Using Nicotine Gum to Assist Nondaily Smokers in Quitting: A Randomized Clinical Trial

Intermittent nicotine access is as effective as continuous access in promoting nicotine seeking and taking in rats

RATIONALE

Nicotine is a principal psychoactive agent in tobacco, contributing to tobacco's addictive potential. Preclinical studies on the effects of voluntary nicotine intake typically use self-administration procedures that provide continuous nicotine access during each self-administration session. However, many smokers consume cigarettes intermittently rather than continuously throughout each day. For drugs including cocaine and opioids, research in laboratory rats shows that intermittent intake can be more effective than continuous intake in producing patterns of drug use relevant to addiction.

OBJECTIVE

We determined how intermittent versus continuous nicotine self-administration influences nicotine seeking and taking behaviours.

METHODS

Female and male rats had continuous (i.e., Long Access; LgA, 6 h/day) or intermittent (IntA; 12 min ON, 60 min OFF, for 6 h/day) access to intravenous nicotine (15 µg/kg/infusion), for 12 daily sessions. We then assessed intake, responding for nicotine under a progressive ratio schedule of drug reinforcement and cue- and nicotine-induced reinstatement of drug seeking. We also estimated nicotine pharmacokinetic parameters during LgA and IntA self-administration.

RESULTS

Overall, LgA rats took twice more nicotine than did IntA rats, yielding more sustained increases in estimated brain concentrations of the drug. However, the two groups showed similar motivation to seek and take nicotine, as measured using reinstatement and progressive ratio procedures, respectively.

CONCLUSIONS

Intermittent nicotine use is just as effective as continuous use in producing addiction-relevant behaviours, despite significantly less nicotine exposure. This has implications for modeling nicotine self-administration patterns in human smokers and resulting effects on brain and behaviour.

The efficacy and acceptability of pharmacological monotherapies and e-cigarette on smoking cessation: a systemic review and network meta-analysis

Background and aims

Several pharmacological interventions, such as nicotine replacement therapy (NRT), varenicline, and bupropion, have been approved for clinical use of smoking cessation. E-cigarettes (EC) are increasingly explored by many RCTs for their potentiality in smoking cessation. In addition, some RCTs are attempting to explore new drugs for smoking cessation, such as cytisine. This network meta-analysis (NMA) aims to investigate how these drugs and e-cigarettes compare regarding their efficacy and acceptability.

Materials and methods

This systematic review and NMA searched all clinical studies on smoking cessation using pharmacological monotherapies or e-cigarettes published from January 2011 to May 2022 using MEDLINE, COCHRANE Library, and PsychINFO databases. NRTs were divided into transdermal (TDN) and oronasal nicotine (ONN) by administrative routes, thus 7 network nodes were set up for direct and indirect comparison. Two different indicators measured the efficacy: prevalent and continuous smoking abstinence. The drop-out rates measured the acceptability.

Results

The final 40 clinical studies included in this study comprised 77 study cohorts and 25,889 participants. Varenicline is more effective intervention to assist in smoking cessation during 16-32 weeks follow-up, and is very likely to prompt dropout. Cytisine shows more effectiveness in continuous smoking cessation but may also lead to dropout. E-cigarettes and oronasal nicotine are more effective than no treatment in encouraging prevalent abstinence, but least likely to prompt dropout. Finally, transdermal nicotine delivery is more effective than no treatment in continuous abstinence, with neither significant effect on prevalent abstinence nor dropout rate.

Conclusion

This review suggested and agreed that Varenicline, Cytisine and transdermal nicotine delivery, as smoking cessation intervention, have advantages and disadvantages. However, we had to have reservations about e-cigarettes as a way to quit smoking in adolescents.

Assessing acute nicotine impact on choroidal thickness: a randomized, double-blinded study comparing smoking cessation aids, including nicotine gum and electronic cigarettes

PURPOSE

To explore whether differences in choroidal thickness arise from nicotine consumption in healthy young individuals, specifically comparing the effects of nicotine gum to electronic cigarette (vaping), while maintaining a consistent 4 mg nicotine dosage.

METHODS

In a randomized double-blinded prospective cross-sectional study, 20 healthy participants (mean age ± standard deviation: 23 ± 2.36 years) were randomly assigned to either the nicotine gum or vaping group. Choroidal thickness (ChT) measurements were conducted using optical coherence tomography (OCT) (Topcon 3D OCT-1 Maestro System) at baseline, 30, and 60 min after ingesting 4 mg of nicotine, with ChT measurements taken from five different horizontal areas.

RESULTS

Neither the nicotine delivery method (gum or vaping) demonstrated a statistically significant impact on ChT mean scores among subjects in the five measured areas at baseline, 30, and 60 min (p > 0.05). However, significant differences were observed in ChT mean scores within subjects across the five areas (F (1.83, 72) = 36.43, p < 0.001), regardless of other study factors such as group, time, and visit (p > 0.05). A statistically significant interaction was identified between the factors of area and time concerning participants' ChT mean scores when stratified by the type of smoking (tobacco, vaping, and dual) (p = 0.003).

CONCLUSION

The results of this study revealed that nicotine, up to particular concentration of 4 mg, does not have a statistically significant vasoconstrictive effect on choroidal thickness, regardless of the delivery method, within the examined group. These findings offer valuable insights into the relationship between nicotine intake and choroidal dynamics in young adults.

Switching away from smoking at 12 months among adult JUUL users varying in recent history of quit attempts made with and without smoking cessation medication

Some smokers switch away from smoking using e-cigarettes, but guidelines recommend trying approved medications first. We analyzed switching in adult smokers using JUUL by their recent history of quit attempts and use of smoking cessation medications. Participants were 8511 adult (21+) established smokers (at baseline), in which 50.3% are daily smokers, in a longitudinal observational study who completed a survey 12 months after first purchasing a JUUL Starter Kit. At baseline, participants reported attempts to quit smoking in the prior year and use of pharmacotherapy (nicotine replacement therapy [NRT] or prescription medication) in their most recent attempt. The outcomes were switching (self-reported no past-30-day smoking) and 50%+ reductions in cigarette consumption. Multivariable analyses were adjusted for baseline covariates. Two thirds of the participants had made a quit attempt in the year before purchasing JUUL. Overall, 59% [58%, 60%] had switched at 12 months. Switching was more likely in those who had used NRT and who attempted quitting without medication versus those who used prescription medications or made no quit attempt. In adjusted multivariable analyses, only making a past-year quit attempt (vs. not) was associated with higher odds of switching (OR = 1.15 [1.04, 1.28]). Over 60% of dual users reduced cigarette consumption by ≥50%. These associations were largely similar in daily smokers. Twelve months after purchasing JUUL, almost all smokers reported either switching or reducing their smoking by 50%+, including those who had recently failed to quit smoking with approved pharmacotherapies. E-cigarettes provide an alternative route to abstinence from smoking for smokers with a history of cessation and cessation treatment failure.

Evaluation of an innovative mHealth-based integrated modality for smoking cessation in Chinese smokers: protocol for a randomized controlled trial

BACKGROUND AND AIMS

Developing accessible, affordable, and effective approaches to smoking cessation is crucial for tobacco control. Mobile health (mHealth) based interventions have the potential to aid smokers in quitting, and integrating treatments from multiple sources may further enhance their accessibility and effectiveness. As part of our efforts in smoking cessation, we developed a novel behavioral intervention delivery modality for smoking cessation that integrated three interventions using the WeChat app, called the "Way to Quit" modality (WQ modality). It is presented here the protocol for a randomized controlled trial evaluating the effectiveness, feasibility, and cost-effectiveness of the WQ modality in Chinese smokers.

METHODS

Eligible participants (n = 460) will be recruited via online advertisement in Beijing, China. They will be randomly assigned to receive either quitline-based treatment (QT, n = 230) or WQ modality-based treatment (WQ, n = 230) using a block randomization method. Participants in the QT group will receive telephone-assisted treatment over a four-week period (multi-call quitline protocol), while those in the WQ group will receive integrated interventions based on the WQ modality for four weeks. A four-week supply of nicotine replacement therapy (gums) will be provided to all participants. Participants will be asked to complete phone or online follow-up at 1, 3, 6, and 12-months. At 1-month follow-up, individuals with self-reported smoking abstinence for more than 7 days will be invited to receive an exhaled carbon monoxide (CO) test for biochemical validation. The primary aim is to determine whether the WQ modality is effective in assisting smokers in quitting smoking. The secondary aims are to evaluate the acceptability, satisfaction, and cost-effectiveness of the WQ modality.

DISCUSSION

If the WQ modality is determined to be effective, acceptable, and affordable, it will be relatively easy to reach and provide professional cessation treatments to the communities, thus helping to reduce the disparities in smoking cessation services between different regions and socioeconomic groups.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2200066427, Registered December 5, 2022.

Testing the Outcomes of a Smoking Cessation Smartphone App for Nondaily Smokers: Protocol for a Proof-of-concept Randomized Controlled Trial

BACKGROUND

Nondaily smoking is a widespread, increasingly prevalent pattern of smoking, particularly in ethnic minority and vulnerable populations. To date, no effective treatment approach for this type of smokers has been identified.

OBJECTIVE

This study aims to use a randomized controlled trial to evaluate proof-of-concept markers of the Smiling instead of Smoking (SiS) app, a smoking cessation smartphone app designed specifically for nondaily smokers. This app was developed iteratively and is now in its third version. Previous studies have demonstrated acceptability and feasibility when participants were onboarded in person (study 1) and remotely (study 2) and showed within-person changes in line with hypothesized mechanisms of change. This is the first randomized test of this app.

METHODS

In total, 225 adult nondaily smokers will be asked to undertake a quit attempt while using smoking cessation support materials for a period of 7 weeks. Participants will be randomized to use the SiS smartphone app, the National Cancer Institute smartphone app QuitGuide, or the National Cancer Institute smoking cessation brochure "Clearing the Air." Participants will take part in a 15-minute scripted onboarding phone call during which study staff will introduce participants to their support materials. Survey links will be sent 2, 6, 12, and 24 weeks after the participants' initially chosen quit date. The primary outcome is self-efficacy to remain abstinent from smoking at treatment end, measured using the Smoking Self-Efficacy Questionnaire. Secondary outcomes cover several domains relevant to treatment development and implementation: treatment acceptability (eg, satisfaction with smoking cessation support, measured using the Client Satisfaction Questionnaire, and app usability, measured using the System Usability Scale); treatment feasibility (eg, measured using the number of days participants used the SiS or QuitGuide app during the prescribed treatment period); and, in an exploratory way, treatment efficacy assessed using self-reported 30-day point prevalence abstinence.

RESULTS

Recruitment began in January 2021 and ended June 2022. The final 24-week follow-up was completed in January 2023. This trial is funded by the American Cancer Society.

CONCLUSIONS

This study is designed to test whether the prescribed use of the SiS app results in greater self-efficacy to abstain from smoking in nondaily smokers than commonly recommended alternative treatments and whether the SiS app treatment is acceptable and feasible. Positive results will mean that the SiS app warrants testing in a large-scale randomized controlled trial to test its effectiveness in supporting smoking cessation in nondaily smokers. The design of this study also provides insights into issues pertinent to smoking cessation smartphone app treatment development and implementation by measuring, in a randomized design, markers of treatment satisfaction, engagement with the technology and content of the treatment, and adherence to the treatment plan.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04672239; https://clinicaltrials.gov/ct2/show/NCT04672239.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40867.

Changes in Dependence Over One Year among US Adults Who Smoke Cigarettes and Switched Completely or Partially to Use of the JUUL-Brand Electronic Nicotine Delivery System

Background

Electronic nicotine delivery systems (ENDS) are substitute sources of nicotine for adults who smoke cigarettes. Understanding changes in dependence as people switch from cigarettes to ENDS is relevant to public health. This study assessed changes in dependence among adults who switched completely or partially (dual users) from cigarettes to JUUL-brand ENDS over 12 months.

Methods

US adults who smoke and purchased a JUUL Starter Kit (n = 17,619) completed a baseline assessment and were invited to 1-, 2-, 3-, 6-, 9- and 12-month follow-ups. Dependence on cigarettes at baseline and on JUUL at follow-ups was assessed with the Tobacco Dependence Index (TDI; Range 1-5). Analyses estimated the minimal important difference (MID) for the scale, compared JUUL dependence to baseline cigarette dependence and assessed changes in JUUL dependence over 1-year, including among those using JUUL at all follow-ups.

Results

Participants who switched at month 2 had month 1 JUUL TDI scores 0.24 points greater than those who continued smoking (p<0.001); thus MID=0.24. Among both switchers and dual users overall, dependence on JUUL 1 and 12 months later was lower than baseline dependence on cigarettes (ps<0.001); participants who smoked every day showed more consistent and larger reductions. Among participants who persistently used JUUL without smoking, dependence increased 0.01 points per month (p<0.001), but was leveling off over time.

Conclusions

Dependence on JUUL was lower than baseline cigarette dependence. Increases in JUUL dependence were small over 12 months of continual JUUL use. These data indicate that ENDS, including JUUL, have lower dependence potential than cigarettes.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Trial Registration

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

Efficacy and utilization of an acceptance and commitment therapy-based smartphone application for smoking cessation among Black adults: secondary analysis of the iCanQuit randomized trial

BACKGROUND AND AIMS

Black adults who smoke are less likely to seek treatment and to succeed in quitting compared with other racial groups. The lack of efficacious and engaging trials for smoking cessation further contributes to this disparity. This study explored whether an acceptance and commitment therapy (ACT)-based smartphone application (iCanQuit) was more efficacious for smoking cessation than a United States Clinical Practice Guidelines (USCPG)-based smartphone application (QuitGuide) among Black adults.

DESIGN

Secondary analysis of a two-arm randomized trial with 12-month follow-up.

SETTING

United States (US).

PARTICIPANTS

A total of 554 Black adults who smoke daily were recruited from 34 US states and enrolled between May 2017 and September 2018.

INTERVENTIONS

Participants were randomized to receive iCanQuit (n = 274) or QuitGuide (n = 280) for 12 months.

MEASUREMENTS

Smoking cessation outcomes were measured at 3, 6, and 12 months. The primary outcome was self-reported complete-case 30-day point prevalence abstinence (PPA) at 12 months. Secondary outcomes were 7-day PPA, missing-as-smoking imputation, multiple imputation, prolonged abstinence, and cessation of all tobacco products at 12 months. Study retention, treatment engagement, and change in ACT-based processes were also compared between arms.

FINDINGS

Study retention was 89% at 12 months and did not differ by arm (P > 0.05). The complete-case 30-day PPA was 28% for iCanQuit versus 20% for QuitGuide at 12 months (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.03, 2.46). Similar associations were observed for the missing-as-smoking imputation, although non-significant (25% iCanQuit vs 18% QuitGuide; OR = 1.50; 95% CI = 0.98, 2.30). iCanQuit vs QuitGuide participants were significantly more engaged with iCanQuit application as measured by the number of logins from baseline to 6 months (incidence rate ratio = 3.26; 95% CI = 2.58, 4.13). Increased acceptance of cues to smoke mediated the effect of treatment on cessation (indirect effect: OR = 0.20; 95% CI = 0.05, 0.29).

CONCLUSIONS

Among Black adults, an acceptance and commitment therapy-based smartphone application appeared to be more efficacious and engaging for smoking cessation than the United States Clinical Practice Guidelines-based QuitGuide application.

A Smoking Cessation App for Nondaily Smokers (Version 2 of the Smiling Instead of Smoking App): Acceptability and Feasibility Study

Background

Recent evidence highlights the significant detrimental impact of nondaily smoking on health and its disproportionate prevalence in underserved populations; however, little work has been done to develop treatments specifically geared toward quitting nondaily smoking.

Objective

This study aims to test the feasibility, acceptability, and conceptual underpinnings of version 2 of the Smiling Instead of Smoking (SiS2) smartphone app, which was developed specifically for nondaily smokers and uses a positive psychology approach.

Methods

In a prospective, single-group study, nondaily smokers (N=100) were prescribed use of the SiS2 app for 7 weeks while undergoing a quit attempt. The app assigned daily positive psychology exercises and behavioral tasks every 2 to 3 days, which guided smokers through using the smoking cessation tools offered in the app. Participants answered surveys at baseline and at 2, 6, 12, and 24 weeks postquit. Feasibility was evaluated based on app use and acceptability based on survey responses. The underlying conceptual framework was tested by examining whether theorized within-person changes occurred from baseline to end of treatment on scales measuring self-efficacy, desire to smoke, and processing of self-relevant health information (ie, pros and cons of smoking, importance of the pros and cons of quitting, and motivation).

Results

Participants used the SiS2 app on an average of 24.7 (SD 13.8) days out of the 49 prescribed days. At the end of treatment, most participants rated the functions of the app as very easy to use (eg, 70/95, 74% regarding cigarette log and 59/95, 62% regarding happiness exercises). The average score on the System Usability Scale was 79.8 (SD 17.3; A grade; A+ ≥84.1, B+ <78.8). Most participants reported that the app helped them in their quit attempt (83/95, 87%), and helped them stay positive while quitting (78/95, 82%). Large effects were found for within-person decreases in the desire to smoke (b=−1.5, 95% CI −1.9 to −1.1; P<.001; g_av=1.01), the importance of the pros of smoking (b=-20.7, 95% CI −27.2 to −14.3; P<.001; g_av=0.83), and perceived psychoactive benefits of smoking (b=−0.8, 95% CI −1.0 to −0.5; P<.001; g_av=0.80). Medium effects were found for increases in self-efficacy for remaining abstinent when encountering internal (b=13.1, 95% CI 7.6 to 18.7; P<.001; g_av=0.53) and external (b=11.2, 95% CI 6.1 to 16.1; P<.001; g_av=0.49) smoking cues. Smaller effects, contrary to expectations, were found for decreases in motivation to quit smoking (P=.005) and the perceived importance of the pros of quitting (P=.009). Self-reported 30-day point prevalence abstinence rates were 40%, 56%, and 56% at 6, 12, and 24 weeks after the quit day, respectively.

Conclusions

The SiS2 app was feasible and acceptable, showed promising changes in constructs relevant to smoking cessation, and had high self-reported quit rates by nondaily smokers. The SiS2 app warrants testing in a randomized controlled trial.

Preparing for the Quit Day: Comparing Beliefs of Nondaily Versus Daily Young Adult Smokers as They Prepare for a Quit Attempt

INTRODUCTION

Most smoking cessation approaches are modeled on heavy daily smoking. With increasing prevalence of nondaily smoking, it may be necessary to modify these approaches for nondaily smokers.

AIMS

To provide information about beliefs and attitudes relevant to smoking cessation for nondaily smokers.

METHODS

Secondary analysis of two prospective studies on young adult smokers (18-24 years of age) provided brief advice to quit smoking. Measures include baseline levels of constructs relevant to smoking cessation counseling and perceived benefits of and barriers to smoking cessation.

RESULTS

Participants (n = 40 nondaily, 122 daily smokers) were predominantly White (70% and 84%, respectively), gender-balanced (50% and 43% female), full-time college students (89% and 95%). At baseline, nondaily smokers reported lower levels of nicotine dependence (p < .001; nondaily: Fagerström Test for Nicotine Dependence (FTND) = 0.8 ± 1.5, daily: FTND = 3.1 ± 1.9), lower urge to smoke (p < .001), greater self-efficacy when facing external smoking stimuli (p = .03), expecting to experience fewer positive effects (reduced negative affect, p = <.001, stimulation, p = .02), and valuing the importance of smoking effects less (ps < .01) than daily smokers. During counseling, nondaily smokers generated both fewer benefits of cessation (Wald X2(df = 1) = 4.91, p = .027) and fewer barriers (Wald X2(df = 1) = 5.99, p =.014) than daily smokers. Withdrawal was not listed by nondaily smokers as a barrier (p < .01).

CONCLUSIONS

Constructs relevant to smoking cessation for daily smokers were less salient to young nondaily smokers, compared with moderately addicted young daily smokers, as indicated by responses to standardized scales and by the generation of fewer benefits and barriers in counseling. Interventions may need to find novel ways to engage nondaily smokers, particularly young adult, in smoking cessation efforts.

IMPLICATIONS

This study is unique in eliciting benefits and barriers from nondaily smokers as they are about to make a quit attempt. This is a critically important point in time, as this is the point in time in which an action plan is formed and can be informed and enhanced by smoking cessation support. Our study further allowed direct comparison to daily smokers undergoing the same procedures, which allowed the identification of unique factors that may impact nondaily smokers in their quit attempt, which may guide intervention efforts. Use of a mixed method design further strengthen the rigor of this study.

Cue-based treatment for light smokers: A proof of concept pilot

INTRODUCTION

Light smoking (smoking ≤ 10 cigarettes per day or on some days) has become increasingly prevalent in the US and increases morbidity and mortality. Many light smokers do not experience significant nicotine withdrawal but instead smoke in response to cues. Minimal evidence exists supporting interventions to help light smokers quit smoking.

METHODS

We present results from a proof-of-concept pilot study designed to evaluate the feasibility and acceptability of a cue-based smoking cessation intervention targeted to light daily and intermittent smokers. Participants were randomized to one of two arms: Arm 1) standard smoking cessation treatment or Arm 2) standard smoking cessation treatment + enhanced cue-based treatment that included interactive texting to extend cue exposure treatment to real-world settings and cue management counseling.Outcomes included feasibility (number of participants who were recruited and who completed the intervention), acceptability (intervention ratings), and preliminary efficacy (7-day point prevalence abstinence).

RESULTS

We randomized 24 English and Spanish-speaking light smokers, 13 to the treatment arm and 11 to the control arm. Across both arms, 77% attended all counseling sessions, 90% rated these sessions as very useful and 100% said that they would recommend the intervention to a friend. 15% in the treatment arm had biochemically-validated smoking abstinence compared to 0% in the standard counseling arm.

CONCLUSIONS

Results from this proof-of-concept study demonstrated that a cue-based intervention is feasible and acceptable among light smokers and suggests the need for a fully powered study to assess this approach.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03416621.

Very Light Daily Smoking in Young Adults: Relationships Between Nicotine Dependence and Lapse

INTRODUCTION

Very light daily smoking is increasingly common among young adults. Evidence suggests that levels of nicotine dependence vary significantly among young adults who engage in very light daily smoking. However, the links between dependence and clinically relevant outcomes (eg, lapse) in this population remain unclear. The goal of this study was to address this gap by evaluating how well different nicotine dependence scales predict lapse behavior among very light daily smoking young adults.

AIMS AND METHODS

Very light daily smokers (1-5 cigarettes/day) aged 18-25 participated in an initial laboratory session, during which nicotine dependence was assessed using four commonly used measures: the Fagerstrӧm Test for Cigarette Dependence (FTCD), the Hooked On Nicotine Checklist (HONC), the Transdisciplinary Tobacco Use Research Centers (TTURC) Nicotine Dependence Inventory, and the Wisconsin Inventory of Smoking Dependence Motives (WISDM). After a baseline period, eligible participants (n = 40) completed a 10-day abstinence incentive period in which they attempted to refrain from smoking to earn monetary rewards. Cox proportional hazards models were used to test whether dependence predicted days to first lapse.

RESULTS

FTCD scores significantly predicted days to lapse, as did scores on the FTCD item assessing time to first cigarette of the day (TTFC). No other dependence measures predicted time to lapse. Both the FTCD and TTFC continued to independently predict time to lapse after controlling for smoking frequency and duration.

CONCLUSIONS

The FTCD may be a particularly useful tool for capturing clinically meaningful variability in nicotine dependence among young adults who engage in very light daily smoking.

IMPLICATIONS

This is the first study to directly link self-reported nicotine dependence with the ability to achieve and maintain abstinence among very light daily smoking young adults. The results may aid clinicians in selecting among variable measures of nicotine dependence when assessing and treating this population.

Effectiveness of nicotine gum in preventing lapses in the face of temptation to smoke among non-daily smokers: a secondary analysis

BACKGROUND AND AIMS

Non-daily smokers (NDS) comprise a large fraction of US smokers. Despite little or no dependence, as typically assessed, intermittent smokers (ITS) have difficulty quitting smoking. A randomized clinical trial comparing the effect of nicotine gum with placebo on quitting smoking in non-daily smokers did not find an effect on overall abstinence. We undertook an analysis to assess whether using nicotine gum versus placebo when tempted to smoke could reduce incidence of lapses in those situations.

DESIGN

Within a 6-week randomized, placebo-controlled clinical trial of nicotine gum, analyses contrasted the outcome of temptation episodes where gum was or was not used.

SETTING

Smoking cessation research clinic in Pittsburgh, PA, USA.

PARTICIPANTS

A total of 255 adult ITS (131 nicotine gum, 124 placebo) seeking help for smoking cessation.

INTERVENTION

Nicotine gum (2 mg) versus placebo for up to 8 weeks, with as-needed dosing instructions.

MEASUREMENTS

Outcome was lapsing in temptation episodes, as reported by participants via ecological momentary assessment (EMA). Propensity scores predicting gum use from situational factors (e.g. mood, social setting, smoking cues) served as a control variable.

FINDINGS

Participants reported 2713 temptation episodes, 46.0% (1248) of which resulted in smoking (lapsing). There was a significant gum use × active treatment interaction (P = 0.0009). Using nicotine gum decreased the odds of lapsing by 55% compared with using placebo [odds ratio (OR) = 0.45; 0.22-0.94]; when gum was not used, the assigned gum condition made no significant difference (OR = 1.53; 0.78-3.01; Bayes factor = 0.14). The nicotine effect was not reliably different when participants were trying to achieve abstinence versus when trying to maintain abstinence (OR = 0.44; 0.10, 2.03; P = 0.294; Bayes factor = 0.11), for men and women (OR = 1.68; 0.58, 4.87; P = 0.343; Bayes factor = 0.10), or for participants with some or no dependence (OR = 0.88; 0.30, 2.59; P = 0.811; Bayes factor = 0.06).

CONCLUSIONS

When used in response to temptation to smoke, 2 mg nicotine gum can help to prevent lapses among non-daily smokers.

Clinical implications of nicotine as an antimicrobial agent and immune modulator

Nicotine is perhaps the most important and potent, pharmacologically active substance in tobacco products. This commentary examines the possible effects that nicotine has on microbial viability and also on the host's immune system as it responds to the indigenous microflora (the microbiome) due to nicotine-induced changes to the indigenous microbial environment and any associated antigenic stimulation / immunization that may occur. To our knowledge, the analysis of such profound microbiologic changes attributable to a tobacco-related product, such as nicotine, has not been fully explored in the context of its consequences on the viability of the microbiome/microbiota and on some of the host's basic physiologic processes, such as the immune response, and its possible association on the induction and persistence of certain immunologically related diseases. Future studies should be aimed at uncovering the molecular mechanisms involved in such interactions, especially in the context of manipulating them for therapeutic purposes.

Ecological momentary assessment of temptations and lapses in non-daily smokers

RATIONALE

Little is known about relapse among non-daily, intermittent smokers (ITS), who have difficulty quitting, despite a lack of dependence.

OBJECTIVES

To analyze situations associated with temptations to smoke and smoking lapses among ITS trying to maintain abstinence.

METHODS

Participants were 130 initially abstinent ITS in the placebo arm of a smoking cessation study. EMA data captured participants' situations and states in temptations (n = 976), including those that eventuated in lapses (n = 147), for up to 6 weeks. Randomly timed assessments assessed background states (n = 11,446). Participants also reported coping performed to prevent lapses. Multilevel analyses compared temptations to background situations, and lapse episodes to resolved temptations.

RESULTS

Temptations were marked by exposure to smoking cues, including others smoking, lax smoking restrictions, and alcohol consumption, as well as more negative affect. Lapses did not differ from resolved temptations in craving intensity, but were more often associated with smoking cues and availability of cigarettes, alcohol consumption, and worse affect, and were more often attributed to good moods. Both behavioral and cognitive coping responses were associated with avoiding lapsing, but behavioral coping had much larger effects. The effects of affective distress on lapse risk were mediated by its effects on coping.

CONCLUSIONS

Smoking cues play a major role in ITS' temptations and lapses, perhaps indicating a degree of behavioral dependence. Affective distress also played a role in ITS lapses, undermining the idea that the affective distress seen in daily smokers' lapses is due to nicotine withdrawal. The data reinforce the important role of coping in preventing lapses.

Counseling alone or in combination with nicotine replacement therapy for treatment of black non-daily smokers: a randomized trial

BACKGROUND AND AIMS

One-third of US tobacco users are non-daily smokers (NDS). Black NDS have strikingly high levels of nicotine and carcinogen exposure. No smoking cessation studies have been conducted with this high-risk group. This study compared the effectiveness in black NDS of smoking cessation counseling alone or in combination with the participant's choice of nicotine replacement therapy.

DESIGN

Two-arm parallel-group individually randomized clinical trial (allocation ratio of 2 : 1 intervention to control) SETTING: Academic medical and federally qualified health centers in three US cities.

PARTICIPANTS

Non-Hispanic black adult NDS receiving counseling with nicotine replacement therapy (C + NRT, n = 185) or counseling alone (C, n = 93).

INTERVENTIONS

Twelve weeks of in-person and telephone smoking cessation counseling in combination with nicotine replacement therapy (NRT; C + NRT) or counseling alone (C). All participants received five sessions of counseling; those randomized to C + NRT received their choice of nicotine gum, patch and/or lozenge after a 9-day product trial period. The target quit day was set at 2 weeks post-baseline for both groups.

MEASUREMENTS

Primary outcome was biochemically verified 30-day abstinence at week 12. Secondary outcomes were change in nicotine and carcinogen exposure [4-(methynitrosamino)-1-(3) pyridyle-1-butanol; NNAL] and tobacco consumption patterns.

FINDINGS

Abstinence was 11.4% in C + NRT and 8.6% in C [odds ratio (OR) = 1.4, 95% confidence interval (CI) = 0.6, 3.2, P = 0.48]. Both groups experienced significant reduction in NNAL (C + NRT: 53% reduction, C: 50% reduction, within-group P < 0.0001) but non-significant changes in cotinine (P = 0.69). C + NRT reported more days abstinent (P < 0.001) and fewer total cigarettes (P = 0.002) compared with C. There was no evidence of compensation with other tobacco products.

CONCLUSIONS

Among black non-daily smokers in the United States, there was no difference in abstinence between nicotine replacement therapy (NRT) and counseling alone. NRT led to greater increase in days abstinent and reduction in cigarettes, with no evidence of compensation from other sources of nicotine.

Factors Associated With Cannabis Use Among African American Nondaily Smokers

OBJECTIVES

Cannabis and tobacco dual use is a growing concern in the United States, especially among African Americans (AAs). Dual use increases nicotine dependence and poses negative health effects. Despite decreasing numbers of people who smoke daily, nondaily smokers (NDS) are increasing. Polytobacco use, including blunt use, is higher in AA NDS than AAs who smoke daily. This study examined factors associated with cannabis use among AA NDS.

METHODS

Adult AA NDS participated in a randomized controlled trial (n = 278) for smoking cessation. A subset of this sample (n = 262; mean age 48.2 years; 50% male) was analyzed to identify correlates of cannabis use. Logistic regression assessed the associations of demographic, smoking-related, and psychosocial variables with cannabis use.

RESULTS

Participants smoked cigarettes on an average of 18 days of the last 30 and used 4.5 cigarettes on smoking days. Of the participants analyzed, 38% used cannabis, including blunts (ie, cigars hollowed out filled with cannabis) at baseline. Cannabis use was associated with polytobacco product use not including blunts (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.18-3.77, P = 0.012), depressive symptoms (OR 1.22, 95% CI 1.05-1.42, P = 0.011), and younger age (OR 0.97, 95% CI 0.94-0.99, P = 0.004).

CONCLUSIONS

Rates of cannabis and tobacco dual use in our sample exceed national rates. Dual use poses harmful health effects that exceed the risk of either substance alone. Findings will inform future work in tailoring treatments to vulnerable groups of people who use both tobacco and cannabis.