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

Associations of Menstrual Cycle and Progesterone-to-Estradiol Ratio With Alcohol Consumption in Alcohol Use Disorder: A Sex-Separated Multicenter Longitudinal Study

OBJECTIVE

Alcohol use disorder (AUD) constitutes a critical public health issue and has sex-specific characteristics. Initial evidence suggests that progesterone and estradiol might reduce or increase alcohol intake, respectively. However, there is a need for a better understanding of how the menstrual cycle in females and the ratio of progesterone to estradiol in females and males influence alcohol use patterns in individuals with AUD.

METHODS

In this sex-separated multicenter longitudinal study, the authors analyzed 12-month data on real-life alcohol use (from 21,460 smartphone entries), menstrual cycle, and serum progesterone-to-estradiol ratios (from 667 blood samples at four individual study visits) in 74 naturally cycling females and 278 males with AUD between 2020 and 2022, using generalized and general linear mixed modeling.

RESULTS

Menstrual cycle phases were significantly associated with binge drinking and progesterone-to-estradiol ratio. During the late luteal phase, females showed a lower predicted binge drinking probability of 13% and a higher predicted marginal mean of progesterone-to-estradiol ratio of 95 compared with during the menstrual, follicular, and ovulatory phases (binge drinking probability and odds ratios vs. late luteal phase, respectively: 17%, odds ratio=1.340, 95% CI=1.031, 1.742; 19%, odds ratio=1.523, 95% CI=1.190, 1.949; and 20%, odds ratio=1.683, 95% CI=1.285, 2.206; difference in progesterone-to-estradiol ratios, respectively: -61, 95% CI=-105.492, -16.095; -78, 95% CI=-119.322, -37.039; and -71, 95% CI=-114.568, -27.534). In males, a higher progesterone-to-estradiol ratio was related to lower probabilities of binge drinking and of any alcohol use, with a 10-unit increase in the hormone ratio resulting in odds ratios of 0.918 (95% CI=0.843, 0.999) and 0.914 (95% CI=0.845, 0.988), respectively.

CONCLUSIONS

These ecologically valid findings suggest that high progesterone-to-estradiol ratios can have a protective effect against problematic alcohol use in females and males with AUD, highlighting the progesterone-to-estradiol ratio as a promising treatment target. Moreover, the results indicate that females with AUD may benefit from menstrual cycle phase-tailored treatments.

Substance Use Over Time Among Sexual and Gender Minority People: Differences at the Intersection of Sex and Gender

Purpose: Sexual and gender minority (SGM) people are at greater risk for substance use than heterosexual and cisgender people, but most prior work is limited by cross-sectional analyses or the examination of single substance use. This study examined substance use over time among SGM people to identify patterns of polysubstance use at the intersection of sex and gender. Methods: Data were collected annually over 4 years from SGM respondents (n = 11,822) in The Population Research in Identity and Disparities for Equality (PRIDE) Study. Differences in substance use patterns (any prior 30-day use of 15 substances) by gender subgroup were examined with latent class analysis, and multinomial regression models tested relationships between gender subgroup and substance use. Results: Eight classes of substance use were observed. The three most common patterns were low substance use (49%), heavy episodic alcohol use (≥5 alcoholic drinks on one occasion) with some cannabis and tobacco use (14%), and cannabis use with some tobacco and declining heavy episodic alcohol use (13%). Differences observed included lower odds of patterns defined by heavy episodic alcohol use with some cannabis and tobacco use in all gender subgroups relative to cisgender men and persons with low substance use (odds ratios [ORs] 0.26-0.60). Gender expansive people assigned female at birth, gender expansive people assigned male at birth, and transgender men had greater odds of reporting cannabis use with small percentages of heavy episodic alcohol and tobacco use (ORs: 1.41-1.60). Conclusion: This study suggests that there are unique patterns of polysubstance use over time among gender subgroups of SGM people.

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.

Effects of Ovarian Hormone Levels on Stress, Cigarette Craving, and Smoking in a Laboratory Relapse Paradigm Among Females Who Smoke Daily

INTRODUCTION

Females, versus males, have shown a slower decline in smoking prevalence, greater smoking-related mortality and morbidity, and tend to have more difficulty achieving and maintaining abstinence. Identifying sex-specific risk factors is needed to improve outcomes. Though ovarian hormones have been evaluated for their role in smoking and relapse, measures tend to be static and infrequent, failing to capture the influence of increasing or decreasing levels.

AIMS AND METHODS

The present study evaluated the effect of static and fluctuating levels of ovarian hormones (ie, progesterone, estradiol, and estrogen to progesterone [E/P] ratio) on stress reactivity, cigarette craving, and smoking during a laboratory relapse paradigm. Female participants (assigned female at birth) reporting daily cigarette smoking (N = 91, ages 18-45) were recruited from the community. Participants provided daily salivary ovarian hormone levels leading up to a laboratory session, in which stress was induced and stress reactivity, cigarette craving, latency to smoke, and ad-libitum smoking were measured.

RESULTS

Static levels of estradiol were associated with stress reactivity (β = 0.28, SE = 0.13) and static E/P ratio was associated with smoking in the laboratory (HR = 1.4). Preceding 3-day changes in estradiol and E/P ratio, but neither static levels nor preceding 3-day changes in progesterone were associated with stress reactivity, cigarette craving, or smoking in a relapse paradigm.

CONCLUSIONS

Ovarian hormones are among several sex-specific factors involved in the complex neuroendocrine response to stress, and their interaction with other biological, social, and psychological factors in the real-world environment is not yet fully understood.

IMPLICATIONS

Findings of the present study provide novel information regarding the role of ovarian hormones among female participants who smoke daily in stress reactivity and smoking in the context of a laboratory relapse paradigm and highlight several avenues for future research. We found that same-day estradiol levels were associated with increased subjective stress reactivity and same-day estrogen to progesterone ratio was associated with increased likelihood of smoking in a relapse paradigm. Ovarian hormones are among several sex-specific factors contributing to the complex neuroendocrine response to stress, and their interaction with other biological, social, and psychological factors in the real-world environment is not yet fully understood.

Methodological approach for an integrated female-specific study of anxiety and smoking comorbidity

Two primary ovarian hormones that fluctuate across the female menstrual cycle-estradiol and progesterone-have been independently linked in separate literatures to nicotine reinforcement and anxiety psychopathology. We identify existing methodological limitations in these literatures, describe an example protocol that was developed to address such limitations, highlight case examples, and offer insights on the resulting advantages and challenges. This protocol was an observational, prospective, within-subjects study of female cigarette smokers who were followed over the course of a complete menstrual cycle. Non-treatment seeking, female cigarette smokers (N = 50), between the ages of 18-40 who have a normal menstrual cycle (25-35 days in length) were recruited from the community. Females with anxiety or mood psychopathology represented 38.0% of the sample. Salivary progesterone and estradiol were assessed each morning via at-home saliva collection methods. Self-reported within-day momentary ratings of anxiety and nicotine reinforcement were collected using ecological momentary assessment (EMA) via a mobile app. Protocol compliance was >85%. Within- and between-subjects heterogeneity was observed in the progesterone and estradiol, anxiety, and nicotine craving measures, especially in the context of anxiety psychopathology. We aimed to integrate the anxiety and nicotine dependence literatures and advance the empirical study of the role of ovarian hormones. This protocol reflects an intensive, yet feasible approach to collecting daily-level naturalistic data related to estradiol, progesterone, anxiety, and nicotine reinforcement.

Heightened sensitivity to the disinhibiting effect of alcohol in women during the late follicular phase of the menstrual cycle

Compared with men, women are disproportionately affected by alcohol, including greater risks of physiological damage, behavioral impairment, and relapse. One likely mechanism underlying the sexual disparity in this vulnerability is the fluctuation of ovarian hormones, particularly estradiol (E2), across phases of the menstrual cycle. Several preclinical and clinical studies have shown that higher E2 levels positively correlate with drinking, suggesting E2 may play a significant role in modulating drinking. Inhibitory control also modulates drinking; when it is reduced or compromised by alcohol, the drinker's ability to stop the self-administration of alcohol could be impaired, leading to a binge episode. The present study aimed to examine the degree to which menstrual cycle phase can influence the disinhibiting effect of alcohol. Twenty-four healthy young adult women participated in a within-subjects placebo-controlled study of the acute disinhibiting effect of 0.60 g/kg alcohol over the course of two test sessions. A cued go/no-go task measured the disinhibiting effects of alcohol and placebo beverages during the early follicular phase of the cycle when E2 levels were low and the late follicular phase (i.e., ovulation) when E2 was elevated. Results showed that the disinhibiting effect of alcohol increased nearly twofold during the late follicular phase when E2 was elevated. These findings highlight the role of alcohol-induced disinhibition as a potential behavioral mechanism by which fluctuations in ovarian hormones as a function of the menstrual cycle contribute to increased risk for excessive alcohol use in women. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

The importance of translationally evaluating steroid hormone contributions to substance use

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

Feasibility of Remotely Assessing Hormonal Contraceptive Use and Smoking-Related Symptomatology: Evidence from a Preliminary Prospective Cohort Study

Background

Half of women who smoke cigarettes also use hormonal contraceptives (HCs). Prior research suggests that variations in ovarian hormones may undermine smoking cessation efforts made by premenopausal women. However, clinical findings of these hormonal effects are inconsistent, potentially due to methodological limitations. The goal of this preliminary prospective cohort study is to determine the feasibility and acceptability of a fully remote protocol to longitudinally examine changes in smoking-related behavior and symptoms in relation to hormone use in women of reproductive age.

Methods

Eligible participants (n = 60) were biologically female, current age 18-35 years old, smokes ≥ 5 cigarettes/day, and classified into three groups: naturally-cycling (NC; n = 17), using a monophasic oral contraceptive (OC; n = 21), or using depot medroxyprogesterone acetate (DMPA; n = 22). Participants completed daily surveys and weekly dried blood spot collections.

Results

Overall, 92% (55/60) participants completed the study with 90% of daily surveys completed and 87% of participants collecting at least 5 of the 6 dried blood spot samples. Participants were "somewhat" (13%) or "extremely" (87%) likely to participate in the study again. Preliminary observations also suggested differences in self-reported cigarettes/day and premenstrual pain over time by study group.

Conclusions

This study outlines a fully remote protocol that may be used to clarify the relationships between hormonal contraceptive use and smoking-related outcomes over time. Preliminary results add to existing evidence that HC use may reduce relapse risk for premenopausal women.

Mid-Luteal Progesterone Is Inversely Associated with Premenstrual Food Cravings

It is not clear whether progesterone and estradiol associate with premenstrual food cravings, which significantly contribute to cardiometabolic adverse effects associated with obesity. We sought to investigate this question in the present study based on the prior literature showing a protective effect of progesterone on drug craving and extensive neurobiological overlaps between food and drug cravings. We enrolled 37 non-illicit drug- or medication-using women in the study to provide daily ratings of premenstrual food cravings and other symptoms across two-three menstrual cycles, based on which we classified them as premenstrual dysphoric disorder (PMDD) or control participants. In addition, the participants provided blood samples at eight clinic visits across the menstrual cycle. We aligned their mid-luteal progesterone and estradiol using a validated method which relies upon the peak serum luteinizing hormone and analyzed estradiol and progesterone using ultraperformance liquid chromatography tandem mass spectrometry. Hierarchical modeling, adjusted for BMI, showed a significant inverse effect of progesterone (p = 0.038) but no effect of estradiol on premenstrual food cravings. The association was not unique to PMDD or control participants. Results of research to date in humans and rodents showing that progesterone has dampening effects on the salience of the reinforcer translate to premenstrual food cravings.

Safety and tolerability of progesterone treatment for women with cocaine use disorder: a pilot treatment trial

Background: Problematic cocaine use remains a significant public health issue, particularly among women. However, no concerted efforts have been made to target a pharmacological treatment option for women with cocaine use disorder (CUD) despite preclinical, human laboratory, and a limited number of clinical studies demonstrating that progesterone can attenuate the effects of cocaine to a greater extent in women than men.Objectives: To evaluate the safety, tolerability, and preliminary efficacy of progesterone for treating women with CUD.Methods: A 10-week double-blind randomized treatment trial was conducted. Prior to randomization, participants were required to achieve cocaine abstinence (1 week) before assignment to progesterone (up to 400 mg/day) or placebo. The primary efficacy outcomes were days to relapse and cocaine abstinence during the last 3 weeks of the trial. The frequency of side effects was also assessed.Results: 227 women were assessed for eligibility. Twenty-five women entered treatment and 21 were randomized to progesterone (n = 11) or placebo (n = 10). The majority of women relapsed in less than 4 days with no differences between the two groups. Further, there were no significant differences between the progesterone and placebo groups in terms of cocaine abstinence during the last 3 weeks of the trial (27% and 10% respectively). The most commonly reported side effects were headache and fatigue, but no group differences were noted.Conclusions: Progesterone was well tolerated and safe and supports further study is in a larger sample to determine if exogenous progesterone is an effective treatment option for women with CUD.(ClinicalTrials.gov Identifier: NCT00632099).

Sex Differences in Psychostimulant Abuse: Implications for Estrogen Receptors and Histone Deacetylases

Substance abuse is a chronic pathological disorder that negatively affects many health and neurological processes. A growing body of literature has revealed gender differences in substance use. Compared to men, women display distinct drug-use phenotypes accompanied by recovery and rehabilitation disparities. These observations have led to the notion that sex-dependent susceptibilities exist along the progression to addiction. Within this scope, neuroadaptations following psychostimulant exposure are thought to be distinct for each sex. This review summarizes clinical findings and animal research reporting sex differences in the subjective and behavioral responses to cocaine, methamphetamine, and nicotine. This discussion is followed by an examination of epigenetic and molecular alterations implicated in the addiction process. Special consideration is given to histone deacetylases and estrogen receptor-mediated gene expression.

Characterization of salivary progesterone in female smokers

INTRODUCTION

Fluctuations in ovarian hormones have been associated with changes in cigarette smoking behavior, which can be measured through both serum or less invasive salivary procedures. The primary aim of this exploratory study is to characterize the progesterone profiles of salivary progesterone measurements and to compare that with the profiles estimated from a previously measured serum sample.

METHODS

Non-treatment seeking, cigarette smoking women (n=82; ages 18-45) provided daily salivary hormone samples every morning for 14 consecutive days. Time dependent random effects functions were used to approximate daily salivary progesterone (ng/ml) levels over the course of a standardized menstrual cycle. Serum measures of progesterone from a previous study of female cigarette smokers were examined for consistency with established profiles and compared to the salivary profile using the same methodology.

RESULTS

The salivary model fit exhibits relative stability during the follicular phase and a clear unimodal peak during the luteal phase. Parameter estimates from the non-linear function show correspondence to serum data. Although the profiles estimated from salivary and serum data agree in functional form, we observed larger between-subject heterogeneity both in the follicular level and the peak luteal level in salivary measures.

CONCLUSIONS

The pattern of salivary and serum progesterone measured across the menstrual cycle is similar in form, which is noteworthy given that the saliva and serum samples were drawn from independent sample of female smokers. Inter- and intra-individual variation in salivary measures may be greater than in serum measures.

IMPLICATIONS

Measuring progesterone level variation across the menstrual cycle via saliva samples has several benefits relative to serum sampling methods in that they are easily obtained, non-invasive and low-cost. Inter- and intra-individual variation in measurements may be greater than those in serum measurements. However, the functional form of the salivary progesterone profile is isomorphic to serum progesterone.

The Effects of Menstrual Cycle Hormones on Responses to Varenicline and Naltrexone Among Female Heavy Drinking Smokers

Aims

Women often experience poorer smoking cessation outcomes in comparison to men. Menstrual cycle phase and sex hormones may influence smoking behavior and alter response to opioid antagonist medications. Less is known about the effects of sex hormones in response to pharmacotherapy for female heavy drinking smokers.

Methods

This study is a secondary analysis of premenopausal female heavy drinking smokers who completed a 12-week randomized clinical trial comparing varenicline plus placebo versus varenicline plus naltrexone for smoking cessation and drinking reduction. Participants (n = 26; total observations = 66) provided saliva samples for assays of progesterone (P4) and estradiol (E2) post-randomization at Weeks 4, 8 and 12. We examined the effects of P4/E2 ratio and medication on smoking and drinking outcomes.

Results

For drinking outcomes, there was a significant interaction for percent days abstinent (b = 0.017, P = 0.05), suggesting that greater P4/E2 ratio is associated with greater percent days abstinent for women assigned to the varenicline plus naltrexone condition. There were no interaction effects for the remaining drinking outcomes (P’s ≥ 0.12). Results found no significant interaction effect of P4/E2 ratio and medication on smoking abstinence (P = 0.19).

Conclusion

Our results imply that when women show a greater P4/E2 ratio, typically observed during the luteal phase of the menstrual cycle, they experience an added benefit of naltrexone, versus placebo, for drinking outcomes as shown by greater percent days abstinent. Additional studies in larger samples are warranted as sex hormones offer important information above and beyond comparing women versus men.

Perceived Disease Risk of Smoking, Barriers to Quitting, and Cessation Intervention Preferences by Sex Amongst Homeless Adult Concurrent Tobacco Product Users and Conventional Cigarette-Only Users

Adults experiencing homelessness smoke conventional cigarettes and engage in concurrent tobacco product use at very high rates; however, little is known about how use patterns, perceived disease risk, barriers to quitting smoking, and smoking cessation intervention preferences differ by sex in this group. Participants comprised a convenience sample of 626 adult conventional cigarette smokers experiencing homelessness. Participants self-reported their sex, smoking history, mental health and substance use diagnosis history, other concurrent tobacco product use (CU), disease risk perceptions, perceived barriers to quitting smoking, and preferences regarding tobacco cessation interventions via a computer-administered survey. CU rates were 58.1% amongst men and 45.3% amongst women smokers. In both sexes, CUs started smoking earlier (p-values < 0.001) and were more likely to have been diagnosed with a non-nicotine substance use disorder (p-values < 0.014) relative to cigarette-only users. Among men only, CUs were younger, smoked more cigarettes per day and were more likely to identify as non-Hispanic White (p-values < 0.003) than cigarette-only users. Additionally, male CUs reported a greater risk of developing ≥1 smoking-related disease if they did not quit for good; were more likely to endorse craving cigarettes, being around other smokers, habit, stress/mood swings, and coping with life stress as barriers for quitting smoking; and were less likely to prefer medications to quit smoking relative to male cigarette-only users (p-values < 0.04). On the other hand, female CUs reported a greater risk of developing ≥1 smoking-related disease even if they quit for good; were more likely to endorse stress/mood swings and coping with life stress as barriers for quitting smoking relative to female cigarette-only users (p-values < 0.05); and did not differentially prefer one cessation medication over another. Overall, findings confirm high rates of CU among both sexes, characterize those who may be more likely to be CUs, and reveal opportunities to educate men and women experiencing homeless on the benefits of evidence-based interventions for smoking cessation.

Ongoing tobacco use in women who experience homelessness and unstable housing: A prospective study to inform tobacco cessation interventions and policies

BACKGROUND

Tobacco use is common in people who experience homelessness. However, despite biological differences in use by sex and lower quit rates in women, research in homeless and unstably housed (HUH) women is sparse. We identified correlates of use specific to this population, with the goal of informing tobacco cessation programs tailored for HUH women.

METHODS

We conducted a prospective study among HUH women recruited from San Francisco homeless shelters, street encampments, free meal programs and low-income hotels. Between June 2016 and January 2019, study participants completed six monthly interviews to examine factors associated with tobacco use, defined as urinary cotinine >10 pg/mL or self-reported prior 30-day use.

RESULTS

Among 245 participants, 40% were Black, the median age was 53, 75% currently used tobacco and 89% had ≥one 24-hour quit attempt in the prior year. Tobacco use was more common in women with PTSD (66% vs. 48%) and depression (54% vs. 35%) compared to women without these conditions. Adjusted odds of tobacco use decreased significantly with increasing age (OR_{/5 yrs}: 0.81; 95% CI:0.68, 0.96) and increased with an increasing number of additional substances used (OR: 2.52; 95% CI: 1.88, 3.39).

CONCLUSION

Outside of a treatment setting and within a community-recruited sample population composed of HUH women, the number of additional substances used is a primary correlate of ongoing tobacco use. Tailored cessation interventions that prioritize the issue of multiple substance use, and public health policies that allocate funding to address it, may increase tobacco cessation in this population.

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

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

Sex Differences in the Nicotinic Acetylcholine Receptor System of Rodents: Impacts on Nicotine and Alcohol Reward Behaviors

Alcohol and nicotine are the two most widely used and misused drugs around the world, and co-consumption of both substances is highly prevalent. Multiple lines of evidence show a profound effect of sex in many aspects of alcohol and nicotine reward, with women having more difficulty quitting smoking and showing a faster progression toward developing alcohol use disorder compared with men. Both alcohol and nicotine require neuronal nicotinic acetylcholine receptors (nAChRs) to elicit rewarding effects within the mesolimbic system, representing a shared molecular pathway that likely contributes to the frequent comorbidity of alcohol and nicotine dependence. However, the majority of preclinical studies on the mechanisms of alcohol and nicotine reward behaviors utilize only male rodents, and thus our understanding of alcohol and nicotine neuropharmacology relies heavily on male data. As preclinical research informs the development and refinement of therapies to help patients reduce drug consumption, it is critical to understand the way biological sex and sex hormones influence the rewarding properties of alcohol and nicotine. In this review, we summarize what is known about sex differences in rodent models of alcohol and nicotine reward behaviors with a focus on neuronal nAChRs, highlighting exciting areas for future research. Additionally, we discuss the way circulating sex hormones may interact with neuronal nAChRs to influence reward-related behavior.

Homeless women's perspectives on smoking and smoking cessation programs: A qualitative study

BACKGROUND

Individuals who are unsheltered or experiencing homelessness are more likely to smoke than those in the general population and have a higher prevalence of tobacco-related illnesses. Those who are unhoused make quit attempts at rates similar to the general population, however rates of successful quitting are much lower. Women bear a higher burden of smoking-related diseases and are less successful in their cessation efforts than men. Despite these increased risks and challenges, cessation programs specifically designed to meet the needs of women experiencing homelessness are extremely rare.

METHODS

To examine perceptions of smoking cessation programs among women who are unstably housed, we conducted in-depth, semi-structured interviews with twenty-nine women experiencing homelessness or unstable housing who had histories of tobacco and substance use. Interviews explored the social context of smoking, as well as interest in, barriers to, and facilitators of quitting. We used a grounded theory approach to analyze the transcripts.

RESULTS

Participants reported a number of structural barriers to cessation. They reported obstacles to participating in existing cessation programs, including chronic stress related to experiences of being unsheltered and fear of being exposed to neighborhood violence. These conditions were paired with a strong need to self-isolate in order to maintain personal safety, which runs counter to traditional group-based cessation programs.

CONCLUSION

A dissonance exists between current smoking cessation programs and the needs of women who are unsheltered or unstably housed. Alternative cessation treatment delivery models that address extremely high levels of chronic stress violence, and avoidance of group settings are needed, as are programs that provide options for safe participation.

Progesterone serum levels correlate negatively with craving in female postmenopausal in-patients with alcohol use disorder: A sex- and menopausal status-separated study

OBJECTIVE

Alcohol use disorder (AUD) shows a high prevalence and often takes a severe and chronic course. However, the underlying mechanisms still need to be better understood. There is increasing evidence for a role of sex hormones in AUD and for the importance of sex-separated concepts in addiction research. Nevertheless, only few data give insight into how progesterone is involved in AUD.

METHOD

Serum progesterone levels were measured at baseline (during early abstinence) in 186 in-patients with AUD (19% premenopausal females, 20% postmenopausal females, 61% males) and at median 5 days later. They were compared with those of 233 healthy control subjects (24% premenopausal females, 19% postmenopausal females, 57% males). We quantified craving with the Obsessive Compulsive Drinking Scale (OCDS) and visual analogue scales (VAS). Alcohol-related hospital readmissions within a 24-month period following initial in-patient treatment were recorded. We conducted analyses separately for sex and for menopausal status in female participants.

RESULTS

Postmenopausal females with AUD reported higher craving than premenopausal females. In postmenopausal females, higher baseline progesterone levels correlated with lower OCDS total craving and VAS craving, i.e., lower state craving and lower average, maximum, and less frequent craving during withdrawal. In males with AUD, progesterone levels at baseline tended to be higher than in controls and declined to follow-up. Alcohol-related readmissions were not significantly associated with serum progesterone levels.

CONCLUSION

We provide first evidence that progesterone levels correlate with craving in females with AUD.

Addictive behaviors across the menstrual cycle: a systematic review

Research examining relations between menstrual cycle phase and female addictive behaviors is accumulating. Theories suggest addictive behaviors may increase during specific phases of the menstrual cycle resulting from cyclical fluctuations in hormones and affect. In line with self-medication theory, we predicted that addictive behaviors would increase premenstrually and menstrually, phases marked by elevations in negative affect, relative to the follicular and luteal phases. We also hypothesized, coinciding with reward-sensitivity theory, that addictive behaviors may increase during ovulation, a phase characterized by increased positive affect, compared to the same phases. This systematic review summarizes extant literature examining the menstrual cycle phase-addictive behavior relationship and underlying motivations. Articles pertaining to menstrual cycle phase and addictive behaviors within the PsycINFO, CINAL, and PubMED databases were screened to determine eligibility following PRISMA guidelines (n = 1568). Thirty-four articles examining alcohol use, cannabis use, nicotine use, caffeine use, and gambling behavior across menstrual cycle phase met inclusion criteria. Consistent with self-medication theory, strong evidence indicated that nicotine use increased premenstrually and menstrually. Other factors increasing both nicotine and alcohol use premenstrually and menstrually include having a premenstrual dysphoric disorder diagnosis or having premenstrual syndrome. Motivations for using alcohol and nicotine may too vary by menstrual cycle phase. Results were less consistent or understudied for other addictive behaviors and thus conclusions cannot be drawn. Menstrual cycle phase appears to be a female-specific factor affecting some addictive behaviors, particularly nicotine use, and should be considered when conducting addictive behavior research or clinical interventions for reproductive-aged females with addictive disorders.

Increases in endogenous progesterone attenuate smoking in a cohort of nontreatment seeking women: An exploratory prospective study

Despite advances in prevention and treatment, cigarette smoking remains a leading cause of preventable death in the United States. Although men and women are equally likely to attempt to quit smoking cigarettes, women are far less likely to achieve abstinence both during and following cessation treatment. Recent evidence suggests that ovarian hormone levels may play a role in successful abstinence attempts in women smokers. The primary goal of this exploratory prospective observational study was to estimate the association between within-participant levels of progesterone and estradiol with associated cigarettes smoked per day in adult women smokers (n = 104). The primary study outcome was self-reported cigarettes smoked per day (CPD) during a 2-week observational period collected using a daily smoking diary. Additionally, participants collected saliva daily, from which hormone levels (progesterone and estradiol) were derived. Higher within-participant progesterone levels were associated with a significant decrease in CPD (p = .008) whereas within-participant estradiol levels were unrelated to CPD (p = .25). Regression models indicated a single change in the trajectory of smoking behavior for both within-participant progesterone and estradiol. When progesterone values were below the change point, there was a significant inverse relationship between within-participant progesterone levels and smoking behavior (p = .025) whereas the relationship was attenuated for higher within-participant progesterone levels (p = .59). The effect of estradiol on smoking behavior was not significant when it was either below (p = .92) or above (p = .16) the change point. Higher within-participant levels of progesterone but not estradiol are associated with reduced CPD in nontreatment seeking women smokers.

Two weeks of image-guided left dorsolateral prefrontal cortex repetitive transcranial magnetic stimulation improves smoking cessation: A double-blind, sham-controlled, randomized clinical trial

BACKGROUND

Previous studies have found that repetitive transcranial magnetic stimulation (rTMS) to the left dorsal lateral prefrontal cortex (LDLPFC) transiently reduces smoking craving, decreases cigarette consumption, and increases abstinence rates.

OBJECTIVE

We investigated whether 10 daily MRI-guided rTMS sessions over two weeks to the LDLPFC paired with craving cues could reduce cigarette consumption and induce smoking cessation.

METHODS

We enrolled 42 treatment-seeking nicotine-dependent smokers (≥10 cigarettes per day) in a randomized, double-blind, sham-controlled trial. Participants received 10 daily sessions over 2 weeks of either active or sham MRI-guided rTMS (10Hz, 3000 pulses each session) to the LDLPFC concurrently with video smoking cues. The primary outcome was a reduction in biochemically confirmed cigarette consumption with a secondary outcome of abstinence on the target quit date. We also recorded cue-induced craving and withdrawal symptoms.

RESULTS

Compared to sham (n = 17), participants receiving active rTMS (n = 21) smoked significantly fewer cigarettes per day during the 2-week treatment (mean [SD], 13.73[9.18] vs. 11.06[9.29], P < .005) and at 1-month follow-up (12.78[9.53] vs. 7.93[7.24], P < .001). Active rTMS participants were also more likely to quit by their target quit rate (23.81%vs. 0%, OR 11.67, 90% CL, 0.96-141.32, x2 = 4.66, P = .031). Furthermore, rTMS significantly reduced mean craving throughout the treatments and at follow-up (29.93[13.12] vs. 25.01[14.45], P < .001). Interestingly across the active treatment sample, more lateral coil location was associated with more success in quitting (-43.43[0.40] vs. -41.79[2.24], P < .013).

CONCLUSIONS

Daily MRI-guided rTMS to the LDLPFC for 10 days reduces cigarette consumption and cued craving for up to one month and also increases the likelihood of smoking cessation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02401672.

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).

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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

Smoking Across the Menopausal Transition in a 10-Year Longitudinal Sample: The Role of Sex Hormones and Depressive Symptoms

INTRODUCTION

Current cigarette smoking rates among older women remain problematic, especially given that this population experiences increased smoking-related health consequences. Despite these increased health concerns, little research to date has explored smoking patterns across the menopausal transition (pre-, early-peri-, late-peri-, and postmenopausal) or the effect of unique factors such as sex hormones and depression during this transition.

METHODS

This study used 10 yearly waves of data from the Study of Women's Health Across the Nation, a longitudinal dataset. Data included 1397 women endorsing ever smoking regularly at baseline. Random-effects logistic regression models were used to examine smoking transitions.

RESULTS

Although there were no associations between menopausal transition stage and smoking behavior, increased estradiol was associated with an increased likelihood of quitting regular smoking (eg, transitioning from regular smoking to non-regular or no smoking; odds ratio [OR] = 1.28), whereas increased testosterone was associated with an increased likelihood of relapsing to regular smoking (eg, transitioning from former or nonregular smoking to regular smoking OR = 2.56). Depression was associated with increased likelihood of continued smoking (OR = 0.97) and relapse (OR = 1.03).

CONCLUSIONS

The results emphasize the need to develop interventions to target initiated or continued smoking among women across the menopausal transition and specifically highlight the importance of developing treatments that target depressive symptoms in this population. In addition, although singular hormone measures were associated with smoking behavior, there is a need for future study of dynamic changes in hormones, as well as the impact of progesterone on smoking behaviors across the menopausal transition.

IMPLICATIONS

To date, no studies have examined smoking behaviors across the menopausal transition. In this study, although menopausal transition status was not significantly related to transitions in smoking behavior, important relationships between sex hormones and depression were observed. Increased estradiol was associated with an increased likelihood of quitting regular smoking, whereas increased testosterone was associated with an increased likelihood of relapsing to regular smoking behavior. Higher depression scores were related to continued smoking and relapse to regular smoking behavior. These results highlight the need to develop interventions to target smoking cessation among women across the menopausal transition.

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Commentary on Tosun et al. (2019): Dynamic changes in sex hormones and smoking cessation

There is growing evidence suggesting that exogenous progesterone may improve smoking cessation outcomes among women. We hypothesize that exogenous progesterone administration can result in stable progesterone levels, and that it is the absence of dynamic hormone change that may lead to improved smoking cessation outcomes.

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

BACKGROUND AND AIMS

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

DESIGN

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

SETTING

Minneapolis/St Paul metro area, Minnesota, USA.

PARTICIPANTS

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

INTERVENTION

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

MEASUREMENTS

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

FINDINGS

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

CONCLUSIONS

Oral micronized progesterone may aid smoking cessation in women.

Interactive effects of ovarian steroid hormones on alcohol use and binge drinking across the menstrual cycle

Patterns and features of substance use and abuse vary across the menstrual cycle in humans. Yet, little work has systematically examined the within-person relationships between ovarian hormone changes and alcohol use across the menstrual cycle. Our study was the first to examine the roles of within-person levels of estradiol (E2) and progesterone (P4) in relation to daily alcohol use and binge drinking in young women. Participants were 22 naturally cycling women, ages 18-22, recruited through a university subject pool who reported any alcohol use and who completed a screening visit assessing study eligibility, followed by 35 subsequent days of data collection. E2 and P4 were obtained via enzyme immunoassay of saliva samples collected by participants each morning, 30 min after waking. Presence and degree of daily substance use were obtained using an adaptation of the Timeline FollowBack Interview completed daily. Results indicated that elevated E2 in the context of decreased P4 levels were associated with higher risk of drinking and binge drinking. These effects were present only on weekend days. Results are suggestive of a dual risk model in which both ovulatory E2 increases and perimenstrual P4 decreases increase risk for drinking. Differential associations of steroids with drinking across the menstrual cycle may suggest the need for clinical assessment of substance use to take into account hormone dynamics and menstrual cycle phase. (PsycINFO Database Record

Economic demand analysis of within-session dose-reduction during nicotine self-administration

BACKGROUND

This study determined if a within-session dose-reduction design sufficiently captures elasticity of demand for nicotine in male and female rats using environmental enrichment to manipulate demand elasticity.

METHODS

Male and female Sprague-Dawley rats were trained to self-administer nicotine (60 μg/kg/infusion). In Experiment 1, rats began daily dose-reduction for nine sessions following acquisition. Rats then underwent a minimum of five within-session dose-reduction sessions where each dose was available for 10 min. In Experiment 2, rats were reared in isolated, social, or enriched housing followed by acquisition of nicotine self-administration. Rats then underwent within-session dose-reduction. Housing environments were then switched, followed by additional testing sessions. Consumption was calculated for each dose and exponential demand curves were fit.

RESULTS

No sex differences in acquisition of nicotine self-administration were detected for either experiment. In experiment 1, demand intensity (Q₀; estimated intake if nicotine were freely available), was higher with between- compared to within-session dose-reduction, although elasticity of demand (α; rate of decline in nicotine intake as a function of increasing unit price), was lower. In Experiment 2, animals reared in enrichment had fewer infusions during acquisition compared to animals in isolation. Enriched males had reduced demand intensity compared to both isolated and social males, whereas isolated females had reduced intensity compared to enriched females.

CONCLUSIONS

The within-session dose-reduction procedure for nicotine self-administration replicated effects of environmental enrichment on consumption behaviors. Additionally, this procedure captured differences in nicotine demand due to sex, laying important groundwork for future translational research on mechanisms of nicotine dependence.

Oral Contraceptives and Cigarette Smoking: A Review of the Literature and Future Directions

INTRODUCTION

Evidence continues to mount indicating that endogenous sex hormones (eg, progesterone and estradiol) play a significant role in smoking-related outcomes. Although approximately one out of four premenopausal smokers use oral contraceptives (OCs), which significantly alter progesterone and estradiol levels, relatively little is known about how OCs may influence smoking-related outcomes. Thus, the goal of this review article is to describe the state of the literature and offer recommendations for future directions.

METHODS

In March 2017, we searched seven databases, with a restriction to articles written in English, using the following keywords: nicotine, smoker(s), smoking, tobacco, cigarettes, abstinence, withdrawal, and craving(s). We did not restrict on the publication date, type, or study design.

RESULTS

A total of 13 studies were identified. Three studies indicated faster nicotine metabolism in OC users compared to nonusers. Five of six laboratory studies that examined physiological stress response noted heightened response in OC users compared to nonusers. Three studies examined cessation-related symptomatology (eg, craving) with mixed results. One cross-sectional study observed greater odds of current smoking among OC users, and no studies have explored the relationship between OC use and cessation outcomes.

CONCLUSIONS

Relatively few studies were identified on the role of OCs in smoking-related outcomes. Future work could explore the relationship between OC use and mood, stress, weight gain, and brain function/connectivity, as well as cessation outcomes. Understanding the role of OC use in these areas may lead to the development of novel smoking cessation interventions for premenopausal women.

IMPLICATIONS

This is the first review of the relationship between oral contraceptives (OCs) and smoking-related outcomes. The existing literature suggests that the use of OCs is related to increased nicotine metabolism and physiological stress response. However, the relationship between OC use and smoking-related symptoms (eg, craving) is mixed. Further, no published data were available on OC use and smoking cessation outcomes. Therefore, we recommend additional research be conducted to characterize the relationship between OC use and smoking cessation outcomes, perhaps as a function of the effect of OC use on mood, stress, weight gain, and brain function/connectivity.

Exogenous progesterone for cannabis withdrawal in women: Feasibility trial of a novel multimodal methodology

BACKGROUND

Sex differences in cannabis use disorder (CUD) and its treatment have been identified. Women report more severe withdrawal and have shown worse treatment outcomes. Ovarian hormones are implicated in these differences and research suggests that exogenous progesterone may be an effective pharmacotherapy.

METHODS

The current randomized, placebo-controlled, feasibility trial tested a novel multimodal methodology for administering exogenous progesterone during acute cannabis withdrawal. Eight heavy cannabis using women received micronized progesterone (200 mg bid) (n = 3) or matching placebo (n = 5) during the early follicular phase of their menstrual cycle over a 5-day study period while abstaining from cannabis. Laboratory visits (days 1 and 5) included biological and self-report assessments, while home-based procedures (days 2-4) included ambulatory assessments, video data capture and tele-drug testing, and biological assessments. Primary outcomes were medication adherence and salivary hormone levels, and the exploratory outcome was cannabis withdrawal severity.

RESULTS

Medication adherence rates were high as assessed via self-report (100.0%) and video data capture (98.0%). Salivary progesterone levels differed between groups over time (p < 0.027) and the progesterone group achieved levels within the normal range during the luteal phase in healthy adults. All tele-drug tests were negative confirming cannabis abstinence and there was an indication (p = 0.07) of reduced cannabis craving among participants receiving progesterone.

CONCLUSION

More effective and sex-based treatments for cannabis use disorder are needed. The current study provides a novel multimodal methodology with low participant burden for investigating new medications for cannabis withdrawal. Clinical trials of progesterone for cannabis withdrawal may be warranted.

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

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

Emotional distress and tobacco demand during the menstrual cycle in female smokers

Fluctuations in ovarian hormones over the menstrual cycle contribute to cigarette reward, however less is known about menstrual cycle influences on emotional distress in female smokers. We examined between-group differences in emotional distress (negative affectivity, emotion dysregulation, distress intolerance) and hypothetical cigarette purchasing (i.e. tobacco demand) among female smokers at three different menstrual stages. Women (n = 32) were non-treatment seeking daily smokers not on hormonal contraceptive, and were currently in their follicular (estradiol-dominant; n = 10), early-mid luteal (progesterone-dominant; n = 15), and late-luteal phase (decreasing progesterone/estradiol; n = 7). Effect sizes are reported given the small sample. Women in the late-luteal phase, relative to the follicular and early-mid luteal phases, reported higher levels of negative affectivity (d = 0.69), emotion dysregulation (d = 1.03), and distress intolerance (d = -0.86). Compared to the early-mid luteal and late-luteal phases, women in the follicular phase reported the highest hypothetical cigarette consumption when cigarettes were free (d = 0.71) and made the largest maximum expenditures on cigarettes (d = 0.74). Findings offer preliminary evidence that the late-luteal phase is characterized by emotional distress, and the follicular phase is associated with elevated tobacco demand, which if replicated could implicate ovarian hormones in emotion-focused smoking.

Role of Exogenous Progesterone in the Treatment of Men and Women with Substance Use Disorders: A Narrative Review

Substance use disorders (SUDs) remain problematic as many individuals are untreated or do not benefit from the currently available interventions. Thus, there is an urgent need to develop novel pharmacological interventions to treat SUDs. Evidence suggests that the female sex hormone, progesterone, attenuates the craving for and the euphoric effects of drugs of abuse. Research to date has demonstrated that progesterone may modulate responses to drugs of abuse and may have utility as a novel treatment for SUDs. A literature search was conducted to identify and examine studies that administered exogenous progesterone. Sixteen publications were identified, exploring the utility of exogenous progesterone or its metabolite, allopregnanolone, among a range of substances, including amphetamines (one study), benzodiazepines (one study), cocaine (nine studies), and tobacco/nicotine (five studies). Results indicated that exogenous progesterone and, its metabolite allopregnanolone, demonstrated preliminary efficacy as a treatment for substance use in both men and women. Notably, progesterone appears to target negative affect and augment cognitive functioning, especially among female substance users. Additional research is needed to explore the potential use of exogenous progesterone and allopregnanolone in the treatment of SUDs, including that associated with alcohol and opioids, but considering the current promising findings, exogenous progesterone and allopregnanolone may have utility as novel pharmacological treatments for SUDs.

Ovarian Hormones and Transdermal Nicotine Administration Independently and Synergistically Suppress Tobacco Withdrawal Symptoms and Smoking Reinstatement in the Human Laboratory

Modeling intra-individual fluctuations in estradiol and progesterone may provide unique insight into the effects of ovarian hormones on the etiology and treatment of nicotine dependence. This randomized placebo-controlled laboratory study tested the independent and interactive effects of intra-individual ovarian hormone variation and nicotine on suppression of tobacco withdrawal symptoms and smoking behavior. Female smokers randomized to 21 mg nicotine (TNP; n=37) or placebo (PBO; n=43) transdermal patch following overnight abstinence completed three sessions occurring during hormonally distinct menstrual cycle phases. At each session, participants provided saliva for hormone assays and completed repeated self-report measures (ie, tobacco withdrawal symptoms, smoking urge, and negative affect (NA)) followed by an analog smoking reinstatement task for which participants could earn money to delay smoking and subsequently purchase cigarettes to smoke. Higher (vs lower) progesterone levels were associated with greater reductions in NA. Higher (vs lower) progesterone levels and progesterone to estradiol ratios were associated with reducing smoking urges over time to a greater extent with TNP compared to PBO. There was an interaction between Patch and estradiol on NA. With TNP, higher-than-usual estradiol was associated with greater decreases in NA. However with PBO, lower-than-usual estradiol was associated with greater decreases in NA. These results suggest that the effects of TNP on mood- and smoking-related outcomes may vary depending on the ovarian hormone levels.

Hormonal contraceptive use in smokers: Prevalence of use and associations with smoking motives

INTRODUCTION

While endogenous sex hormones influence smoking-related outcomes, little is known about the role of hormonal contraceptives (HCs). This is despite dated estimates suggesting that HC use is prevalent among female smokers. Therefore, we sought to update estimates of the prevalence of HC use among female smokers and explore the association of HC use with various smoking motives (SMs).

METHODS

This online cross-sectional survey recruited female smokers between the ages of 18-35. Survey questions assessed smoking behavior, SMs, use of HCs, and menstrual cycle regularity.

RESULTS

Participants (n=734) were, on average (±standard deviation), 20.7±2.7 years old and smoked 7.3±6.7 cigarettes/day. The majority of females reported a history of HC use (85%) and half reported current use (48%). Cyclical HC users (n=227) scored significantly lower on three SMs compared to naturally-cycling women in the follicular phase (n=62) and significantly higher on 15 SMs compared to naturally-cycling women in the luteal phase (n=29). Women on cyclical HCs differed from women on long-acting HCs (n=128) on two SMs. Further, the naturally-cycling women in the follicular phase scoring significantly higher on 15 SMs compared to those in the luteal phase.

DISCUSSION

These observations indicate that HC use remains prevalent in female smokers and may influence SMs. Additional research should replicate these observations and explore the implications on smoking cessation outcomes.

Use of hormonal contraceptives and smoking cessation: A preliminary report

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

Sex-specific attenuation of impulsive action by progesterone in a go/no-go task for cocaine in rats

RATIONALE

Previous work indicated that progesterone (PRO) reduced impulsive choice for cocaine in female but not male rats (Smethells et al. Psychopharmacology 233:2999-3008, 2016). Impulsive action, typically measured by responding for a reinforcer during a signaled period of nonavailability of natural reinforcers, predicts initiation and escalation of drug use in animals and humans. The present study examined impulsive action for cocaine using PRO in male and female rats trained on a go/no-go task.

OBJECTIVE

Rats were trained on a go/no-go task to respond for cocaine infusions (0.4 mg/kg/inf). During the "go" component, responding was reinforced on a VI 30-s schedule, whereas during the "no-go" component, withholding a response was reinforced on a differential reinforcement of other behavior (DRO) 30-s schedule. A response during the no-go component resets the DRO timer and served as a measure of impulsive action. After baseline responding was established, rats were pretreated with vehicle (VEH) or PRO (0.5 mg/kg), and DRO resets and responding during the go component for cocaine were compared in males vs. females.

RESULTS

DRO resets were significantly lower following PRO treatment compared to VEH in female, but not male, rats. Response rates and overall infusions during the go component were not significantly altered by PRO in either females or males.

CONCLUSION

Treatment with PRO resulted in a sex-specific reduction in impulsive action for cocaine, while not affecting cocaine self-administration.

Progesterone for smoking relapse prevention following delivery: A pilot, randomized, double-blind study

INTRODUCTION

Close to half of women who were smokers prior to conception quit smoking in pregnancy, when endogenous progesterone levels are high. However, at least half resume pre-pregnancy smoking levels within weeks after delivery and when progesterone levels drop. The current pilot study tested the feasibility and preliminary efficacy of postpartum progesterone replacement in preventing relapse to smoking in postpartum women with a history of pre-pregnancy smoking.

METHODS

This was an 8-week, double-blind, parallel, randomized, placebo-controlled pilot trial of 41 women with a history of pre-pregnancy smoking who achieved abstinence by 32 weeks of gestation. Immediately following delivery women were randomized to oral micronized progesterone (200mg twice daily) or placebo via computerized urn randomization program. The main outcome measures were descriptions of study feasibility: recruitment and retention. Secondary outcomes were 7-day point prevalence of abstinence at week 8, time to relapse and smoking cravings.

RESULTS

The trial was feasible with adequate randomization, 64% (41/64) of eligible women, and trial retention, 78% (32/41) completed the trial. Women taking progesterone were 1.8 times more likely to be abstinent during week 8 and took longer to relapse (10 vs. 4 weeks) compared to the placebo group, although these differences did not reach statistical significance. After adjusting for age and pre-quit smoking level, the number needed to treat was 7. There was a 10% greater decline per week in craving ratings in the progesterone group compared to placebo (β=-0.10, 95% CI: -0.15, -0.04, p<0.01). No serious adverse events occurred during the trial.

CONCLUSIONS

These preliminary findings support the promise of progesterone treatment in postpartum smokers and could constitute a therapeutic breakthrough.If these preliminary findings can be evaluated and replicated in a larger study with sufficient power, this may constitute an acceptable and safe smoking relapse prevention strategy for use during lactation.

Sex differences in nicotine preference

Smoking is the major cause of preventable deaths worldwide, and although there is a decline in overall smoking prevalence in developed countries, the decline in women is less pronounced than in men. Women become dependent faster and experience greater difficulties in quitting. Similar trends have been observed in animal models of nicotine/tobacco addiction. Individual differences in vulnerability to drug abuse are also observed in nicotine/tobacco addiction and point to the importance of sex differences. This Review, summarizes findings from three experimental approaches used to depict nicotine preference in animal models, intravenous and oral nicotine self-administration and nicotine-induced conditioned place preference. Nicotine preference is considered to be reflected in the animal's motivation to administer the drug (intravenously or orally) or to prefer an environment paired with the presence of the drug (conditioned place preference). These approaches all point to the importance of sex and age of the subjects; the preference of females and adolescents appear to be more pronounced than that of males and adults, respectively. A closer look at these factors will help us understand the mechanisms that underlie nicotine addiction and develop strategies to cope. Ignoring sex differences and reaching conclusions based only on studies using male subjects has resulted in erroneous generalizations in the past. Sex differences in nicotine preference have been clearly documented, and awareness on this aspect of nicotine dependence will significantly impact our success in translational research. © 2016 Wiley Periodicals, Inc.

Exercise or saccharin during abstinence block estrus-induced increases in nicotine-seeking

Recent evidence suggests that adolescent and young adult females may be particularly responsive to nicotine use interventions that include exercise or environmental enrichment. This possibility was addressed in the current study by comparing the efficacy of exercise versus non-exercise environmental enrichment (saccharin) during abstinence at reducing subsequent nicotine-seeking/relapse vulnerability in an adolescent-onset rat model. The efficacy of each intervention was examined as a function of estrous cycle phase given findings indicating that hormonal status influences relapse vulnerability and treatment outcome in females. Once adolescent female rats acquired nicotine self-administration, they were given 23-h/day access to nicotine (0.01mg/kg/infusion) for 10days. Following the last self-administration session, rats began a 10-day forced abstinence period with 2-h/day access to an unlocked wheel (exercise, n=15), a bottle containing a saccharin-sweetened solution (0.25%; saccharin, n=19), or without access to a wheel or saccharin (control, n=20). Nicotine-seeking, as assessed under an extinction/cued-induced reinstatement procedure, was examined on day 11 of abstinence. Levels of nicotine-seeking were highest in females tested during estrus as compared to females tested during non-estrus phases. Exercise or saccharin during abstinence reduced nicotine-seeking in females tested during estrus, but neither affected the low levels of nicotine-seeking observed in females tested during non-estrus phases, presumably due to a floor effect. These results demonstrate that exercise or saccharin during abstinence decrease nicotine-seeking, and suggest that either would be effective as an early intervention for nicotine use and addiction in females.

Sex as a biological variable: Drug use and abuse

The study of sex as a biological variable is a necessary emphasis across a wide array of endpoints, including basic neuroscience, medicine, mental health, physiology and behavior. The present review summarizes work from clinical and preclinical populations on sex differences in drug use and abuse, ranging from initiation to escalation/dysregulation and from drug cessation/abstinence to relapse. These differences are analyzed in the context of the addiction cycle conceptualization of Koob and his colleagues and address patterns of drug use (binge/intoxication), motivation underlying its use (withdrawal/negative affect) and likelihood and causes of craving and relapse of drug taking (preoccupation/anticipation). Following this overview, an assessment of the basis for the reported sex differences is discussed in the context of the affective (rewarding and aversive) properties of drugs of abuse and how such properties and their balance vary with sex and contribute to drug intake. Finally, the interaction of sex with several experiential (drug history) and subject (age) factors and how these interactions affect reward and aversion are discussed to highlight the importance of understanding such interactions in predicting drug use and abuse. We note that sex as a biological variable remains one of critical evaluation and that such investigations of sex differences in drug use and abuse continue and be expanded to assess all facets of their mediation, including these affective properties, how their balance may be impacted by the multiple conditions under which drugs are taken and how this overall balance affects drug use and addiction vulnerability.

Prospective evaluation of luteal phase length and natural fertility

OBJECTIVE

To evaluate the impact of a short luteal phase on fecundity.

DESIGN

Prospective time-to-pregnancy cohort study.

SETTING

Not applicable.

PATIENT(S)

Women trying to conceive, ages 30-44 years, without known infertility.

INTERVENTION(S)

Daily diaries, ovulation prediction testing, standardized pregnancy testing.

MAIN OUTCOME MEASURE(S)

Subsequent cycle fecundity.

RESULT(S)

Included in the analysis were 1,635 cycles from 284 women. A short luteal phase (≤11 days including the day of ovulation) occurred in 18% of observed cycles. Mean luteal phase length was 14 days. Significantly more women with a short luteal phase were smokers. After adjustment for age, women with a short luteal phase had 0.82 times the odds of pregnancy in the subsequent cycle immediately following the short luteal phase compared with women without a short luteal phase. Women with a short luteal length in the first observed cycle had significantly lower fertility after the first 6 months of pregnancy attempt, but at 12 months there was no significant difference in cumulative probability of pregnancy.

CONCLUSION(S)

Although an isolated cycle with a short luteal phase may negatively affect short-term fertility, incidence of infertility at 12 months was not significantly higher among these women.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01028365.

How to study sex differences in addiction using animal models

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

Effects of intimate partner violence, PTSD, and alcohol use on cigarette smoking in a nationally representative sample

BACKGROUND AND OBJECTIVES

Separate literatures indicate that intimate partner violence (IPV), posttraumatic stress disorder (PTSD), and alcohol use are independently associated with increased risk for cigarette smoking. No previous studies have examined the co-occurrence of these problems on smoking quantity and potential gender-specific relationships. This study will address this gap in the literature.

METHODS

Data from Wave 2 of the National Epidemiologic Study on Alcohol and Related Conditions (NESARC) were examined. Variables were assessed during the past year. Individuals (N = 25,604) who reported being married, dating, or involved in a romantic relationship were included.

RESULTS

Among men, PTSD and alcohol use were associated with more cigarettes smoked per day. Among women, PTSD, alcohol use, and IPV victimization were associated with more cigarettes smoked per day. Women who experienced IPV victimization smoked approximately three additional cigarettes per day.

DISCUSSION AND CONCLUSIONS

IPV victimization, PTSD, and alcohol use were associated with cigarettes smoked among women, while IPV experiences were not associated with smoking risk among men.

SCIENTIFIC SIGNIFICANCE

These findings represent an important contribution to the existing literature in that it elucidates the compounding relationship between a common and complex comorbidity and cigarette smoking. Findings indicate a critical need to implement routine smoking screening and intervention in venues where intimate partner violence is commonly encountered, such as advocacy and substance use treatment settings. (Am J Addict 2016;25:283-290).

Sex Differences in Behavioral Dyscontrol: Role in Drug Addiction and Novel Treatments

The purpose of this review is to discuss recent findings related to sex differences in behavioral dyscontrol that lead to drug addiction, and clinical implications for humans are discussed. This review includes research conducted in animals and humans that reveals fundamental aspects of behavioral dyscontrol. The importance of sex differences in aspects of behavioral dyscontrol, such as impulsivity and compulsivity, is discussed as major determinants of drug addiction. Behavioral dyscontrol during adolescence is also an important consideration, as this is the time of onset for drug addiction. These vulnerability factors additively increase drug-abuse vulnerability, and they are integral aspects of addiction that covary and interact with sex differences. Sex differences in treatments for drug addiction are also reviewed in terms of their ability to modify the behavioral dyscontrol that underlies addictive behavior. Customized treatments to reduce behavioral dyscontrol are discussed, such as (1) using natural consequences such as non-drug rewards (e.g., exercise) to maintain abstinence, or using punishment as a consequence for drug use, (2) targeting factors that underlie behavioral dyscontrol, such as impulsivity or anxiety, by repurposing medications to relieve these underlying conditions, and (3) combining two or more novel behavioral or pharmacological treatments to produce additive reductions in drug seeking. Recent published work has indicated that factors contributing to behavioral dyscontrol are an important target for advancing our knowledge on the etiology of drug abuse, intervening with the drug addiction process and developing novel treatments.

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.