Cancer Patients Enrolled in a Smoking Cessation Clinical Trial: Characteristics and Correlates of Smoking Rate and Nicotine Dependence

Examining Predictors of Nicotine Dependence in Korean Adolescents : Comparing Ever Quitters and Never Quitters

Despite growing research on adolescent smokers, evidence for the differences between the two smoker groups who are ever quitters and never quitters is limited. The study aimed to examine predictors of nicotine dependence (ND) in Korean adolescents by comparing ever quitters and never quitters. Data from 349 adolescents were collected through an online survey. Among respondents, most of them were male, living with families, and were enrolled at schools. Data were analyzed by dividing participants into two groups - ever quitters and never quitters. The study found that adolescents' ND was commonly predicted by smoking peers and anxiety. However, schooling status was significantly associated with ever quitters' ND only. In the total sample, never-quitters were associated with higher ND compared to ever-quitters. This study did not control for differences among ever quitters in terms of the number of attempts to quit smoking and did not significantly control age effects in the sample. Based on study results, we suggest various policy implications. Cessation intervention should be designed keeping in mind the smokers' previous quit attempts and their motivation. It is also recommended that individually tailored smoking cessation programs be used to address the heterogenous nature of the adolescents.

Systematic Review of Smoking Cessation Interventions for Smokers Diagnosed with Cancer

The detrimental impact of smoking on health and wellbeing are irrefutable. Additionally, smoking is associated with the development of cancer, a reduction treatment outcomes and poorer health outcomes. Nevertheless, a significant number of people continue to smoke following a cancer diagnosis. Little is understood of the smoking cessation services provided to smokers with cancer or their engagement with them. This systematic review aimed to identify existing smoking cessation interventions for this cohort diagnosed with breast, head and neck, lung and cervical cancers (linked to risk). Systematic searches of Pubmed, Embase, Psych Info and CINAHL from 1 January 2015 to 15 December 2020 were conducted. Included studies examined the characteristics of smoking cessation interventions and impact on referrals and quit attempts. The impact on healthcare professionals was included if reported. Included studies were restricted to adults with a cancer diagnosis and published in English. No restriction was placed on study designs, and narrative data synthesis was conducted due to heterogeneity. A review protocol was registered on PROSPERO CRD 42020214204, and reporting adheres to PRISMA reporting guidelines. Data were screened, extracted in duplicate and an assessment of the quality of evidence undertaken using Mixed Methods Assessment Tool. 23 studies met the inclusion criteria, representing USA, Canada, England, Lebanon, Australia and including randomized controlled trials (9), observational studies (10), quality improvement (3), and one qualitative study. Hospital and cancer clinics [including a dental clinic] were the settings for all studies. 43% (10/23) of studies reported interventions for smokers diagnosed with head and neck cancer, 13% (3/23) for smokers diagnosed with lung cancer, one study provides evidence for breast cancer, and the remaining nine studies (39%) report on multiple cancers including the ones specified in this review. Methodological quality was variable. There were limited data to identify one optimal intervention for this cohort. Key elements included the timing and frequency of quit conversations, use of electronic records, pharmacotherapy including extended use of varenicline, increased counselling sessions and a service embedded in oncology departments. More studies are required to ensure tailored smoking cessation pathways are co-developed for smokers with a diagnosis of cancer to support this population.

Feasibility of Patient Navigation-Based Smoking Cessation Program in Cancer Patients

Continued smoking after a cancer diagnosis is causally associated with increased risks of all-cause and cancer-specific mortality, and of smoking-related second primary cancers. Patient navigation provides individualized assistance to address barriers to smoking cessation treatment and represents a promising bridge to smoking cessation in persons with cancer who smoke cigarettes. We conducted a single-arm interventional cohort study of current smokers identified through prospective health record screening and recruited from Penn State Cancer Institute outpatient clinics. Consented participants received two telephone intervention sessions and gain-framed messaging-based smoking cessation educational materials designed for persons with cancer. The primary study outcome was the feasibility of the patient navigation-based intervention; the secondary outcome was the engagement in smoking cessation treatment at the two-month follow-up. Of 1168 unique screened Cancer Institute patients, 134 (11.5%) were identified as current cigarette smokers. Among 67 patients approached at outpatient clinics, 24 (35.8%) were interested in participating, 12 (17.9%) were enrolled, eight (11.9%) completed the intervention sessions and study assessments, and six engaged in smoking cessation treatment. The participants expressed satisfaction with the intervention sessions (median = 8.5, scale 0–10). The low recruitment rates preclude patient navigation as a feasible method for connecting cancer patients to smoking cessation treatment resources.

Relative expected value of drugs versus competing rewards underpins vulnerability to and recovery from addiction

Behavioural economic theories of addiction contend that greater expected value of drug relative to alternative non-drug rewards is the core mechanism underpinning vulnerability to and recovery from addiction. To evaluate this claim, we exhaustively review studies with human drug users that have measured concurrent choice between drugs vs. alternative rewards, and explored individual differences. These studies show that drug choice can be modulated by drug cues, drug devaluation, imposition of costs/punishment and negative mood induction. Regarding individual differences, dependence severity was reliably associated with overall drug preference, and self-reported drug use to cope with negative affect was reliably associated with greater sensitivity to mood induced increases in drug choice. By contrast, there were no reliable individual differences in sensitivity to the effect of drug cues, drug devaluation or punishment on drug choice. These findings provide insight into the mechanisms that underpin vulnerability to dependence: vulnerability is conferred by greater relative value ascribed to drugs, and relative drug value is further augmented by negative affective states in those who report drug use coping motives. However, dependence does not appear to be characterised by abnormal cue-reactivity, habit learning or compulsion. We then briefly review emerging literature which demonstrates that therapeutic interventions and recovery from addiction might be attributed to changes in the expected relative value of drug versus alternative rewards. Finally, we outline a speculative computational account of the distortions in decision-making that precede action selection in addiction, and we explain how this account provides a blueprint for future research on the determinants of drug choice, and mechanisms of treatment and recovery from addiction. We conclude that a unified economic decision-making account of addiction has great promise in reconciling diverse addiction theories, and neuropsychological evaluation of the underlying decision mechanisms is a fruitful area for future research and treatment.

Contribution of alcohol- and cigarette-related cues to concurrent reinforcer choice in humans

Drug-related cues have been extensively studied for their contributions to decision-making processes involving drug consumption. Less studied is how drug-related stimuli may impact decisions involving outcomes not directly related to substance use. Studies using concurrent choice tasks have demonstrated that cocaine and cannabis cues result in robust and selective biases for monetary reinforcers contiguous with those cues. The purpose of this study was to provide a conceptual replication of these findings with alcohol and cigarettes. Participants recruited using crowdsourcing completed a cued concurrent choice task involving presentation of two cues (one drug and one neutral) followed by concurrent monetary offers below each image. Alcohol (Experiment 1; N = 103) and cigarette (Experiment 2; N = 256) visual cues were evaluated. Participants with hazardous alcohol use and current cigarette use showed greater-than-indifference selection for the alcohol- (p = .004) and cigarette-cued (p = .02) monetary choices, respectively. Qualitative responses indicated that the most popular rationale for responding was "image quality" despite images having no explicit impact on the reinforcer received. Low alcohol use (p = .03) and non-cigarette using controls (p < .001) showed an avoidance bias with lower-than-indifference selection for drug-cued choices. These findings replicate and extend observations that spatially contiguous drug-related cues can bias decisions involving concurrently presented non-drug reinforcers.

The Role of Anxiety in Smoking Onset, Severity, and Cessation-Related Outcomes: a Review of Recent Literature

PURPOSE OF REVIEW

Anxiety is one of the most common mental health conditions globally and co-occurs with smoking at a markedly high rate. The present review offers a narrative overview of the most recent research on the role of anxiety in smoking onset, maintenance, and cessation-related outcomes. Additionally, given the rise in electronic cigarette use, we review the emerging literature on the influence of anxiety on e-cigarette use.

RECENT FINDINGS

Evidence across studies varied as to the role of anxiety or anxiety symptoms in smoking behavior. The most consistent findings suggested that those with anxiety are more likely to be a smoker, supporting a high rate of co-occurrence across these conditions. Less consistent evidence was observed for the association between anxiety and onset, indicators of severity, and cessation outcomes. Although there is robust evidence for an association between smoking and anxiety, there were considerable discrepancies for the precise role of anxiety in smoking onset, severity, and cessation outcomes. Future work utilizing more sophisticated methodologies is needed to identify causal relations as well as putative moderators and mediators of the anxiety-smoking relation.

Addiction is driven by excessive goal-directed drug choice under negative affect: translational critique of habit and compulsion theory

Drug addiction may be a goal-directed choice driven by excessive drug value in negative affective states, a habit driven by strong stimulus-response associations, or a compulsion driven by insensitivity to costs imposed on drug seeking. Laboratory animal and human evidence for these three theories is evaluated. Excessive goal theory is supported by dependence severity being associated with greater drug choice/economic demand. Drug choice is demonstrably goal-directed (driven by the expected value of the drug) and can be augmented by stress/negative mood induction and withdrawal-effects amplified in those with psychiatric symptoms and drug use coping motives. Furthermore, psychiatric symptoms confer risk of dependence, and coping motives mediate this risk. Habit theory of addiction has weaker support. Habitual behaviour seen in drug-exposed animals often does not occur in complex decision scenarios, or where responding is rewarded, so habit is unlikely to explain most human addictive behaviour where these conditions apply. Furthermore, most human studies have not found greater propensity to habitual behaviour in drug users or as a function of dependence severity, and the minority that have can be explained by task disengagement producing impaired explicit contingency knowledge. Compulsion theory of addiction also has weak support. The persistence of punished drug seeking in animals is better explained by greater drug value (evinced by the association with economic demand) than by insensitivity to costs. Furthermore, human studies have provided weak evidence that propensity to discount cost imposed on drug seeking is associated with dependence severity. These data suggest that human addiction is primarily driven by excessive goal-directed drug choice under negative affect, and less by habit or compulsion. Addiction is pathological because negative states powerfully increase expected drug value acutely outweighing abstinence goals.

Toward a health-promoting system for cancer survivors: Patient and provider multiple behavior change

OBJECTIVE

This paper examines how and why to improve care systems for disease management and health promotion for the growing population of cancer survivors with cardiovascular multi-morbidities.

METHOD

We reviewed research characterizing cancer survivors' and their multiple providers' common sense cognitive models of survivors' main health threats, preventable causes of adverse health events, and optimal coping strategies.

RESULTS

Findings indicate that no entity in the health care system self-identifies as claiming primary responsibility to address longstanding unhealthy lifestyle behaviors that heighten survivors' susceptibility to both cancer and cardiovascular disease (CVD) and whose improvement could enhance quality of life.

CONCLUSIONS

To address this gap, we propose systems-level changes that integrate health promotion into existing survivorship services by including behavioral risk factor vital signs in the electronic medical record, with default proactive referral to a health promotionist (a paraprofessional coach adept with mobile technologies and supervised by a professional expert in health behavior change). By using the patient's digital tracking data to coach remotely and periodically report progress to providers, the health promotionist closes a gap, creating a connected care system that supports, reinforces, and maintains accountability for healthy lifestyle improvement. No comparable resource solely dedicated to treatment of chronic disease risk behaviors (smoking, obesity, physical inactivity, treatment nonadherence) exists in current models of integrated care. Integrating health promotionists into care delivery channels would remove burden from overtaxed PCPs and instantiate a comprehensive, actionable systems-level schema of health risks and coping strategies needed to have preventive impact with minimal interference to clinical work flow. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A concurrent pictorial drug choice task marks multiple risk factors in treatment-engaged smokers and drinkers

Concurrent choice tasks, where participants choose between a drug versus natural reward, predict dependence vulnerability in animals and humans. However, the sensitivity of concurrent choice tasks to multiple risk factors in treatment-engaged drug users has not been comprehensively tested. In experiment 1, 33 recently hospitalized smokers who were engaged with the smoking cessation service made forced choices between enlarging pictures of people smoking versus not smoking. In experiment 2, 48 drinkers who were engaged in an outpatient alcohol treatment service made forced choices between enlarging pictures of alcohol versus food. In these experiments, percent drug picture choice was significantly associated with dependence severity, craving, self-reported reasons for drug use (negative coping and cued craving), depression, anxiety, withdrawal intolerance, drug use frequency prior to treatment, and current abstinence status (coefficients ranged from r=0.39 to 0.66). The concurrent pictorial drug choice task is sensitive to multiple risk factors in clinical, treatment-engaged drug users, and may be used to identify individuals requiring more support, to test experimental treatment manipulations, and to translate to animal concurrent self-administration procedures.

Contribution of cannabis-related cues to concurrent reinforcer choice in humans

BACKGROUND

Drug-related cues play a critical role in the development and persistence of substance use disorder. Few human laboratory studies have evaluated how these cues contribute to decisions between concurrently presented reinforcers, and none have examined the specific role of cannabis cues. This study evaluated the contribution of cannabis-related cues to concurrent monetary reinforcer choice in humans.

METHODS

Participants with a cannabis use history (i.e., use in the past two weeks and 50 or more lifetime uses; n = 71) and controls without this history (i.e., 5 or less lifetime uses; n = 79) were recruited using Amazon Mechanical Turk. A cued concurrent choice task was used in which cannabis trials presented two cues (one cannabis and one neutral) side-by-side followed by concurrent monetary offers below each image. The primary dependent measure was choice for cannabis-cued monetary reinforcers on equal value trials. Secondary analyses evaluated individual difference variables related to choice bias.

RESULTS

Participants in the cannabis group showed a significant bias for cannabis-cued choices (mean 76.0%) whereas participants in the control group showed a significant bias against cannabis-cued choices (mean 30.3%). Reaction times on cannabis trials were faster than neutral filler trials and did not differ by group. Cannabis-cued choice was significantly associated with more frequent cannabis use (r = .44), higher cannabis demand intensity (r = .28), and lower cannabis elasticity (r = -.30).

CONCLUSIONS

These findings suggest that cannabis-related cues can influence reinforcer choice and potentially promote disadvantageous decision-making related to non-drug reinforcers.

Negative Mood Induction Increases Choice of Heroin Versus Food Pictures in Opiate-Dependent Individuals: Correlation With Self-Medication Coping Motives and Subjective Reactivity

Acute growth in negative affect is thought to play a major role in triggering relapse in opiate-dependent individuals. Consistent with this view, three lab studies have demonstrated that negative mood induction increases opiate craving in opiate-dependent individuals. The current study sought to confirm these effects with a behavioral measure of heroin seeking, and test whether the effect is associated with self-reported opiate use to cope with negative affect and subjective reactivity to mood induction. Participants were heroin-dependent individuals engaged with treatment services (n = 47) and control participants (n = 25). Heroin users completed a questionnaire assessing reasons for using heroin: negative affect, social pressure, and cued craving. Baseline heroin choice was measured by preference to enlarge heroin versus food thumbnail pictures in two-alternative forced-choice trials. Negative mood was then induced by depressive statements and music before heroin choice was tested again. Subjective reactivity was indexed by negative and positive mood reported at the pre-induction to post-test timepoints. Heroin users chose heroin images more frequently than controls overall ( p = .001) and showed a negative mood-induced increase in heroin choice compared to control participants (interaction p < .05). Mood-induced heroin choice was associated with self-reported heroin use to cope with negative affect ( p < .05), but not social pressure ( p = .39) or cued craving ( p = .52), and with subjective mood reactivity ( p = .007). These data suggest that acute negative mood is a trigger for heroin seeking in heroin-dependent individuals, and this effect is pronounced in those who report using heroin to cope with negative affect, and those who show greater subjective reactivity to negative triggers. Interventions should seek to target negative coping motives to build resilience to affective triggers for relapse.

Contribution of cocaine-related cues to concurrent monetary choice in humans

RATIONALE

Theoretical accounts highlight the importance of drug-related cues for the development and persistence of drug-taking behavior. Few studies have evaluated the ability of spatially contiguous drug cues to bias decisions between two concurrently presented non-drug reinforcers.

OBJECTIVE

Evaluate the contribution of spatially contiguous cocaine cues to choice between two concurrently presented monetary reinforcers METHODS: Participants with cocaine use disorder completed a cued concurrent choice task. Two cues (one cocaine and one control image) were presented side-by-side followed by concurrent monetary offers below each image. Concurrent choice was measured for cocaine-side advantageous, equal, and disadvantageous concurrent monetary offers. The primary dependent measure was bias for selecting cocaine-cued monetary reinforcers. Three experiments tested selectivity of cocaine-cued bias in individuals with a cocaine use history (Experiment 1), replication when including additional control trials (Experiment 2), and a potential attentional mechanism evaluated using eye-tracking technology (Experiment 3).

RESULTS

Significant and robust cocaine-cued bias at equal monetary value was observed in three experiments (mean percent choice = 65-77%) and higher Drug Abuse Screening Test (DAST) scores were associated with greater cocaine-choice bias. These experiments demonstrated that cocaine-cued bias was (1) selective to individuals with a cocaine use history, (2) specific to trials involving a cocaine cue, and (3) partially associated with attentional bias.

CONCLUSIONS

These experiments provide evidence that drug-related cues can influence choice and potentially promote maladaptive decision making during concurrent choice events. Future research evaluating prospective associations of drug-cued bias with drug-associated behaviors will help reveal the clinical relevance for substance use disorder.

The association between self-reported varenicline adherence and varenicline blood levels in a sample of cancer patients receiving treatment for tobacco dependence

Introduction

The degree to which smokers quit successfully with varenicline is strongly associated with their adherence to the medication regimen. Thus, measuring varenicline adherence to identify smokers needing additional intervention is a priority. Few studies, however, have examined the validity of self-reported varenicline adherence, using a biological assessment of adherence as a reference. No study has examined this issue among cancer patients trying to quit smoking, who may show unique patterns of adherence given their medical comorbidity.

Methods

This study used data from 76 cancer patients who received varenicline and provided self-reported varenicline adherence data (pill count) and a blood sample to determine varenicline metabolites 4 weeks after initiating varenicline.

Results

Receiver operating characteristic (ROC) curve analyses of plasma varenicline levels showed that 4 ng/ml was the optimal cut-point for differentiating adherence with significant (p's < 0.04) area under the curve values, ranging from 0.73–0.80 for 3-day, 7-day, and 4-week self-reported pill count; specificity values ranged from 0.63–0.78 and sensitivity values ranged from 0.82–0.94. Using this cut-point, adherence was high (88%). However, plasma varenicline levels were weakly correlated with 3-day and 4-week pill count and total pill count (12 weeks) was not correlated with plasma varenicline levels. Patients with head and neck cancer, gastrointestinal cancer, and more advanced disease showed lower varenicline adherence and lower plasma varenicline.

Conclusions

Using the 4 ng/ml cut-point, this study suggests validity of short-term self-reported varenicline adherence among cancer patients undergoing tobacco dependence treatment in contrast to studies in the general population, which supported 12-week pill count.

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First study of the validity of self-reported varenicline use among cancer patients

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Identified cut-point for varenicline plasma adherence

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Supports the validity of short-term self-reported varenicline adherence

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Cancer-related variables influence varenicline adherence

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Varenicline adherence may be higher among cancer patients