Testing the nicotine dependence measure mFTQ for adolescent smokers: A multinational investigation

Does the time to nicotine dependence vary by internalizing symptoms for young people who use e-cigarettes? An analysis of the Population Assessment of Tobacco and Health (PATH) study, (Waves 1-5; 2013-2019)

OBJECTIVE

To determine the relationship between past-year internalizing symptoms and the time to first report of signs of nicotine dependence among young people.

METHODS

Secondary analysis using data from the Population Assessment of Tobacco and Health (PATH) (Waves 1-5; 2013-2019). The study included 2,102 (N = 5,031,691) young people (age 12-23 years) who reported past-30-day (P30D) e-cigarette use in one or more waves. Kaplan Meier curves, stratified by past year internalizing symptoms were used to estimate the time to the first report of three nicotine dependence symptoms (i.e., use within 30 min of waking, cravings, and really needing to use) following the first P30D e-cigarette use. Cox proportional hazard models were used to estimate crude and adjusted hazard ratios (AHR), comparing any past year internalizing symptoms to no past year internalizing symptoms.

RESULTS

We found no significant differences between past year internalizing symptoms and the time to the first report of cravings (AHR = 1.30, 95 % CI = 92-1.85), really needing to use (AHR = 1.31; 95 % CI = 0.92-1.89) and use within 30 min of waking for follow-up times 0-156 weeks (AHR = 0.84; 95 % CI = 0.55-1.30) and > 156 weeks (AHR = 0.41; 95 % CI = 0.04-4.67) respectively.

CONCLUSION

Past year internalizing symptoms did not modify the time to the first report of nicotine dependence among youth with P30D e-cigarette use. Further research is needed to understand how changing internalizing symptoms and e-cigarette use frequency influence nicotine dependence over time and, how this relationship impacts cessation behavior.

Comparison of Indicators of Dependence for Vaping and Smoking: Trends Between 2017 and 2022 Among Youth in Canada, England, and the United States

INTRODUCTION

The current study sought to examine trends in indicators of dependence for youth vaping and smoking during a period of rapid evolution in the e-cigarette market.

AIMS AND METHODS

Data are from repeat cross-sectional online surveys conducted between 2017 and 2022 among youth aged 16-19 in Canada, England, and the United States (US). Participants were 23 145 respondents who vaped and/or smoked in the past 30 days. Four dependence indicators were assessed for smoking and vaping (perceived addiction, frequent strong urges, time to first use after waking, days used in past month) and two for vaping only (use events per day, e-cigarette dependence scale). Regression models examined differences by survey wave and country, adjusting for sex, age, race, and exclusive/dual use.

RESULTS

All six indicators of dependence increased between 2017 and 2022 among youth who vaped in the past 30 days (p < .001 for all). For example, more youth reported strong urges to vape at least most days in 2022 than in 2017 (Canada: 26.5% to 53.4%; England: 25.5% to 45.4%; US: 31.6% to 50.3%). In 2017, indicators of vaping dependence were substantially lower than for smoking; however, by 2022, youth vaping was associated with a greater number of days used in the past month (Canada, US), shorter time to first use (all countries), and a higher likelihood of frequent strong urges (Canada, US) compared to youth smoking.

CONCLUSIONS

From 2017 to 2022, indicators of vaping dependence increased substantially. By 2022, vaping dependence indices were comparable to those of smoking.

IMPLICATIONS

Indicators of vaping dependence among youth have increased substantially since 2017 to levels that are comparable to cigarette dependence among youth who smoke. Future research should examine factors underlying the increase in dependence among youth who vape, including changes to the nicotine profile and design of e-cigarette products.

Time to first report of signs of nicotine dependence among youth who use e-cigarettes and cigarettes in the United States: A nationally representative cohort study, findings from the Population Assessment of Tobacco and Health, 2013-2019

OBJECTIVE

To determine the time to first report of signs of nicotine dependence among youth exclusive e-cigarette users and compare this time to that for exclusive cigarette users.

METHODS

Secondary analysis of data (Waves 1-5; 2013-2019) from the Population Assessment of Tobacco and Health was conducted. Youth never tobacco users in the United States who reported exclusive past-30-day (P30D) e-cigarette or cigarette use (n = 2940, N = 5,391,642) in at least one wave were included in the current analysis. Survival analysis was used to estimate the time to the first report of three nicotine dependence indicators (i.e., "use within 30 minutes of waking"; "cravings" and "really needing to use") following the first report of P30D use. Multivariable Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR).

RESULTS

There were no significant differences in the time to first report of "use within 30 minutes of waking" (aHR = 1.1, 95% CI = 0.87-1.40) and "cravings" (aHR = 1.09, 95% CI = 0.81-1.47) between exclusive P30D e-cigarette use and exclusive P30D cigarette use. However, compared to exclusive P30D e-cigarette use, the hazard of first reporting "really needing to use" tobacco was 39% (aHR 1.39; 95% CI: 1.05-1.84) times higher for those who reported exclusive P30D cigarette use after controlling for covariates.

CONCLUSION

Compared to exclusive P30D cigarette use, no differences in the time to first report of signs of nicotine dependence ("use within 30 minutes" and "cravings") were observed among exclusive P30D e-cigarette users. Policymakers and regulatory agencies should consider this evidence when assessing the abuse liability of e-cigarette products.

Symptoms of nicotine dependence by e-cigarette and cigarette use behavior and brand: A population-based, nationally representative cross-sectional study

BACKGROUND

Many modern e-cigarette brands contain equivalent or higher nicotine levels than traditional cigarettes.

OBJECTIVE

To examine differences in four nicotine dependence indicators (i.e., use within 30minutes of waking, cravings, needing to use, and frequent use) among adolescents (aged 12-17 years) with past 30-day (P30D) exclusive use of e-cigarettes, cigarettes, or dual use of both.

METHODS

Data were from Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health (PATH) study (n=1060; N=2053,659). Multivariable logistic regression was performed to determine differences in indicators by P30D e-cigarette and cigarette use behavior (exclusive vs. dual use) and brand (e-cigarette use: JUUL vs. non-JUUL vs. Unknown).

RESULTS

The odds of frequent use among adolescents with JUUL (AOR: 2.11; 95% CI=1.02-4.37) and non-JUUL (AOR: 2.12; 95% CI=0.95-4.77) use were similar and paralleled that for dual use (AOR: 3.50; 95% CI=1.46-8.43) but were stronger (JUUL only) than exclusive cigarette use. The odds of using within 30minutes of waking for adolescents with JUUL (AOR: 2.23; 95% CI=0.80-6.25) and non-JUUL (AOR:1.42; 95% CI=0.47-4.32) use were similar and paralleled that for both dual (AOR=3.00; 95% CI=1.01-8.88) and exclusive cigarette use. For adolescents who used unknown brands, the odds of all indicators paralleled exclusive cigarette use but were lower than JUUL, non-JUUL, and dual use.

CONCLUSION

Compared to exclusive cigarette use, symptoms of nicotine dependence are similar for adolescents with exclusive e-cigarette use, irrespective of brand. Symptoms of nicotine dependence for JUUL and non-JUUL use parallel dual use. Tobacco regulation should consider these findings when assessing the abuse liability of e-cigarettes.

Identifying adolescents' gaming preferences for a tobacco prevention social game: A qualitative study

INTRODUCTION

Considering the dangers of adolescent tobacco use, the successful design of behavioral programs is crucial for tobacco prevention. According to preliminary research, social game interventions can improve adolescent tobacco outcomes. The current qualitative study aims to (1) uncover the gaming elements that adolescents deem important for a positive learning experience, and (2) confirm these gaming elements with adolescents who are presented with a tobacco prevention game concept that applies these elements.

METHODS

Findings from this study are drawn from two phases. Phase 1 involved in-person focus group discussions (n = 15) and Phase 2 included three online focus groups and a paired interview with another set of adolescents (n = 15). The study was conducted under a project that aimed to design and test a social game-based tobacco prevention program for adolescents (Storm-Heroes). With open coding and thematic analysis, two research team members identified repeated topics and relevant quotes to organize them into themes. The themes evolved as new content was identified during the process. This process was repeated until thematic saturation was reached.

RESULTS

Thematic analysis across Phase 1 and Phase 2 revealed four major themes: 1) Balance during gaming challenges, 2) Healthy social interaction, 3) Performance and creative freedom, and 4) Fictional world and game mechanics for tobacco prevention.

CONCLUSION

This study identified specific intervention features that best fit the needs of adolescents in the context of a social game for tobacco prevention. For future research, we will use a participatory approach to allow adolescents to take part in the design process, improve Storm-Heroes, and develop health promotional messages that can be incorporated into the program. Ultimately, a board game for tobacco prevention is expected to bring adolescents together to create lasting memories that nudge them away from tobacco use and the harm it can cause.

Monitoring Cigarette Smoking and Relapse in Young Adults With and Without Remote Biochemical Verification: Randomized Brief Cessation Study

BACKGROUND

Technological advancements to study young adult smoking, relapse, and to deliver interventions remotely offer conceptual appeal, but the incorporation of technological enhancement must demonstrate benefit over traditional methods without adversely affecting outcomes. Further, integrating remote biochemical verification of smoking and abstinence may yield value in the confirmation of self-reported smoking, in addition to ecologically valid, real-time assessments.

OBJECTIVE

The goal of this study was to evaluate the impact of remote biochemical verification on 24-hour self-reported smoking and biochemical verification agreement, retention, compliance with remote sessions, and abstinence during a brief, 5-week cessation attempt and relapse monitoring phase.

METHODS

Participants (N=39; aged 18-25 years; mean age 21.6, SD 2.1 years; n=22, 56% male; n=29, 74% White) who smoked cigarettes daily engaged in a 5-week cessation and monitoring study (including a 48-hour quit attempt and provision of tobacco treatment in the form of nicotine replacement therapy, brief cessation counseling, and financial incentives for abstinence during the 2-day quit attempt only). Smoking (cigarettes per day) was self-reported through ecological momentary assessment (EMA) procedures, and participants were randomized to either (1) the inclusion of remote biochemical verification (EMA + remote carbon monoxide [rCO]) 2× per day or (2) in-person, weekly CO (wCO). Groups were compared on the following outcomes: (1) agreement in self-reported smoking and breath carbon monoxide (CO) at common study time points, (2) EMA session compliance, (3) retention in study procedures, and (4) abstinence from smoking during the 2-day quit attempt and at the end of the 5-week study.

RESULTS

No significant differences were demonstrated between the rCO group and the wCO (weekly in-person study visit) group on agreement between 24-hour self-reported smoking and breath CO (moderate to poor), compliance with remote sessions, or retention, though these outcomes numerically favored the wCO group. Abstinence was numerically higher in the wCO group after the 2-day quit attempt and significantly different at the end of treatment (day 35), favoring the wCO group.

CONCLUSIONS

Though study results should be interpreted with caution given the small sample size, findings suggest that the inclusion of rCO breath added to EMA compared to EMA with weekly, in-person CO collection in young adults did not yield benefit and may have even adversely affected outcomes. Our results suggest that technological advancements may improve data accuracy through objective measurement but may also introduce barriers and burdens and could result in higher rates of missing data. The inclusion of technology to inform smoking cessation research and intervention delivery among young adults should consider (1) the research question and necessity of biochemical verification and then (2) how to seamlessly incorporate monitoring into personalized and dynamic systems to avoid the added burden and detrimental effects to compliance and honesty in self-report.

Mobile Text Messaging for Tobacco Risk Communication Among Young Adult Community College Students: Randomized Trial of Project Debunk

BACKGROUND

The use of new and emerging tobacco products (NETPs) and conventional tobacco products (CTPs) has been linked to several alarming medical conditions among young adults (YAs). Considering that 96% of YAs own mobile phones, SMS text messaging may be an effective strategy for tobacco risk communication.

OBJECTIVE

Project Debunk is a community-based randomized trial aiming to identify specific types of messages that effectively improve perceived NETP and CTP risk among YAs in community colleges.

METHODS

With YAs recruited offline from 3 campuses at the Houston Community College (September 2016 to July 2017), we conducted a 6-month randomized trial with 8 arms based on the combination of 3 message categories: framing (gain-framed vs loss-framed), depth (simple vs complex), and appeal (emotional vs rational). Participants received fully automated web-based SMS text messages in two 30-day campaigns (2 messages per day). We conducted repeated-measures mixed-effect models stratified by message type received, predicting perceived CTP and NETP risks. Owing to multiple testing with 7 models, an association was deemed significant for P<.007 (.05 divided by 7).

RESULTS

A total of 636 participants completed the baseline survey, were randomized to 1 of 8 conditions (between 73 and 86 participants per condition), and received messages from both campaigns. By the 2-month post campaign 2 assessment point, 70.1% (446/636) completed all outcome measures. By the end of both campaigns, participants had a significant increase in perceived NETP risk over time (P<.001); however, participants had a marginal increase in perceived CTP risk (P=.008). Separately for each group, there was a significant increase in perceived NETP risk among participants who received rational messages (P=.005), those who received emotional messages (P=.006), those who received simple messages (P=.003), and those who received gain-framed messages (P=.003).

CONCLUSIONS

In this trial, YAs had an increase in perceived NETP risk. However, with stratification, we observed a significant increase in perceived NETP risk upon exposure to rational, emotional, simple, and gain-framed messages. In addition, YAs generally had an increase in perceived CTP risk and presented nonsignificant but observable improvement upon exposure to emotional, complex, and loss-framed messages. With the results of this study, researchers and practitioners implementing mobile health programs may take advantage of our tailored messages through larger technology-based programs such as smartphone apps and social media campaigns.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03457480; https://clinicaltrials.gov/ct2/show/NCT03457480.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/10977.

Use frequency and symptoms of nicotine dependence among adolescent E-cigarette users: Comparison of JUUL and Non-JUUL users

OBJECTIVE

Nicotine exposure among adolescent e-cigarette users remains a public health concern. JUUL, a popular e-cigarette brand among youth, is particularly alarming given the high nicotine delivery (59 mg/mL). This study compares e-cigarette use frequency and symptoms of nicotine dependence among adolescent JUUL and non-JUUL users.

METHODS

We analyzed data from the 2020 National Youth Tobacco Survey. Participants were n = 1713 U.S. middle and high school students who reported past 30-day e-cigarette use. We compared adolescent e-cigarette users who reported JUUL use to those who did not. Outcomes were: (1) symptoms of nicotine dependence (i.e. nicotine cravings; use within 30 min of waking); (2) past 30-day e-cigarette use frequency, categorized as 1-5 days, 6-19 days, and 20-30 days. Covariates were sex, race/ethnicity, other tobacco product use, primary e-cigarette device type (i.e., disposable; pod; mod/tank).

RESULTS

Overall, 49.5% of adolescent e-cigarette users reported using JUUL in the past 30 days, 40.1% reported symptoms of nicotine dependence, and 36.2% reported using an e-cigarette on 20-30 days. JUUL users were 1.77 (95% CI: 1.36-2.31) times as likely to report symptoms of nicotine dependence and 1.43 (95% CI: 1.02-2.01) time as likely to report using e-cigarettes on 20-30 days, compared to 1-5 days, relative to non-JUUL users, controlling for covariates.

CONCLUSION

JUUL use was associated with greater odds of nicotine dependence and more frequent e-cigarette use among adolescents. Greater prevention and regulatory efforts should be made to prevent adolescent use of high dose nicotine devices such as JUUL.

Cigarette smoking frequency, quantity, dependence, and quit intentions during adolescence: Comparison of menthol and non-menthol smokers (National Youth Tobacco Survey 2017-2020)

BACKGROUND

Use of menthol cigarettes is linked to sustained cigarette smoking adults. However, the relationship between menthol and smoking profile has not been thoroughly explored in adolescent cigarette smokers. This study examines the relationship between use of menthol cigarette and smoking frequency (i.e., days per month), quantity (i.e., cigarettes per day), quit intentions, and nicotine dependence (i.e., craving tobacco; use within 30 min of waking).

METHODS

We pooled four years (2017-2020) of cross-sectional data from the National Youth Tobacco Survey. Participants were 2699 adolescent, past 30-day cigarette smokers. Multinomial logistic regression models examined the relationship between menthol and cigarette smoking frequency and quantity. Logistic regressions examined the relationship between menthol and intentions to quit smoking and nicotine dependence. Models controlled for socio-demographics and other tobacco use.

RESULTS

Menthol cigarette smokers had greater risk of smoking 20-30 days per month relative to 1-5 days per month (RRR: 1.90; 95% CI: 1.41 - 2.54) and greater risk of smoking 11+ cigarettes per day relative to 1 or less cigarettes per day (RRR: 1.35; 95% CI: 1.01 - 1.80), adjusting for covariates. Menthol cigarette smokers had lower odds of intentions to quit smoking (Adj OR: 0.70; 95% CI: 0.58 - 0.84) but great odds of craving tobacco (OR: 1.47; 95% CI: 1.20 - 1.81) and using tobacco within 30 minutes of waking (OR: 1.63; 95% CI: 1.29 - 2.05), adjusting for covariates CONCLUSION: Findings suggest the relationship between menthol and cigarette smoking profile (i.e., frequency, quantity, quit intentions) is different for youth than that of adults. This study adds adolescent-specific evidence to existing research that suggests menthol reinforces sustained cigarette smoking among youth.

Higher Levels of Nicotine Dependence in Adolescence are Associated with Younger Onset Age of Violent Criminality: A Follow-Up Study of Former Adolescent Psychiatric Inpatients

OBJECTIVE

Earlier studies have reported that smoking is associated with violent behaviour. This study investigated nicotine dependence (ND), defined as already present in adolescence, and its relation to subsequent violent criminal offending.

METHOD

The baseline dataset is composed of 508 former adolescent inpatients, admitted to a psychiatric hospital between the ages of 13-17. Adolescent ND was assessed using the modified Fagerström Tolerance Questionnaire. Follow-up data on crimes up to young adulthood was acquired from the Legal Register Centre of Finland. The study analyzes the participants with violent offences (n = 78) and those without any criminal history (n = 368).

RESULTS

Over 80% of the violent offenders had ND already in adolescences. One third (32.2%) of those with high ND had committed their first violent crime before 18 years of age, the proportions being 15.2% in moderate and 7.1% in no-ND groups. The likelihood for committing first violent crimes at a younger age was increased in the participants with high (adjusted Hazard Ratio (aHR) = 2.66, p = .008) or moderate ND (aHR = 2.40, p = .011).

CONCLUSIONS

Adolescent psychiatric patients, showing moderate to high levels of addiction to nicotine, should be a target population for adolescent focused smoking cessation interventions and programs. Adolescents addicted to nicotine may benefit from intensive clinical attention in order to avoid more adverse and unfavorable outcomes in life, beyond merely physical health related problems.

Profile of Substance Misuse among Adolescent and Young Adult Gabapentinoid Users: A Register-Based Follow-up Study of Former Adolescent Psychiatric Inpatients

Our study examined characteristics of adolescent and young adult study participants using gabapentinoids (gabapentin, pregabalin), with previous history of adolescent psychiatric inpatient hospitalization. Particular focus was on temporal association of age, at first prescription for gabapentinoids, to age at tobacco smoking initiation, regular alcohol use, diagnosis of substance dependence and prescriptions for benzodiazepines and opioids. Methods: The initial study population contained 508 adolescents (300 females, 208 males) admitted to psychiatric inpatient care in Oulu University hospital between the ages 13-17 years. Register-based follow-up information on prescriptions for gabapentinoids, benzodiazepines and opioids, as well as ICD-10 diagnosis for hospital-treated substance dependence, was obtained from the Finnish national health care registers. Results: The users of gabapentinoids accounted for 9.1% of the initial study population. Of adolescence-related characteristics, suicidal ideation, suicide attempts and non-suicidal self-injury was emphasized in females using gabapentinoids. The majority of participants using gabapentinoids had benzodiazepines (80.4%) and opioids (71.7%) as comorbid drugs. Initiation of tobacco smoking and alcohol use and first prescriptions for of benzodiazepines and opioids, and a diagnosis of substance dependence commonly predated first prescriptions for gabapentinoids. Conclusions: In clinical practice, the decision to prescribe gabapentinoids to adolescents or young adults must be made with caution, particularly for those with substance use problems and/or without a clinically approved indication.

Nicotine dependence in adolescence predicts later drug criminality: a register-based follow-up of adolescent psychiatric inpatients

Cigarette smoking is common among adolescent psychiatric patients and often precedes the initiation of substance and illicit drug use. This study investigates the association of nicotine dependence (ND), assessed already in adolescence, to subsequent drug crime offenses committed up to young adulthood. The special focus was to examine the dose-response between adolescent ND and later drug-crime offenses. The initial data consist of former adolescent psychiatric inpatients treated in psychiatric inpatient care between the ages 13-17 years. Adolescent DSM-IV based psychiatric disorders were based on the semi-structural diagnostic K-SADS-PL interview. ND in adolescence was measured using the modified Fagerström Tolerance Questionnaire for children and adolescents. Follow-up data on crimes of the study subjects from 15 years of age to early adulthood was obtained from the nationwide Legal Register Center of Finland. A total of 60 (11.8%) drug crime offenders were identified from the initial study population. The likelihood for drug crime offending was statistically significantly increased among those with moderate to severe ND already in adolescence. The higher level of adolescent ND indicated greater number of drug offenses. The common characteristics of drug crime offenders were male gender, out-of-home placement background, exposure to parental divorce and a diagnosis for affective, conduct and substance-use disorder in adolescence. Our study finding, that higher level of ND in adolescence predicts greater number of drug crime offenses up to young adulthood, warrants identification of adolescent smokers at-risk of later drug-related crimes.

The presence and stability of nicotine dependence symptoms among adolescents after the implementation of a smoking prevention program

INTRODUCTION

Symptoms of nicotine dependence among adolescents occur at an early stage in smoking onset and can be present even with low exposure to cigarettes. We aim to examine the early occurrence of symptoms of nicotine dependence and how they predict later smoking behavior.

METHODS

Participants were ninety-four currently smoking 9th-graders attending high school in Targu Mures, Romania. They were followed for 6 months with two assessment points: baseline, and follow-up at 6 months. We assessed the following: 1) the number of smoked cigarettes in the last 30 days, 7 days, and 24 hours using the Minnesota Smoking Index; 2) vulnerability to addiction manifested in cessation difficulties, using the 9-item version of the Hooked On Nicotine Checklist (HONC), 3) loss of autonomy using the endorsement of at least one HONC item, and 4) dependence, using the modified Fagerström Tolerance Questionnaire (mFTQ). We performed statistical analysis with SPSS version 19, using paired-sample t-tests for comparing the differences between baseline and follow-up data. We also conducted linear regression analysis to demonstrate the predictive role of the assessed variables, such as the scores of the mFTQ and the HONC in maintaining smoking and reported smoking status.

RESULTS

Regression models indicated that baseline-measures for symptoms of dependence (β=0.64, p<0.001), vulnerability to addiction (β=0.47, p<0.001), and loss of autonomy (β=0.34, p<0.001) regarding smoking cessation were significant predictors of smoking, explaining 41.7% of the variability of the reported increase in cigarette consumption. At follow-up at 6-months, the three variables were responsible for 14.9% for the variance in cigarette consumption (R2=0.14, F(1,92)=16.05, p<0.01).

CONCLUSIONS

Nicotine dependence at baseline and at follow-up show significant differences in the control group while in the intervention group the scores remained stable. The findings suggest that participation in the Romanian version of ASPIRE was protective against progression towards nicotine addiction.

Three-month effects of Project EX: A smoking intervention pilot program with Korean adolescents

Despite current prevention and cessation efforts, adolescent smoking remains a pressing issue worldwide, including in Korea. The current study evaluates Project EX-Korea, a teen tobacco use cessation program, three months after baseline. The quasi-experimental trial intervention involved 160 smokers in 10th to 12th grade, 85 from the program condition schools and 75 from the control. At three-month follow-up, the intent-to-treat (ITT) quit rate in the program group (30.2%) was 3.6 times that of the rate in the standard care control group (9.2%; p < 0.05). Among those who did not quit, those in the program group smoked less on average than those in the control group, but there was no difference in follow-up mFTQ scores between the two non-quitter groups. As teen tobacco use cessation programming is much needed in Korea, Project EX is a plausible program to implement among Korean adolescents.

•

Teen tobacco use cessation programming is still much needed in Korea and worldwide.

•

Project EX is a credible tobacco cessation program to help Korean adolescents quit.

•

The program group's quit rate was 3.6 times that of the control group's quit rate.

•

Non-quitters in the program group smoked less than those in the control group.