Changes in cigarette use and nicotine dependence in the United States: evidence from the 2001-2002 wave of the national epidemiologic survey of alcoholism and related conditions

Nicotine Use and DSM-IV Nicotine Dependence in the United States, 2001-2002 and 2012-2013

OBJECTIVE

Nationally representative data on changes in 12-month prevalences of nicotine use, DSM-IV nicotine dependence, and DSM-IV nicotine dependence among users were analyzed to test the "hardening hypothesis," which proposes that declines in nicotine use resulting from population-level control measures leave a growing proportion of highly dependent users.

METHODS

Data were derived from two nationally representative surveys of U.S. adults: the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, N=43,093) and the 2012-2013 NESARC-III (N=36,309). Weighted estimates of nicotine use, DSM-IV nicotine dependence, and an approximation of the Fagerström Test for Nicotine Dependence were compared for the 2001-2002 NESARC and 2012-2013 NESARC-III among the overall population and among nicotine users. Adjusted risk differences were obtained from logistic regression analyses using the predicted marginal approach.

RESULTS

Between the 2001-2002 and 2012-2013 surveys, rates of 12-month nicotine use declined slightly (from 27.7% to 26.9%), but increased slightly but significantly when adjusted for sociodemographic characteristics (adjusted risk difference=1.4%). Larger significant increases were seen in 12-month nicotine dependence (adjusted risk difference=2.6%) and nicotine dependence among users (adjusted risk difference=6.4%). With few exceptions, increases in nicotine use, nicotine dependence, and nicotine dependence among users were statistically significant across most sociodemographic subgroups. Notable increases were seen among men; middle and older age groups; whites, blacks, and Hispanics; and the socioeconomically disadvantaged.

CONCLUSIONS

Smaller increases in 12-month nicotine use relative to larger increases in 12-month nicotine dependence and nicotine dependence among users suggests that increases in nicotine dependence between the 2001-2002 and 2012-2013 surveys are findings that support the hardening hypothesis. Vulnerable subgroups of the population in terms of hardening were identified who would benefit from targeted nicotine dependence intervention programs to help them in overcoming dependence and quitting nicotine use.

Longitudinal Associations of Cigarette Prices With Smoking Cessation: The Coronary Artery Risk Development in Young Adults Study

INTRODUCTION

Few studies have used longitudinal cohort data to examine associations of cigarette prices with smoking cessation or whether price sensitivity varies by income or education. This study examines these associations in a multicenter US cohort and explores whether associations vary by education and income.

METHODS

Longitudinal data from baseline daily cigarette smokers aged 18-30 years in the Coronary Artery Risk Development in Young Adults study were linked to inflation-adjusted cigarette carton prices from the Council for Community and Economic Research Cost of Living Index based on residential address at baseline and in years 7, 10, and 15 (1985-2001). Multivariable Cox models estimated hazard ratios (HRs) of first (any) smoking cessation and sustained smoking cessation (no relapse) associated with each $1 increase in time-dependent cigarette price over 15 years of follow-up. Models were adjusted for sociodemographic, health-related, and policy covariates. We assessed effect modification by education and household income.

RESULTS

Among 1489 participants, a $1.00 higher cigarette carton price was associated with a 16% higher likelihood of first smoking cessation (HR = 1.16, 95% CI = 1.11 to 1.21) and an 8% higher likelihood of sustained smoking cessation (HR = 1.08, 95% CI = 1.02 to 1.14). Associations were strongest among participants with lower income for first cessation, and among those with higher income for sustained cessation. Associations were strongest for participants with less than a high school degree for both outcomes.

CONCLUSIONS

Results suggest higher cigarette prices promote smoking cessation among young to middle-aged adults, and that price sensitivity may differ by socioeconomic status.

IMPLICATIONS

Few studies have examined longitudinal associations of cigarette prices with smoking cessation, and findings are mixed on whether price sensitivity varies by education or income. In a cohort of US adult daily smokers, cigarette prices were associated with greater likelihood of both a first cessation and sustained cessation. Price associations with first cessation were stronger among low-income smokers, but associations with sustained cessation were stronger among high-income smokers. Results suggest that although higher cigarette prices may promote short-term smoking cessation among smokers at all income levels, additional supports may be needed to facilitate sustained smoking cessation among low-income smokers.

Development and psychometric properties of the tobacco and nicotine consequences scale (TANCS) to screen for cigarette and e-cigarette misuse in community settings

INTRODUCTION

To date, there are no existing measures of tobacco or nicotine misuse (i.e., negative consequences). The goal of the present study was to develop and test the psychometric properties of a novel scale, the Tobacco and Nicotine Consequences Scale (TANCS) to assess tobacco and nicotine misuse among cigarette smokers and e-cig users.

METHODS

This cross-sectional study collected data using an anonymous survey to assess tobacco and nicotine use expectancies, behaviors, and negative consequences of use. Of the 607 participants who attempted the survey, 491 participants (80.8%) completed the TANCS items. A split-half validation method was used to assess the structure and validity of the TANCS using exploratory and confirmatory factor analysis.

RESULTS

The exploratory factor analysis produced a five-factor solution, and the confirmatory factor analysis supported the factor structure with results providing an excellent fit to the data (CFI = 0.995, TLI = 0.994, RMSEA = 0.015, SRMR = 0.052). A total of 17 items were retained. The overall scale showed excellent reliability (α = 0.91) with subscale alphas between 0.68 and 0.90. The scale was significantly correlated to nicotine dependence and smoking expectancies, measured by the Fagerstrom Test Cigarette Dependence and Smoking Effects Questionnaire, respectively, suggesting the TANCS is a valid measure of tobacco and nicotine misuse. Total and subscale scores differed between participants preferring cigarettes or e-cigarettes.

CONCLUSIONS

The TANCS is a brief, reliable measure of tobacco and nicotine misuse that is correlated to tobacco and nicotine expectancies, use, and dependence. Future work should explore the test-retest reliability and incremental validity of the scale for tobacco use disorder.

Whether to push or pull? Nicotine reduction and non-combusted alternatives - Two strategies for reducing smoking and improving public health

Combustible cigarettes remain the most harmful and addictive tobacco product, and reducing the prevalence of smoking continues to be a critical public health goal. While nicotine is the constituent primarily responsible for addiction to cigarettes, most of the harm associated with smoking comes from byproducts of tobacco combustion. Recently, two different approaches for reducing the harms of smoking have emerged, both of which focus on breaking the link between the addiction to nicotine and the harms caused by smoking. First, the addictive potential of cigarettes could be minimized by requiring a large reduction in the nicotine content of cigarettes. Evidence for a nicotine reduction policy thus far shows that the use of very low nicotine content cigarettes results in a reduction in the number of cigarettes people smoke per day and a reduction in cigarette dependence. Second, emerging alternative nicotine delivery systems (ANDS) like electronic cigarettes may provide sufficient nicotine to act as substitutes for cigarettes while delivering much lower levels of toxicants. Evidence suggests that the emergence of ANDS has increased the percentage of smokers who are able to quit. The present paper will briefly review the evidence for each of these approaches, and consider what contemporary reinforcement and addiction theories can tell us about their likely success. We argue that the most effective endgame approach is one that pursues both nicotine reduction and alternative nicotine delivery systems as complementary.

Trends in cigarette consumption and time to first cigarette on awakening from 2002 to 2015 in the USA: new insights into the ongoing tobacco epidemic

OBJECTIVE

The current study estimates trends in the number of cigarettes smoked per day (CPD) and percentage of smokers having their first CPD within 30 min of waking (time to first cigarette (TTFC)<30 min) among smokers from 2002 to 2015 in the USA overall, and adjusting for demographics. Trends in TTFC<30 min were also estimated by varying levels of cigarette consumption.

METHODS

Data were drawn from the National Household Survey on Drug Use, an annual nationally representative cross-sectional study of the US population aged 12 and older (n=54 079-58 397 per year). Linear time trend analyses of CPD and TTFC<30 min were conducted adjusting for age, gender and income; linear time trend analyses of TTFC among those at varying levels of CPD were then performed.

RESULTS

Estimates suggest that CPD declined overall from 2002 to 2015, and that the prevalence of TTFC<30 min declined overall among smokers (p<0.0001). The proportion of smokers consuming fewer (ie, 1-5, 6-15) CPD has increased while the number consuming 16+ CPD has decreased overall. Among those smoking 1-5 (p=0.0006) and 6-15 (p<0.0001) CPD, TTFC<30 min has increased significantly, but TTFC<30 min has remained unchanged among those smoking 16 or more CPD (p=0.5838).

CONCLUSIONS

Findings suggest that smokers today are consuming fewer CPD, yet are increasingly likely to have their first cigarette earlier on awakening than they were a decade ago. Intervention and outreach efforts aimed at moving the prevalence lower may benefit from evaluating and addressing nicotine dependence even among lighter smokers.

Review: Prevalence and co-occurrence of addictions in US ethnic/racial groups: Implications for genetic research

BACKGROUND AND OBJECTIVES

We conducted a review of the prevalence and co-occurrence of 12 types of addictions in US ethnic/racial groups and discuss the implications of the results for genetic research on addictions.

METHODS

We utilized MEDLINE and PsycINFO databases to review the literature on alcohol, tobacco, marijuana, illicit drugs, gambling, eating/food, internet, sex, love, exercise, work, and shopping. We present results for each addiction based on total US prevalence, prevalence within ethnic groups, and co-occurrence of addictions among ethnic groups when available.

RESULTS

This review indicates very little research has examined the interrelationships of addictive behaviors among US ethnic groups. The studies that exist have focused nearly exclusively on comorbidity of substances and gambling behaviors. Overall findings suggest differences among US ethnic groups in prevalence of addictions and in prevalence of addiction among those who use substances or engage in gambling. Almost no ethnic group comparisons of other addictive behaviors including eating/food, internet, love, sex, exercise, work, and shopping were identified in the literature.

CONCLUSIONS

Despite large-scale research efforts to examine alcohol and substance use disorders in the United States, few studies have been published that examine these addictive behaviors among ethnic groups, and even fewer examine co-occurrence and comorbidity with other addictions.

SCIENTIFIC SIGNIFICANCE

Even with the limited studies, these findings have implications for genetic research on addictive behaviors. We include a discussion of these implications, including issues of population stratification, disaggregation, admixture, and the interplay between genetic and environmental factors in understanding the etiology and treatment of addictions. (Am J Addict 2017;26:424-436).

Daily Smoking and Subjective Health Complaints in Adolescence

INTRODUCTION

Using data from the Health Behaviour in School-aged Children survey, this study used a repeated cross-sectional design to examine associations between daily smoking, gender, and self-reported health complaints in five cohorts of adolescents over a 16-year period.

METHODS

Data were from nationally representative cohorts of 15-year-old youth in Norway in 1993/1994, 1997/1998, 2001/2002, 2005/2006, and 2009/2010 (n _total = 7761). Dependent variables were psychological, somatic, and total health complaints. A mixed GLM model examined main and interaction effects of smoking (daily, intermittent, nonsmoking), year, and gender in predicting complaints. Time periods were segmented to compare trends across smoking groups in specific periods.

RESULTS

Prevalence of daily smoking declined from 15.5% (1993/1994) to 6.0% (2009/2010). All health complaint scores were significantly higher for smokers and for girls (vs. boys). Smoking status by year interactions were significant for all complaint variables during the period of sharpest decline of daily smoking prevalence (2001/2002-2005/2006), with daily smokers experiencing increases in health complaints while intermittent and nonsmokers did not. Smoking status by gender interactions were significant for all health complaint variables, indicating that the main effect for gender (females higher) was even stronger among smokers compared with nonsmokers. Using year as unit of analysis, the size of mean differences between daily smokers and intermittent/nonsmokers in total complaints was significantly negatively correlated with daily smoking prevalence (-.963, n = 5, p < .01).

CONCLUSIONS

As prevalence of daily smoking declined, daily smokers reported higher levels of complaints, suggesting increasing health problems within this group. Girls who smoke daily had particularly elevated levels of complaints.

IMPLICATIONS

This study indicates that the relationship between daily smoking and concurrent health symptomatology in adolescents is changing over time, with higher levels of health complaints reported as overall smoking prevalence declines. To our knowledge, this finding has not previously been reported. If youth are smoking to cope with distress, pain, or other health concerns, tobacco control objectives will be increasingly difficult to achieve with adolescents. Levels of health complaints are particularly high among girls who are daily smokers. The findings suggest that restrictive measures and persuasive communications may not be sufficient tobacco prevention strategies for adolescent populations. Young smokers may need counseling and support.

Nicotine-dependence-varying effects of smoking events on momentary mood changes among adolescents

INTRODUCTION

Theories of nicotine addiction emphasize the initial role of positive reinforcement in the development of regular smoking behavior, and the role of negative reinforcement at later stages. These theories are tested here by examining the effects of amount smoked per smoking event on smoking-related mood changes, and how nicotine dependence (ND) moderates this effect. The current study examines these questions within a sample of light adolescent smokers drawn from the metropolitan Chicago area (N=151, 55.6% female, mean 17.7years).

INSTRUMENTS

Ecological momentary assessment data were collected via handheld computers, and additional variables were drawn from a traditional questionnaire.

METHODS

Effects of the amount smoked per event on changes in positive affect (PA) and negative affect (NA) after vs. before smoking were examined, while controlling for subject-averaged amount smoked, age, gender, and day of week. ND-varying effects were examined using varying effect models to elucidate their change across levels of ND.

RESULTS

The effect of the amount smoked per event was significantly associated with an increase in PA among adolescents with low-to-moderate levels of ND, and was not significant at high ND. Conversely, the effect of the amount smoked was significantly associated with a decrease in NA only for adolescents with low levels of ND.

CONCLUSIONS

These findings support the role of positive reinforcement in early stages of dependent smoking, but do not support the role of negative reinforcement beyond early stages of smoking. Other potential contributing factors to the relationship between smoking behavior and PA/NA change are discussed.

Racial/ethnic differences in use of alcohol, tobacco, and marijuana: is there a cross-over from adolescence to adulthood?

Black adolescents in the US are less likely to use alcohol, marijuana, and tobacco compared with non-Hispanic Whites, but little is known about the consistency of these racial/ethnic differences in substance use across the lifecourse. Understanding lifecourse patterning of substance use is critical to inform prevention and intervention efforts. Data were drawn from four waves of the National Longitudinal Study of Adolescent Health (Add Health; Wave 1 (mean age = 16): N = 14,101; Wave 4 (mean age = 29): N = 11,365). Outcomes included alcohol (including at-risk drinking, defined as 5+/4+ drinks per drinking occasion or 14+/7+ drinks per week on average for men and women, respectively), cigarette, and marijuana use in 30-day/past-year. Random effects models stratified by gender tested differences-in-differences for wave by race interactions, controlling for age, parents' highest education/income, public assistance, and urbanicity. Results indicate that for alcohol, Whites were more likely to use alcohol and engage in at-risk alcohol use at all waves. By mean age 29.9, for example, White men were 2.1 times as likely to engage in at-risk alcohol use (95% C.I. 1.48-2.94). For cigarettes, Whites were more likely to use cigarettes and smoked more at Waves 1 through 3; there were no differences by Wave 4 for men and a diminished difference for women, and difference-in-difference models indicated evidence of convergence. For marijuana, there were no racial/ethnic differences in use for men at any wave. For women, by Wave 4 there was convergence in marijuana use and a cross-over in frequency of use among users, with Black women using more than White women. In summary, no convergence or cross-over for racial/ethnic differences through early adulthood in alcohol use; convergence for cigarette as well as marijuana use. Lifecourse patterns of health disparities secondary to heavy substance use by race and ethnicity may be, at least in part, due to age-related variation in cigarette and marijuana use.

Nicotine dependence and psychiatric and substance use disorder comorbidities among American Indians/Alaska Natives: findings from the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND

American Indians and Alaska Natives (AI/ANs) have high rates of tobacco use compared to the general population. AI/ANs also have elevated rates of psychiatric and substance use disorders associated with nicotine dependence. However, very few studies have examined the comorbidity between nicotine dependence and psychiatric and substance use disorders within this population.

METHODS

This study analyzes the comorbidity of lifetime nicotine dependence with both current and lifetime psychiatric disorders and substance use disorders in a nationally representative sample of 701 AI/AN women and men.

RESULTS

Using 95% confidence interval testing, lifetime nicotine dependence (29.5%) was associated with all main diagnostic categories (any mood disorder, any anxiety disorder, any personality disorder, any alcohol use disorder, and any drug use disorder) both at the lifetime level and current (12-month) level. Of the lifetime disorders, the strongest associations were with psychosis and drug dependence. For (current) 12-month disorders, the strongest associations were with alcohol dependence and drug dependence. Differences were noted between genders regarding personality disorders.

CONCLUSIONS

Culturally appropriate tobacco screening, prevention, and treatment curricula for adult AI/ANs with dual diagnoses are recommended. Understanding historically based factors that may contribute to psychiatric illness and substance use disorders may assist in more effective nicotine treatments for AI/ANs.

What is the evidence for hardening in the cigarette smoking population? Trends in nicotine dependence in the U.S., 2002-2012

BACKGROUND

It is unclear whether declines in cigarette smoking in the U.S. have resulted in a hardened population of "hardcore" smokers. We studied changes in nicotine dependence severity from 2002 to 2012, using data from the National Survey on Drug Use and Health.

METHODS

We used generalized non-linear factor analysis to examine whether individual Nicotine Dependence Syndrome Scale (NDSS) items functioned differently over time, and whether average NDSS scores changed in a sample of 130,637 current smokers. We also examined trends for individual NDSS sub-scales and whether trends were moderated by tobacco consumption and socio-demographic factors.

RESULTS

Consumption levels and dependence severity both declined over the study period. This decline was driven by priority (e.g., avoiding smoke-free locations) and tolerance dimensions of dependence, while drive (e.g., craving and smoking to relieve negative affect) and continuity (e.g., stability) of smoking did not change. Declines for tolerance were greatest among those without serious psychological distress and among middle-aged smokers. Drive and continuity increased among women and low income smokers.

CONCLUSIONS

We did not find evidence of hardening at the population level for smokers in the U.S., 2002-2012. However, there is evidence of hardening when considering drive and continuity-related nicotine dependence among women and low-income smokers, suggesting these sub-groups are experiencing greater severity of craving, smoking to relieve negative affect, and regularity of smoking despite reduced consumption.

Racial/Ethnic differences among smokers: revisited and expanded to help seekers

INTRODUCTION

Most research on racial/ethnic differences among smokers is outdated and does not focus on help seekers. The purpose of this study was to revisit racial/ethnic differences in variables related to cessation in a sample of smokers enrolled in a randomized trial.

METHODS

Adult smokers (N = 417; n = 126 White; n = 123 Hispanic; n = 168 Black) completed measures of demographics, smoking history, alcohol use, depressive symptoms, and readiness to quit.

RESULTS

We found significant differences in these factors across groups. Blacks were more likely to be older, less educated, single, low income, smoke menthol cigarettes, and report greater nicotine dependence. Hispanics were younger, reported fewer years smoking and cigarettes per day, lower nicotine dependence, preferred mentholated cigarettes, and reported greater alcohol use intensity. After controlling for demographics and smoking history, Blacks reported greater depressive symptoms and lower readiness to quit compared with Whites and Hispanics.

CONCLUSIONS

Help-seeking Blacks may exhibit more risk factors for difficulty quitting compared with other groups. Hispanics may have some protective factors, such as lower dependence, but require attention to alcohol use and menthol smoking. Identifying preintervention racial/ethnic differences in characteristics related to cessation is important for developing evidence-based and culturally specific interventions and for reducing tobacco-related health disparities.

Smoking and psychopathology increasingly associated in recent birth cohorts

BACKGROUND

In recent decades, smoking has become an increasingly non-normative behavior. Because deviant behaviors are associated with greater clinical and genetic risks, current-generation smokers may have greater concentrations of psychiatric comorbidity than previous generations. We examined this question empirically by testing whether associations between measures of smoking, psychiatric diagnoses, and risk-associated personality traits, increased across seven birth-cohorts of the 20th century.

METHOD

4326 subjects from a cross-sectional NIMH control sample were categorized into one of seven groups based on birth (born before 1930, and 1930s-80s) and one of three smoking levels (lifetime dependent smoker, never dependent smoker, never smoker). Smoking and ND were assessed using the Fagerstrom Test for Nicotine Dependence; psychiatric diagnoses (drug and alcohol dependence, major depression, and generalized anxiety disorder) using the Composite International Diagnostic Interview-Short Form, and personality traits (neuroticism and extraversion) with the Eysenck Personality Questionnaire.

RESULT

Lifetime prevalence of smoking decreased across the seven cohorts. Associations between smoking and drug dependence, generalized anxiety, and neuroticism, as well as total psychiatric comorbidity, were greater in more recent cohorts [smoking-by-cohort interaction: p<0.01], with greatest increases contributed by nicotine-dependent smokers. Smoking was also independently associated with alcohol dependence and depression, but these associations did not significantly vary across cohorts.

CONCLUSIONS

More recent generations included fewer persons who smoked, but their smoking was associated with greater psychiatric morbidity. Failure to account for systematic variation in comorbidity across smoking cohorts may lead to unwanted heterogeneity in clinical, and possibly genetic, studies of nicotine dependence.

Ethnic differences in smoking rate, nicotine dependence, and cessation-related variables among adult smokers in Hawaii

This study tests hypotheses concerning ethnic disparities in daily cigarette smoking rates, nicotine dependence, cessation motivation, and knowledge and past use of cessation methods (e.g., counseling) and products (e.g., nicotine patch) in a multiethnic sample of smokers in Hawaii. Previous research has revealed significant differences in smoking prevalence among Native Hawaiians, Filipinos, Japanese, and Caucasians in Hawaii. However, no study has examined differences in dependence and cessation-related knowledge and practices among smokers representing these ethnic groups. Participants were recruited through newspaper advertisement as part of a larger smoking cessation intervention study. Participants (N = 919; M age = 45.6, SD = 12.7; 48 % women) eligible to participate provided self-report data through mail and telephone. Participants included 271 self-identified Native Hawaiians, 63 Filipinos, 316 Caucasians, 145 "East Asians" (e.g., Japanese, Chinese), and 124 "other" (e.g., Hispanic, African-American). Pair-wise comparisons of means, controlling for age, gender, income, education, and marital status, indicated that Native Hawaiian smokers reported significantly higher daily smoking rates and higher levels of nicotine dependence compared to East Asians. Native Hawaiian smokers reported significantly lower motivation to quit smoking than Caucasians. Further, Filipino and Native Hawaiian smokers reported lesser knowledge of cessation methods and products, and less frequent use of these methods and products than Caucasians. The results suggest that Native Hawaiian and Filipino smokers could be underserved with regard to receiving cessation-related advice, and may lack adequate access to smoking cessation products and services. In addition, cessation interventions tailored for Native Hawaiian smokers could benefit from a motivational enhancement component.

Cigarette smoking and onset of mood and anxiety disorders

OBJECTIVES

We examined the association between regular cigarette smoking and new onset of mood and anxiety disorders.

METHODS

We used logistic regression analysis to detect associations between regular smoking and new-onset disorders during the 3-year follow-up among 34 653 participants in the longitudinal US National Epidemiologic Survey on Alcohol and Related Conditions (2001-2005). We used instrumental variable methods to assess the appropriateness of these models.

RESULTS

Regular smoking was associated with an increased risk of new onset of mood and anxiety disorders in multivariable analyses (Fdf = 5,61 = 11.73; P < .001). Participants who smoked a larger number of cigarettes daily displayed a trend toward greater likelihood of new-onset disorders. Age moderated the association of smoking with most new-onset disorders. The association was mostly statistically significant and generally stronger in participants aged 18 to 49 years but was smaller and mostly nonsignificant in older adults.

CONCLUSIONS

Our finding of a stronger association between regular cigarette smoking and increased risk of new-onset mood and anxiety disorders among younger adults suggest the need for vigorous antismoking campaigns and policy initiatives targeting this age group.

Do socio-economic gradients in smoking emerge differently across time by gender? Implications for the tobacco epidemic from a pregnancy cohort in California, USA

Understanding current patterns of population smoking by socioeconomic position (SEP) can be substantially enhanced by research that follows birth cohorts over long periods of time, yet such data in the US are rare. Information from birth cohorts followed during critical time periods when the health consequences of smoking became widely known can inform the ways in which current smoking prevalence has been shaped by the historical processes that preceded it. The present study utilizes data from a substudy of the Child Health and Development Study pregnancy cohort (N = 1612). Women were queried about smoking status in 1959-1962, 1971-1972 and 1977-1980. Women were divided into three cohorts based on date of birth. Offspring represented another birth cohort assessed for smoking in 1977-1980. Results indicated that the overall prevalence of smoking exhibited cohort-specific patterns that persisted across time. Notably, the youngest maternal cohort (born 1937-1946) had high smoking prevalence throughout and showed no appreciable decrease (44.7%, 41.4%, 40.1% for 1959-1962, 1971-1972, and 1977-1980). Results also indicated that the relation of smoking to SEP exhibited cohort-specific patterns over time. Among the oldest birth cohort (born 1914-1930), no inverse relation of SEP to smoking was observed at any time; in contrast, an inverse relation emerged by 1959-1962 among the youngest cohort of mothers. Among the adolescent offspring, there was a strong SEP gradient (OR = 2.0, 95% CI = 1.4-3.0) that was stronger than in any maternal birth cohort at any assessment (β = 0.40, SE = 0.1, p<0.01). We conclude that SEP gradients in smoking emerge across birth cohorts rather than time alone, with increasingly strong gradients across time especially among younger cohorts.

Changes in smoking prevalence and number of cigarettes smoked per day following the implementation of a comprehensive tobacco control plan in New York City

The New York City (NYC) Health Department has implemented a comprehensive tobacco control plan since 2002, and there was a 27% decline in adult smoking prevalence in NYC from 2002 to 2008. There are conflicting reports in the literature on whether residual smoker populations have a larger or smaller share of "hardcore" smokers. Changes in daily consumption and daily and nondaily smoking prevalence, common components used to define hardcore smokers, were evaluated in the context of the smoking prevalence decline. Using the NYC Community Health Survey, an annual random digit dial, cross-sectional survey that samples approximately 10,000 adults, the prevalence of current heavy daily, light daily, and nondaily smokers among NYC adults was compared between 2002 and 2008. A five-level categorical cigarettes per day (CPD) variable was also used to compare the population of smokers between the 2 years. From 2002 to 2008, significant declines were seen in the prevalence of daily smoking, heavy daily smoking, and nondaily smoking. Among daily smokers, there is also evidence of population declines in all but the lowest smoking category (one to five CPD). The mean CPD among daily smokers declined significantly, from 14.6 to 12.5. After an overall decline in smoking since 2002, the remaining smokers may be less nicotine dependent, based on changes in daily consumption and daily and nondaily smoking prevalence. These findings suggest the need to increase media and cessation efforts targeted towards lighter smokers.

Predictors of persistent nicotine dependence among adults in the United States

BACKGROUND

Evidence suggests that nicotine dependence is the key barrier to successful smoking cessation. No previous study has documented predictors of persistent nicotine dependence among adults in the community. The goal of this study is to prospectively identify predictors of continued nicotine dependence over a 3-year period among adults.

METHODS

Data were drawn from Waves I and II of the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC), a nationally representative sample of 34,653 adults in the United States. Logistic regression analyses were used to estimate the odds of persistent nicotine dependence at Wave 2 given the presence of various sociodemographic and psychiatric predictors at Wave 1.

RESULTS

Mood, anxiety, personality and illicit substance use disorders were associated with significantly increased risk of persistent nicotine dependence. The strength of these relationships was attenuated slightly after adjusting for demographic differences, but remained statistically significant. Persistent nicotine dependence was more common among unmarried, younger females with lower income levels and lower educational attainment.

CONCLUSIONS

To our knowledge, this study is the first to prospectively identify predictors of persistent nicotine dependence among adults. Our results suggest that the incorporation of mental health treatment into alternative smoking cessation approaches may help to increase the effectiveness of these programs and that a greater focus of these services on vulnerable segments of the population is needed in order to reduce continued disparities in smoking in the general population.

The hardening hypothesis: is the ability to quit decreasing due to increasing nicotine dependence? A review and commentary

The "hardening hypothesis" states tobacco control activities have mostly influenced those smokers who found it easier to quit and, thus, remaining smokers are those who are less likely to stop smoking. This paper first describes a conceptual model for hardening. Then the paper describes important methodological distinctions (quit attempts vs. ability to remain abstinent as indicators, measures of hardening per se vs. measures of causes of hardening, and dependence measures that do vs. do not include cigarettes per day (cigs/day).) After this commentary, the paper reviews data from prior reviews and new searches for studies on one type of hardening: the decreasing ability to quit due to increasing nicotine dependence. Overall, all four studies of the general population of smokers found no evidence of decreased ability to quit; however, both secondary analyses of treatment-seeking smokers found quit rates were decreasing over time. Cigs/day and time-to-first cigarette measures of dependence did not increase over time; however, two studies found that DSM-defined dependence appeared to be increasing over time. Although these data suggest hardening may be occurring in treatment seekers but not in the general population of smokers, this conclusion may be premature given the small number of data sets and indirect measures of quit success and dependence in the data sets. Future studies should include questions about quit attempts, ability to abstain, treatment use, and multi-item dependence measures.

Nicotine dependence phenotype and lung cancer risk

BACKGROUND

A behavioral phenotype that characterizes nicotine dependence, the time to first cigarette after waking, is hypothesized to increase the risk of lung cancer.

METHODS

A case-control study of histologically confirmed lung cancer was conducted. The current analysis included 4775 lung cancer cases and 2835 controls who were regular cigarette smokers.

RESULTS

Compared with subjects who smoked their first cigarette > 60 minutes after waking, the pack-years-adjusted odds ratio was 1.31 (95% confidence interval [95% CI], 1.11-1.54) for subjects who smoked 31 minutes to 60 minutes after waking and 1.79 (95% CI, 1.56-2.07) for subjects who smoked within 30 minutes of waking. The risk estimates were similar when smoking was modeled as total years, smoking status (current vs former), number of cigarettes smoked per day, years since quitting, and excess odds ratio. The findings were consistent for all histologic types of lung cancer.

CONCLUSIONS

The findings of the current study indicate that a specific nicotine dependence phenotype that is associated with the amount of smoke uptake per cigarette is independently associated with lung cancer risk. These findings may help to identify high-risk individuals who would benefit from targeted interventions.

Cigarette smoking as part of a syndemic among young men who have sex with men ages 13-29 in New York City

The prevalence of cigarette smoking among young men who have sex with men (YMSM) is significantly higher than among their heterosexual peers. We undertook an analysis to examine cigarette smoking in relation to demographic factors and other risk behaviors among 580 YMSM, ages 13-29, in New York City. Cross-sectional data were collected as part of larger study of risk behaviors using palm devices and targeted active recruitment strategies across all five boroughs of the city. Multivariate modeling suggests that Asian or Pacific Islander and White YMSM are more likely to report cigarette smoking than other racial and ethnic groups, as are men reporting a middle class socioeconomic status. In addition, smoking was related to the likelihood of using a variety of illicit substances, as well as alcohol and pharmaceuticals without a prescription, during the period of assessment. YMSM who smoke cigarettes reported a greater number of casual sex partners and a greater number of transactional sex partners than non-smokers. Episodic analysis of sexual behaviors with casual partners indicated that smokers were more likely to engage in illicit drug and alcohol use immediately before or during sex than did non-smokers. These findings are understood as part of a larger syndemic among YMSM, and suggest that smoking prevention and cessation programs should be embedded as part of larger more holistic health and wellness programs targeting YMSM.

Contribution of parental psychopathology to offspring smoking and nicotine dependence in a genetically informative design

OBJECTIVE

It is not known if parental psychiatric disorders have an independent effect on offspring smoking after controlling for genetic and environmental vulnerability to nicotine dependence. We tested if parental alcohol, drug, or conduct disorders; antisocial personality disorder; depression; and anxiety disorders remained significant predictors of offspring smoking initiation, regular smoking, and nicotine dependence before and after adjusting for genetic and environmental risk for nicotine dependence.

METHOD

Data were obtained via semi-structured interviews with 1,107 twin fathers, 1,919 offspring between the ages of 12 and 32, and 1,023 mothers. Genetic and environmental liability for smoking outcomes was defined by paternal and maternal nicotine dependence. Multinomial logistic regression models were computed to estimate the risk for offspring trying cigarettes, regular smoking, and the Fagerström Test for Nicotine Dependence (FTND) as a function of parental psychopathology and sociodemographics before and after adjusting for genetic and environmental vulnerability to nicotine dependence.

RESULTS

Before adjusting for genetic and environmental risk for nicotine dependence, ever trying cigarettes was associated with maternal depression, regular smoking was associated with maternal alcohol dependence and maternal conduct disorder, and FTND was associated with paternal and maternal conduct disorder and antisocial personality disorder. No parental psychopathology remained significantly associated with regular smoking and FTND after adjusting for genetic and environmental vulnerability to nicotine dependence in a multivariate model.

CONCLUSIONS

The association between parental psychopathology and offspring smoking outcomes is partly explained by genetic and environmental risk for nicotine dependence. Point estimates suggest a trend for an association between parental antisocial personality disorder and offspring regular smoking and nicotine dependence after adjusting for genetic and environmental vulnerability. Studies in larger samples are warranted.

Nicotine dependence as a moderator of a quitline-based message framing intervention

High nicotine dependence is a reliable predictor of difficulty quitting smoking and remaining smoke-free. Evidence also suggests that the effectiveness of various smoking cessation treatments may vary by nicotine dependence level. Nicotine dependence, as assessed by Heaviness of Smoking Index baseline total scores, was evaluated as a potential moderator of a message-framing intervention provided through the New York State Smokers' Quitline (free telephone based service). Smokers were exposed to either gain-framed (n=810) or standard-care (n=1222) counseling and printed materials. Those smoking 10 or more cigarettes per day and medically eligible were also offered a free 2-week supply of nicotine patches, gum, or lozenge. Smokers were contacted for follow-up interviews at 3 months by an independent survey group. There was no interaction of nicotine dependence scores and message condition on the likelihood of achieving 7-day point prevalence smoking abstinence at the 3-month follow-up contact. Among continuing smokers at the 3-month follow-up, smokers who reported higher nicotine dependence scores were more likely to report smoking more cigarettes per day and this effect was greater in response to standard-care messages than gain-framed messages. Smokers with higher dependence scores who received standard-care messages also were less likely to report use of nicotine medications compared with less dependent smokers, while there was no difference in those who received gain-framed messages. These findings lend support to prior research demonstrating nicotine dependence heterogeneity in response to message framing interventions and suggest that gain-framed messages may result in less variable smoking outcomes than standard-care messages.

Alcohol, tobacco, and nonmedical drug use disorders in U.S. Adults aged 65 years and older: data from the 2001-2002 National Epidemiologic Survey of Alcohol and Related Conditions

OBJECTIVES

To examine the prevalence, sociodemographic, and health-related correlates of substance use disorders, including alcohol, tobacco, and nonmedical drug use among adults aged 65 years and older.

DESIGN

The 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, a cross-sectional survey of a population-based sample.

SETTING

The United States.

PARTICIPANTS

Eight thousand two hundred five adults aged 65 years and older.

MEASUREMENTS

Prevalence of lifetime and past 12-month Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, determined alcohol, tobacco, and nonmedical drug use disorders.

RESULTS

Prevalence of any substance use disorder was 21.1% during the lifetime and 5.4% in the past 12 months. Lifetime and past 12-month alcohol use disorders were 16.1% and 1.5%; tobacco use disorders were 8.7% and 4.0%; and nonmedical drug use disorders were 0.6% and 0.2%, respectively. Younger age was associated with greater odds of any lifetime or past 12-month substance use disorders. Men and those who were divorced or separated had greater odds of both lifetime alcohol and tobacco use disorders. Very good or excellent self-rated health was associated with lower odds of lifetime and past 12-month tobacco use disorders. Younger age and being divorced or separated were associated with greater odds of lifetime nonmedical drug use disorder.

CONCLUSIONS

More than one in five older adults ever had a substance use disorder, and more than 1 in 20 had a disorder in the past 12 months, primarily involving alcohol or tobacco. Older adults have increased comorbidities and use of medications, which can increase risks associated with substance use.

Prevalence of the addictions: a problem of the majority or the minority?

An increasing number of research studies over the last three decades suggest that a wide range of substance and process addictions may serve similar functions. The current article considers 11 such potential addictions (tobacco, alcohol, illicit drugs, eating, gambling, Internet, love, sex, exercise, work, and shopping), their prevalence, and co-occurrence, based on a systematic review of the literature. Data from 83 studies (each study n = at least 500 subjects) were presented and supplemented with small-scale data. Depending on which assumptions are made, overall 12-month prevalence of an addiction among U.S. adults varies from 15% to 61%. The authors assert that it is most plausible that 47% of the U.S. adult population suffers from maladaptive signs of an addictive disorder over a 12-month period and that it may be useful to think of addictions as due to problems of lifestyle as well as to person-level factors.

Does sickness absence due to psychiatric disorder predict cause-specific mortality? A 16-year follow-up of the GAZEL occupational cohort study

Mental disorders are a frequent cause of morbidity and sickness absence in working populations; however, the status of psychiatric sickness absence as a predictor of mortality is not established. The authors tested the hypothesis that psychiatric sickness absence predicts mortality from leading medical causes. Data were derived from the French GAZEL cohort study (n = 19,962). Physician-certified sickness absence records were extracted from administrative files (1990-1992) and were linked to mortality data from France's national registry of mortality (1993-2008, mean follow-up: 15.5 years). Analyses were conducted by using Cox regression models. Compared with workers with no sickness absence, those absent due to psychiatric disorder were at increased risk of cause-specific mortality (hazard ratios (HRs) adjusted for age, gender, occupational grade, other sickness absence-suicide: 6.01, 95% confidence interval (CI): 3.07, 11.75; cardiovascular disease: 1.84, 95% CI: 1.10, 3.08; and smoking-related cancer: 1.65, 95% CI: 1.07, 2.53). After full adjustment, the excess risk of suicide remained significant (HR = 5.13, 95% CI: 2.60, 10.13) but failed to reach statistical significance for fatal cardiovascular disease (HR = 1.59, 95% CI: 0.95, 2.66) and smoking-related cancer (HR = 1.31, 95% CI: 0.85, 2.03). Psychiatric sickness absence records could help identify individuals at risk of premature mortality and serve to monitor workers' health.

Alcohol, tobacco, and nonmedical drug use in older U.S. Adults: data from the 2001/02 national epidemiologic survey of alcohol and related conditions

OBJECTIVES

To examine the prevalence and sociodemographic and health-related correlates of substance use, including alcohol, tobacco, and nonmedical drug use, in adults aged 65 and older.

DESIGN

Cross-sectional, retrospective survey of a population-based sample, the 2001/02 National Epidemiologic Survey on Alcohol and Related Conditions.

SETTING

United States.

PARTICIPANTS

Eight thousand two hundred five U.S. adults aged 65 and older.

MEASUREMENTS

Prevalence of lifetime and previous-12-month alcohol, tobacco, and nonmedical drug use and associations between substance use and sociodemographic and health-related factors.

RESULTS

Almost 80% of older adults had used any of the three substances over their lifetimes, and more than 50% reported such use over the previous 12 months. Alcohol was the most commonly used substance over the lifetime (74%) and in the previous 12 months (45%), followed by tobacco (52% lifetime; 14% previous 12 months); far fewer reported nonmedical use of drugs (5% lifetime; 1% previous 12 months). In general, being younger, male, and divorced or separated were factors consistently associated with use of any of the three substances.

CONCLUSION

Most older adults had used substances over their lifetimes and in the previous 12 months. Alcohol is the substance of choice for this age group, followed by tobacco; few report nonmedical drug use.