Menstrual phase and depressive symptoms differences in physiological response to nicotine following acute smoking abstinence

Acceptability of Hormonal Contraceptives as a Smoking Cessation Aid for Women of Reproductive Age: A Web-Based Cross-Sectional Survey

Introduction

Cigarette smoking is the most common cause of preventable cancers and other premature morbidity and mortality. Modifying hormonal patterns using hormonal contraceptives (HCs) may lead to improved smoking cessation outcomes in women, though the acceptability of this is unknown. Therefore, we explored the willingness of reproductive-age women who smoke to use HC for cessation.

Methods

A cross-sectional online survey was conducted with a convenience sample of reproductive-age women living in the United States who self-reported smoking combustible cigarettes. Questions covered smoking history, previous HC use, and willingness to use various HC methods (i.e., injectable, oral, patch, vaginal insert) for cessation. Chi-squared tests and logistic regression were conducted using StataBE 17.1.

Results

Of 358 eligible respondents, n = 312 (86.9%) reported previous HC use. Average age of those with HC use history was 32.1 ± 6.1 years compared with 27.8 ± 6.7 years for those without history of HC use (p = 0.001). Of respondents who reported previous HC use, 75.6% reported willingness to use HCs, compared with 60.9% of those without a history of HC use. Overall, willingness to use various types of HC ranged from 22.6% for the vaginal insert to 59.2% willing to use an oral contraceptive.

Discussion

These observations indicate that most women who smoke cigarettes are willing to use HC for a smoking cessation aid, especially if they have a history of HC use and with an oral form of HC. To improve the rate of smoking cessation for women of reproductive age, future interventions should explore how to incorporate HC for cessation.

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

INTRODUCTION

Menstrual phase influences cigarette smoking-related outcomes. Telephone-based cessation programs (e.g., quitlines) may incorporate the role of the menstrual cycle in an effort to tailor interventions for women.

PURPOSE

The goal of this preliminary randomized clinical trial was to examine the feasibility and acceptability of timing quit date to menstrual phase in women in a quitline setting.

METHODS

We recruited treatment-seeking women with regular menstrual cycles between the ages of 18-40 years. Participants were randomized to the follicular phase (FP; quit date set 6-8 days post onset of menses) or standard of care (SC; no menstrual timing of quit date). All participants received four weeks of nicotine replacement therapy transdermal patch concurrent with six weeks of telephone-based counseling. We explored self-reported and biochemically-verified seven-day point prevalence abstinence at end-of-treatment and three-month follow-up.

RESULTS

Participants (n = 119; FP: n = 58, SC: n = 61) were, on average, 33.4 years old and smoked 13.6 cigarettes/day. The median number of counseling sessions completed was 6 out of 6 available, and 66% of participants completed the intervention. Over 90% of participants reported they would recommend this study to friends/family. Cessation rates did not significantly vary by randomization.

CONCLUSIONS

Results of this preliminary trial indicate that timing quit date to FP is an acceptable and feasible approach to address smoking cessation in women of reproductive age. While we observed similar smoking cessation rates between groups, this preliminary study was not fully powered to determine efficacy. Therefore, the feasibility and acceptability results indicate that a fully-powered efficacy trial is warranted.

Influence of the natural hormonal milieu on brain and behavior in women who smoke cigarettes: Rationale and methodology

Women experience more severe health consequences from smoking, have greater difficulty quitting, and respond less favorably to nicotine replacement therapy than men. The influence of fluctuating ovarian hormones, specifically estradiol (E) and progesterone (P), on brain and behavioral responses during exposure to smoking reminders (i.e., cues) may be a contributing factor. Results from our laboratory suggest that women in the late follicular phase of their menstrual cycle (MC) have enhanced smoking cue (SC) vulnerabilities and reduced functional connectivity in neurocircuitry underlying cognitive control, potentially placing them at greater risk for continued smoking and relapse. The primary aim of this study is to examine and link hormonal status with brain and behavioral responses to SCs over the course of three monthly MCs in naturally cycling women who are chronic cigarette smokers. This longitudinal, counterbalanced study collects brain and behavioral responses to SCs at three time points during a woman's MC. Participants complete psychological and physical examinations, biochemical hormonal verification visits, and at least three laboratory/neuroimaging scan visits. The scan visits include a 10-min SC task during blood oxygen level-dependent (BOLD) data acquisition and are timed to occur during the early follicular phase (low E and P), late follicular phase (high E, unopposed by P), and mid-luteal phase (high P, high E). The primary outcomes include brain responses to SCs (compared to non-SCs), subjective craving, E and P hormone levels, and behavioral responses to SCs. This study addresses a critical gap in our knowledge: namely, the impact of the natural hormonal milieu on brain and behavioral responses to SCs, a powerful relapse trigger. Additionally, this study will provide a roadmap for human sex differences researchers who are obliged to consider the often confounding cyclic hormonal fluctuations of women.

Response to nicotine following overnight smoking abstinence during short-term progesterone treatment in women

Preclinical and clinical literature suggest that sex hormones impact tobacco use behaviors in women. The goal of this double-blind crossover laboratory study was to examine the effect of oral exogenous progesterone (200 mg twice per day) versus placebo on nicotine response using measures of motor speed and cognitive function in women following overnight smoking abstinence. We hypothesized that increased progesterone would blunt the nicotine response whereby producing less change in motor speed and cognition in response to nicotine exposure. Female smokers, age 18-35, were randomized to participate in two 9-day crossover testing weeks. Participants completed a lab session following overnight abstinence where they were administered nicotine nasal spray and asked to complete measures of immediate memory (IMT), delayed memory (DMT), word recall (WR), and finger tapping speed (FT). After the first 9-day testing week, participants resumed smoking and returned the following month to complete the identical lab session in the crossover condition. Forty-seven women were included in this analysis (n = 47). We found no differences in the magnitude of response for IMT, DMT, and WR between conditions. For FT, women had a blunted response to nicotine during the placebo condition. When examining the association between hormone levels and relative performance, we found increases in DMT, WR, and FT but decreases in IMT during the progesterone condition. We observed differences between progesterone versus placebo in relative change in some measures of nicotine response following overnight abstinence. Future studies are needed to further characterize this response. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Menstrual cycle phase, alcohol consumption, alcohol cravings, and mood among women in outpatient treatment for alcohol use disorder

Research shows fluctuations in drinking across the menstrual cycle among women with alcohol use disorder (AUD), but little work has investigated moderators of these fluctuations. This study examined drinking and craving intensity across the menstrual cycle, and the moderating effect of baseline depression and emotional distress during the midlate luteal phase and/or menses, among women receiving AUD treatment. Fifty-nine regularly cycling women reported menstrual history and baseline depression. Over 3 months of treatment, they kept daily logs of drinks, alcohol cravings, and menstruation (yes/no). Emotional distress during the midlate luteal phase and/or menses of their most recent menstrual cycle was also assessed during treatment. Menstrual cycle phase was estimated for each within-treatment day. Mixed model analyses tested main and interactive effects of menstrual cycle phase, baseline depression, and emotional distress during the midlate luteal phase and/or menses on daily drinks and craving intensity. Women drank most during the midlate luteal phase and menses compared with other phases. Among women with lower baseline depression, those with lower distress during the midlate luteal phase and/or menses reported more intense cravings during the midlate luteal phase (ΔM = .77, p = .000) and menses (ΔM = .51, p = .012); those with higher distress reported more intense cravings during menses, compared with all other phases (p < .01). Among women with higher baseline depression, craving intensity remained consistently high. Results document more drinking during the midlate luteal phase and menses and suggest that cycle-related distress and depression moderate the alcohol-menstrual association among women in AUD treatment. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Women and substance use disorders in low- and middle-income countries: A call for advancing research equity in prevention and treatment

Although the prevalence of substance use disorders (SUDs) is higher among men, women with SUDs in low- and middle-income countries (LMICs) face unique challenges. Poverty and adversity, inequality of women, and disparities in access to treatment and prevention services exacerbate biological, psychological and social correlates of substance use disorders for women living in low-resource settings. Increasing the inclusion of women in research has long been a goal, though even high income countries struggle to achieve parity. In LMICs, women with SUDs are often neglected from global research due to underreporting and the disproportionate focus of global substance use research on men. We will discuss risk factors for SUDs that are particularly relevant for women residing in LMICs in order to gain insight into neglected areas of research and opportunities for prevention and treatment.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Ovarian hormones, menstrual cycle phase, and smoking: a review with recommendations for future studies

Cigarette smoking continues to be the leading cause of preventable morbidity and mortality. Similar to other addictive substances, the prevalence of cigarette smoking is greater among men than women, yet women are less successful at quitting smoking. Preclinical and clinical research suggests that ovarian hormones (i.e., estradiol and progesterone), which fluctuate over the course of the menstrual cycle, may contribute to these sex differences. Specifically, research suggests that progesterone may protect against cigarette smoking and nicotine addiction; whereas estradiol may underlie enhanced vulnerability. In this review, we discuss new research on ovarian hormone and menstrual cycle phase effects on smoking-related responses and behavior in women, including studies examining neural responses to smoking cues, hormonal influences on medication-assisted smoking cessation, and acute smoking abstinence. We highlight innovative studies with strong research methodology and provide suggestions for future research that may allow evidence-based knowledge for immediate translation to the clinic to guide novel, hormonally-informed treatment strategies. Thus, rigorous scientific study holds the potential to reduce relapse rates, thus improving the health and saving the lives of the many thousands of women who unfortunately do not respond to current treatments.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Subjective response to nicotine by menstrual phase

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

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