induced difficulty concentrating and restlessness, regardless of its nicotine content, and regardless of whether transdermal nicotine was received or not.

CONCLUSIONS

Thus, sensorimotor aspects of smoking, rather than nicotine itself, appeared to relieve withdrawal. Although ADHD smokers report greater withdrawal symptoms than non-ADHD smokers, they responded strongly to the sensorimotor aspects of smoking during withdrawal. These findings suggest that even lighter, adolescent smokers with ADHD are vulnerable to smoking progression through altered smoking abstinence and withdrawal relief processes.

Clinical Laboratory Evaluation of Electronic Cigarettes/Electronic Nicotine Delivery Systems: Methodological Challenges

OBJECTIVE

Evaluating electronic cigarettes (ECIGs) in the clinical laboratory is critical to understanding their effects. However, laboratory evaluation of ECIGs can be challenging, as they are a novel, varied, and evolving class of products. The objective of this paper is to describe some methodological challenges to the clinical laboratory evaluation of ECIGs.

METHODS

The authors gathered information about challenges involved in the laboratory evaluation of ECIGs. Challenges were categorized and solutions provided when possible.

RESULTS

Methods used to study combustible cigarettes may need to be adapted to account for ECIG novelty and differences within the class. Challenges to ECIG evaluation can include issues related to 1) identification of ECIG devices and liquids, 2) determination of short -term ECIG abstinence, 3) measurement of use behavior, and 4) assessment of dependence. These challenges are discussed, and some suggestions to inform ECIG evaluation using clinical laboratory methods are provided.

CONCLUSIONS

Awareness of challenges and developing, validating, and reporting methods used to address them aids interpretation of results and replication efforts, thus enhancing the rigor of science used to protect public health through appropriate, empirically-based, ECIG regulation.

Predictors of nicotine withdrawal symptoms: findings from the first randomized smoking cessation trial in a low-income country setting

OBJECTIVES

To identify predictors of nicotine withdrawal symptoms among smokers who participated in a randomized cessation trial in a low-income country.

METHODS

We analyzed data from 269 smokers who participated in a randomized, placebo-controlled smoking cessation trial conducted in primary healthcare in Aleppo, Syria. All participants received behavioral counseling and were randomized to receive either 6 weeks of nicotine or placebo patch and were followed for one year.

RESULTS

Throughout the study, lower total withdrawal score was associated with greater education (p = 0.044), older age of smoking initiation (p = 0.017), lower nicotine dependence (p = 0.024), higher confidence in ability to quit (p = 0.020), lower reported depression (p < 0.001), higher adherence to patch (p = 0.026), belief of receiving nicotine patches rather than placebo (p = 0.011), and waterpipe use (p = 0.047).

CONCLUSIONS

Lower nicotine dependence, greater educational attainment, higher confidence in ability to quit and waterpipe use predict lower withdrawal severity. Waterpipe smoking may serve as a barrier to smoking cessation efforts in countries where its use is highly prevalent. Further, expectancies about the effects of pharmacotherapy appear to mediate the experience of nicotine withdrawal.

Validation of a Respiratory Symptom Questionnaire in Adolescent Smokers

OBJECTIVES

Adolescent smokers experience respiratory symptoms as a consequence of smoking, which may be impacted by harm-reduction products. We sought to validate the American Thoracic Society Questionnaire (ATSQ), a measure of respiratory symptoms, in adolescent smokers.

METHODS

Data were drawn from 2 studies of adolescents (ages 14 to 19). Study 1 (N = 118) comprised daily smokers. Study 2 (N = 216) comprised 118 smokers and 98 nonsmokers; a subset of the total sample comprised 70 matched pairs of smokers and non-smokers.

RESULTS

The ATSQ showed high internal consistency. In Study 1, ATSQ scores were positively correlated with dependence. In Study 2, scores were positively correlated with CO, cotinine, and cigarettes per day; and scores were significantly greater for smokers than non-smokers.

CONCLUSIONS

The ATSQ offers a psychometrically valid method for measuring respiratory symptoms in adolescent smokers.

Focused transcranial direct current stimulation (tDCS) over the dorsolateral prefrontal cortex modulates specific domains of self-regulation

Recent neuroscience theories suggest that different kinds of self-regulation may share a common psychobiological mechanism. However, empirical evidence for a domain general self-regulation mechanism is scarce. The aim of this study was to investigate whether focused anodal transcranial direct current stimulation (tDCS), facilitating the activity of the dorsolateral prefrontal cortex (dlPFC), acts on a domain general self-regulation mechanism and thus modulates both affective and appetitive self-regulation. Twenty smokers participated in this within-subject sham controlled study. Effects of anodal left, anodal right and sham tDCS over the dlPFC on affective picture appraisal and nicotine craving-cue appraisal were assessed. Anodal right tDCS over the dlPFC reduced negative affect in emotion appraisal, but neither modulated regulation of positive emotion appraisal nor of craving appraisal. Anodal left stimulation did not induce any significant effects. The results of our study show that domain specific self-regulation networks are at work in the prefrontal cortex. Focused tDCS modulation of this specific self-regulation network could probably be used during the first phase of nicotine abstinence, during which negative affect might easily result in relapse. These findings have implications for neuroscience models of self-regulation and are of relevance for the development of brain stimulation based treatment methods for neuropsychiatric disorders associated with self-regulation deficits.

Hostility and cigarette use: a comparison between smokers and nonsmokers in a matched sample of adolescents

INTRODUCTION

We examined the association between hostility-a personality trait reflective of negativity and cynicism toward others-and smoking in adolescents by measuring (a) several subcomponents of hostility, and (b) facial emotion processing ability, which has been previously linked to hostility.

METHODS

Participants (N = 241 aged 14-19) were 95 smokers and 95 demographically matched nonsmokers as well as 51 nonmatched smokers. All participants completed the Cook-Medley (C-M) hostility scale, which provides a general hostility score and 3 component scores (cynicism, hypersensitivity, and aggressive responding), and a facial emotion processing task. This task, designed to assess emotion recognition, requires quickly identifying the emotion of faces that gradually morph from neutral to high-intensity happy, angry, or fearful.

RESULTS

Independent sample t tests indicated that matched smokers scored significantly higher in cynicism and aggressive responding than nonsmokers. Among smokers, age of smoking onset was negatively correlated with general hostility and aggressive responding. All hostility scales were positively correlated with the intensity needed to recognize happy faces. Counterintuitively, smokers required a greater intensity to recognize angry faces than nonsmokers. No other relations between hostility/smoking status and facial emotion processing were observed.

CONCLUSIONS

Aspects of hostility, particularly aggressive responding, may be a risk factor for early onset smoking. Although hostile participants exhibited a deficiency in their ability to recognize happiness in facial pictures, these results did not translate to differences in smoking status. This study elucidates some of the complex interrelations between hostility, emotion processing, and adolescent smoking, which may have implications for teen smoking prevention.

Clinical significance of early smoking withdrawal effects and their relationships with nicotine metabolism: preliminary results from a pilot study

INTRODUCTION

Although the early time course of smoking withdrawal effects has been characterized, the clinical significance of early withdrawal symptoms and their predictors are unknown. This study evaluated the relationships of early smoking withdrawal effects with quit attempt outcomes and the rate of nicotine metabolism.

METHODS

Eleven treatment-seeking smokers abstained from smoking for 4 hr in the laboratory before a quit attempt. Withdrawal measures included heart rate, sustained attention, and self-report. Following baseline assessment, withdrawal measures were administered every 30 min. At the conclusion of the 4-hr early withdrawal session, participants received a brief smoking cessation intervention and then returned 1 week and 12 weeks later for outcome assessments that included biochemically confirmed smoking abstinence, cigarettes smoked in the past 24hr, and self-reported withdrawal symptoms. The rate of nicotine metabolism was estimated at intake with the nicotine metabolite ratio (trans-3'-hydroxycotinine/cotinine) measured in saliva.

RESULTS

Greater self-reported negative affect and concentration difficulty during early withdrawal, most notably anxiety, were related with poorer quit attempt outcomes. There was some indication that although a faster increase in craving and greater hunger during early withdrawal were associated with more favorable outcomes, a greater decrease in heart rate during this time was associated with poorer outcomes. Faster nicotine metabolism was related to a faster increase in anxiety but a slower increase in craving during early withdrawal.

CONCLUSIONS

These findings lend support to the clinical significance of early smoking withdrawal effects. The rate of nicotine metabolism may be a useful predictor of early withdrawal symptoms.