Tobacco use disorder and treatment: new challenges and opportunities

Multi-ancestry meta-analysis of tobacco use disorder identifies 461 potential risk genes and reveals associations with multiple health outcomes

Tobacco use disorder (TUD) is the most prevalent substance use disorder in the world. Genetic factors influence smoking behaviours and although strides have been made using genome-wide association studies to identify risk variants, most variants identified have been for nicotine consumption, rather than TUD. Here we leveraged four US biobanks to perform a multi-ancestral meta-analysis of TUD (derived via electronic health records) in 653,790 individuals (495,005 European, 114,420 African American and 44,365 Latin American) and data from UK Biobank (ncombined = 898,680). We identified 88 independent risk loci; integration with functional genomic tools uncovered 461 potential risk genes, primarily expressed in the brain. TUD was genetically correlated with smoking and psychiatric traits from traditionally ascertained cohorts, externalizing behaviours in children and hundreds of medical outcomes, including HIV infection, heart disease and pain. This work furthers our biological understanding of TUD and establishes electronic health records as a source of phenotypic information for studying the genetics of TUD.

The Impact of a Nurse-Led Service on Tobacco Treatment Provision Within a Psychiatric Hospital: A Time Series Study

INTRODUCTION

Psychiatric hospitalization is an opportunity to provide evidence-based tobacco treatment to optimize cessation efforts among people living with mental illnesses (MI). The purpose of this study was to examine the effectiveness of nurse-driven initiatives to enhance tobacco treatment within an inpatient psychiatric setting.

AIMS

We assessed the 4-year impact of implementing a nurse-led tobacco treatment service offered to 11,314 inpatients at admissions in a tobacco-free psychiatric facility in Kentucky.

METHOD

Through a time-series design, we compared the differences in rates of screening for tobacco use and providing treatment from September to December 2015 (prior to implementing the nurse-led tobacco treatment services) to each subsequent year in a 4-year period (2016-2019).

RESULTS

Approximately 60.0% of inpatients were persons using tobacco during the assessment period. Although there were no changes in tobacco use prevalence over the 4-year evaluation duration, there were significant increases in the provision of practical counseling and Food and Drug Administration-approved nicotine replacement therapies for persons using tobacco.

CONCLUSIONS

Our findings support the effectiveness of implementing tobacco treatment programs at the organizational level. Psychiatric hospitalizations provide an opportunity to optimize nurse-driven efforts to deliver tobacco treatment to people with MI. Similar models of nurse-led tobacco treatment services can be adopted within inpatient and other mental and behavioral health settings.

Multi-ancestry meta-analysis of tobacco use disorder prioritizes novel candidate risk genes and reveals associations with numerous health outcomes

Tobacco use disorder (TUD) is the most prevalent substance use disorder in the world. Genetic factors influence smoking behaviors, and although strides have been made using genome-wide association studies (GWAS) to identify risk variants, the majority of variants identified have been for nicotine consumption, rather than TUD. We leveraged five biobanks to perform a multi-ancestral meta-analysis of TUD (derived via electronic health records, EHR) in 898,680 individuals (739,895 European, 114,420 African American, 44,365 Latin American). We identified 88 independent risk loci; integration with functional genomic tools uncovered 461 potential risk genes, primarily expressed in the brain. TUD was genetically correlated with smoking and psychiatric traits from traditionally ascertained cohorts, externalizing behaviors in children, and hundreds of medical outcomes, including HIV infection, heart disease, and pain. This work furthers our biological understanding of TUD and establishes EHR as a source of phenotypic information for studying the genetics of TUD.

Development of an Electronic Health Record-Based Algorithm for Predicting Lung Cancer Screening Eligibility in the Population-Based Research to Optimize the Screening Process Lung Research Consortium

PURPOSE

Lung cancer screening (LCS) guidelines in the United States recommend LCS for those age 50-80 years with at least 20 pack-years smoking history who currently smoke or quit within the last 15 years. We tested the performance of simple smoking-related criteria derived from electronic health record (EHR) data and developed and tested the performance of a multivariable model in predicting LCS eligibility.

METHODS

Analyses were completed within the Population-based Research to Optimize the Screening Process Lung Consortium (PROSPR-Lung). In our primary validity analyses, the reference standard LCS eligibility was based on self-reported smoking data collected via survey. Within one PROSPR-Lung health system, we used a training data set and penalized multivariable logistic regression using the Least Absolute Shrinkage and Selection Operator to select EHR-based variables into the prediction model including demographics, smoking history, diagnoses, and prescription medications. A separate test data set assessed model performance. We also conducted external validation analysis in a separate health system and reported AUC, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy metrics associated with the Youden Index.

RESULTS

There were 14,214 individuals with survey data to assess LCS eligibility in primary analyses. The overall performance for assigning LCS eligibility status as measured by the AUC values at the two health systems was 0.940 and 0.938. At the Youden Index cutoff value, performance metrics were as follows: accuracy, 0.855 and 0.895; sensitivity, 0.886 and 0.920; specificity, 0.896 and 0.850; PPV, 0.357 and 0.444; and NPV, 0.988 and 0.992.

CONCLUSION

Our results suggest that health systems can use an EHR-derived multivariable prediction model to aid in the identification of those who may be eligible for LCS.

Untreated substance use disorder affects glycemic control: Results in patients with type 2 diabetes served within a network of community-based healthcare centers in Florida

Introduction

Patients with diabetes and comorbid substance use disorders (SUD) experience poor diabetes management, increased medical complications and mortality. However, research has documented that patients engaged in substance abuse treatment have better management of their comorbid conditions. The current study examines diabetes management among patients with type 2 diabetes, with and without comorbid SUD, receiving care at Florida-based Federally Qualified Health Centers (FQHC) of Health Choice Network (HCN).

Methods

A retrospective analysis was conducted using deidentified electronic health records of 37,452 patients with type 2 diabetes who received care at a HCN site in Florida between 2016 and 2019. A longitudinal logistic regression analysis examined the impact of SUD diagnosis on achievement of diabetes management [HbA1c < 7.0% (53 mmol/mol)] over time. A secondary analysis evaluated, within those with an SUD diagnosis, the likelihood of HbA1c control between those with and without SUD treatment.

Results

The longitudinal assessment of the relationship between SUD status and HbA1c control revealed that those with SUD (N = 6,878, 18.4%) were less likely to control HbA1c over time (OR = 0.56; 95% CI = 0.49-0.63). Among those with SUD, patients engaged in SUD treatment were more likely to control HbA1c (OR = 5.91; 95% CI = 5.05-6.91).

Discussion

Findings highlight that untreated SUD could adversely affect diabetes control and sheds light on the opportunity to enhance care delivery for patients with diabetes and co-occurring SUD.

The association between abused adults and substance abuse in Taiwan, 2000-2015

OBJECTIVE

To investigate whether adults suffering from violence were at risk of substance abuse and provides insight into the relationship between male and female abusers and substance abuse from 2000 to 2015 in Taiwan.

METHODS

This study used data on outpatient, emergency, and inpatient visits for 2 million people enrolled in universal health insurance from 2000 to 2015. ICD-9 diagnosis codes 995.8 (abused adult) and E960-E969 (homicide and injury purposely inflicted by other persons) were defined in this case study, analyzing first-time violence in adults aged 18-64 (study group). Non-abused patients (control group) were matched in a 1:4 ratio, and the paired variables were gender, age (± 1 year), pre-exposure Charlson Comorbidity Index, and year of medical treatment. SAS 9.4 and Cox regression were used for data analysis.

RESULTS

A total of 8,726 people suffered violence (control group: 34,904 people) over 15 years. The prevalence of substance abuse among victims of violence was 78.3/10⁴, 61.9/10⁴, and 51.5/10⁴ for tobacco use disorder, alcoholism, and alcohol abuse, respectively. The risk (adults, overall) of drug abuse, drug dependence, and alcoholism after exposure to violence (average 9 years) was 7.47, 7.15, and 6.86 times (p < 0.01), respectively, compared with those without violence. The risk (adults, males) of drug abuse, drug dependence, and alcohol abuse after exposure to violence (average 9 years) was 6.85, 6.27, and 6.07 times, respectively, higher than those without violence (p < 0.01). Risks of drug dependence, alcohol abuse and alcoholism (adults, females) after exposure to violence (average 9 years) were 14.92, 12.26, and 11.55 times, respectively, higher than non-abused ones (p < 0.01).

CONCLUSION

The risks of substance abuse, after adult violence, are higher than in those who have not suffered violent injuries.

Sex and diet-dependent gene alterations in human and rat brains with a history of nicotine exposure

Introduction

Chronic nicotine exposure induces changes in the expression of key regulatory genes associated with metabolic function and neuronal alterations in the brain. Many bioregulatory genes have been associated with exposure to nicotine, but the modulating effects of sex and diet on gene expression in nicotine-exposed brains have been largely unexplored. Both humans and rodents display motivation for nicotine use and the emergence of withdrawal symptoms during abstinence. Research comparing pre-clinical models with human subjects provides an important opportunity to understand common biomarkers of the harmful effects of nicotine as well as information that may help guide the development of more effective interventions for nicotine cessation.

Methods

Human postmortem dorsolateral prefrontal cortex (dLPFC) tissue BA9 was collected from female and male subjects, smokers and non-smokers (N = 12 per group). Rat frontal lobes were collected from female and male rats that received a regular diet (RD) or a high-fat diet (HFD) (N = 12 per group) for 14 days following implantation of a osmotic mini-pump (Alzet) that delivered nicotine continuously. Controls (control-s) received a sham surgical procedure. RNA was extracted from tissue from human and rat samples and reversed-transcribed to cDNA. Gene expression of CHRNA10 (Cholinergic receptor nicotinic alpha 10), CERKL (Ceramide Kinase-Like), SMYD1 (SET and MYD Domin Containing 1), and FA2H (Fatty Acid 2-Hydrolase) in humans was compared to rats in each subset of groups and quantified by qPCR methods. Additionally, protein expression of FA2H was analyzed by immunohistochemistry (IHC) in human dLPFC.

Results

Humans with a history of smoking displayed decreased CHRNA10 (p = 0.0005), CERKL (p ≤ 0.0001), and SMYD1 (p = 0.0005) expression and increased FA2H (p = 0.0097) expression compared to non-smokers (p < 0.05). Similar patterns of results were observed in nicotine exposed vs. control rats. Interestingly, sex-related differences in gene expression for CERKL and FA2H were observed. In addition, ANCOVA analysis showed a significant effect of nicotine in a sex-different manner, including an increase in CERKL in male and female rats with RD or HFD. In rats exposed to an HFD, FA2H gene expression was lower in nicotine-treated rats compared to RD rats treated with nicotine. Protein expression of FA2H (p = 0.001) by IHC was significantly higher in smokers compared to non-smokers.

Conclusion

These results suggest that a history of long-term nicotine exposure in humans alters the expression of sphingolipid metabolism-related (CERKL, SMYD1, and FA2H) and neuronal (CHRNA10) marker genes similarly as compared to rats. Sex- and diet-dependent differences appear in nicotine-exposed rats, critical in regulating sphingolipid metabolism and nicotinic acetylcholine receptors. This research enhances the construct validity of rat models of nicotine usage by showing a similar pattern of changes in gene expression in human subjects with a smoking history.

The effect of a real-world intervention for smoking cessation in Adults with and without comorbid psychiatric and substance use disorders: A one-year follow-up study

This study evaluated short-term abstinence and prolonged abstinence following a real-world intervention for smoking cessation in a sample of 1,213 adults with nicotine dependence only (ND), nicotine dependence and past history of another substance use disorder (ND-SUD), nicotine dependence and a non-substance use mental health disorder (ND-MD), or nicotine dependence and comorbid substance use disorder and mental health disorder (ND-SUMD). Participants received six sessions of group Cognitive Behavioral Therapy (CBT) and pharmacotherapy. Abstinence was assessed following completion of treatment and at 12-month follow-up. Logistic regression and survival analyses were performed. Participants who were lost to follow-up were included as censored and baseline differences were used as covariates in multivariate analyses. Rates of short-term abstinence and prolonged abstinence were significantly different between ND and ND-SUMD (20.9% versus 36.5%; 14.9% versus 22.4%, respectively). Among participants with follow-up, 37.7% were abstinent at 12-month. Diagnostic group was not associated with abstinence at 12-month follow-up after adjusting for nicotine dependence severity, which was associated with lower likelihood of abstinence (HR=1.11;95%CI:1.03-1.19). CBT plus pharmacotherapy had a positive effect on smoking cessation among the participants in this study. Special attention should be given to adults with more severe nicotine dependence and comorbid psychiatric and substance use disorders.

Alcohol-medication interactions: A systematic review and meta-analysis of placebo-controlled trials

Alcohol and other xenobiotics may limit the therapeutic effects of medications. We aimed at investigating alcohol-medication interactions (AMI) after the exclusion of confounding effects related to other xenobiotics. We performed a systematic review and meta-analysis of controlled studies comparing the effects induced by alcohol versus placebo on pharmacodynamic and/or pharmacokinetic parameters of approved medications. Certainty in the evidence of AMI was assessed when at least 3 independent studies and at least 200 participants were available. We included 107 articles (3097 participants): for diazepam, cannabis, opioids, and methylphenidate, we found significant AMI and enough data to assign the certainty of evidence. Alcohol consumption significantly increases the peak plasma concentration of diazepam (low certainty; almost 290 participants), cannabis (high certainty; almost 650 participants), opioids (low certainty; 560 participants), and methylphenidate (moderate certainty; 290 participants). For most medications, we found some AMI but not enough data to assign them the certainty grades; for some medications, we found no differences between alcohol and placebo in any outcomes evaluated. Our results add further evidence for interactions between alcohol and certain medications after the exclusion of confounding effects related to other xenobiotics. Physicians should advise patients who use these specific medications to avoid alcohol consumption. Further studies with appropriate control groups, enough female participants to investigate sex differences, and elderly population are needed to expand our knowledge in this field. Short phrases suitable for indexing terms.

Tobacco Use Predicts Treatment Dropout and Outcome in an Acute, Transdiagnostic Psychiatric Treatment Setting

Tobacco use is consistently associated with greater levels of depression and anxiety, broadly, and preliminary evidence suggests that current tobacco use is a significant predictor of dropout from psychiatric treatment. The current study extends past work to examine the impact of tobacco use on treatment dropout and outcomes in an acute psychiatric treatment setting. Upon intake to a partial hospitalization program (PHP), patients completed a battery of measures assessing sociodemographic characteristics, current tobacco use, depression and generalized anxiety, and substance use. Patients at the PHP also completed measures assessing levels of depression and generalized anxiety again upon discharge from the program. In line with hypotheses, current tobacco use was a significant predictor of dropout from treatment at the PHP. Importantly, this relationship remained significant when statistically controlling for demographic variables and psychiatric and substance use severity (such as number of previous inpatient psychiatric hospitalizations and degree of alcohol or drug problems). Results from the current study indicate that tobacco use is a significant risk factor for treatment dropout. Further research is needed to replicate these findings and to determine the mechanism underlying this link between tobacco use and treatment dropout for people receiving intensive psychiatric care.

Use of Cigarettes and E-Cigarettes/Vaping Among Transgender People: Results From the 2015 U.S. Transgender Survey

INTRODUCTION

This study examines the demographic characteristics, transgender-specific factors, and discrimination experiences associated with current cigarette smoking, e-cigarette use/vaping, and dual use in a large sample of transgender people.

METHODS

This was a secondary analysis of the 2015 U.S. Transgender Survey (n=27,715). Conducted in 2019, logistic regression models were used to estimate the AORs and 95% CIs of current smoking, e-cigarette use/vaping, and dual use among transgender people.

RESULTS

Overall, 23.6% of respondents used cigarettes, 9.3% used e-cigarettes/vaping products, and 5.2% reported dual use within the past 30 days. Visually nonconforming individuals had greater odds (cigarettes: AOR=1.49, 95% CI=1.35, 1.65; e-cigarettes/vaping: AOR=1.43, 95% CI=1.25, 1.65; dual use: AOR=1.81, 95% CI=1.52, 2.15) than visually conforming individuals. Transgender people who had disclosed their transgender identity to their social networks had greater odds of cigarette smoking (AOR=1.30, 95% CI=1.17, 1.45), e-cigarette use/vaping (AOR=1.30, 95% CI=1.12, 1.52), and dual use (AOR=1.95, 95% CI=1.61, 2.35) than individuals who were out to none or some people within their networks. Experiencing discrimination (i.e., unequal treatment, verbal harassment, or physical assault) significantly increased the odds for cigarette smoking, e-cigarette use/vaping, and dual use. Transgender people who experienced all 3 types of discrimination had 2 times greater odds of current cigarette smoking (AOR=2.06, 95% CI=1.79, 2.37) and dual use (AOR=2.17, 95% CI=1.73, 2.74) than those who had not experienced discrimination.

CONCLUSIONS

Discrimination, visual nonconformity, and being out as transgender increased the odds of cigarette smoking, e-cigarette use/vaping, and dual use. This study informs disease prevention efforts for transgender populations with increased risks for these health behaviors.

Effectiveness of a web platform on university students' motivation to quit smoking

Objective:

to know the dependence on nicotine and the motivation to quit smoking in Nursing and Physiotherapy students of a university in the South of Spain, and to evaluate the impact of an intervention based on the use of information technologies on the motivation to quit smoking.

Method:

a pilot study in two phases: the first being cross-sectional and the second, a before-and-after intervention. The motivation to quit smoking was assessed by means of the Richmond questionnaire, and the dependence on nicotine through the Fagerström questionnaire; additionally, an intervention was performed based on the use of a web platform to increase motivation to quit smoking. Descriptive and inferential statistics were applied.

Results:

the prevalence in the use of tobacco was 4.33% (n=29). 3.45% of the participants had a high level of dependence; and 6.90%, a high level of motivation. The level of motivation did not change after the intervention (p=0.10).

Conclusion:

most of the students have low levels of motivation to quit smoking and of physical dependence to nicotine. The level of motivation to quit smoking does not change after performing the intervention.

Abstinence and retention outcomes in a smoking cessation program among individuals with co-morbid substance use and mental disorders

Tobacco use is the leading cause of preventable death in the world. Although cigarette smoking prevalence has decreased, there are still disparities in morbidity and mortality experienced by individuals with substance use and/or mental disorders when compared to general population. The aim of this study was to compare treatment outcomes between three subgroups of smokers: individuals with substance use disorder (SUD-only), individuals with mental disorder without substance use disorders (MD-only), and individuals with co-morbid substance use and mental disorder (SUD + MD). Data of 498 smokers enrolled in a 6-week smoking cessation program in Brazil were analyzed. Sociodemographic, medical and tobacco use information were collected at baseline. Treatment included group cognitive behavioral therapy (CBT) and pharmacotherapy. The primary outcome was defined as "self-report 4-week quitter" (SR4WQ), a standardized measure to assess treatment success. Retention to treatment was also investigated. Associations between groups were analyzed using unadjusted and adjusted logistic regression models. The results showed that SUD + MD had worse outcomes when compared to the other two groups. After adjusting for level of smoking dependence and the use of medication, abstinence and retention to treatment of SUD-only became equivalent to SUD + MD. Because tobacco and other substance addictions share similar mechanisms, having history of SUD might impair successful results of conventional smoking programs. There is a need to further investigate specific variables associated with treatment success for a more resistant subgroup of individuals in mental health and perhaps to invest in more intensive actions, such as the use of combined pharmacotherapy and adapted CBT approaches.

Considering Drug-Associated Contexts in Substance Use Disorders and Treatment Development

Environmental contexts that are reliably associated with the use of pharmacologically active substances are hypothesized to contribute to substance use disorders. In this review, we provide an updated summary of parallel preclinical and human studies that support this hypothesis. Research conducted in rats shows that environmental contexts that are reliably paired with drug use can renew extinguished drug-seeking behavior and amplify responding elicited by discrete, drug-predictive cues. Akin to drug-associated contexts, interoceptive drug stimuli produced by the psychopharmacological effects of drugs can also influence learning and memory processes that play a role in substance use disorders. Findings from human laboratory studies show that drug-associated contexts, including social stimuli, can have profound effects on cue reactivity, drug use, and drug-related cognitive expectancies. This translationally relevant research supports the idea that treatments for substance use disorders could be improved by considering drug-associated contexts as a factor in treatment interventions. We conclude this review with ideas for how to integrate drug-associated contexts into treatment-oriented research based on 4 approaches: pharmacology, brain stimulation, mindfulness-based relapse prevention, and cognitive behavioral group therapy. Throughout, we focus on alcohol- and tobacco-related research, which are two of the most prevalent and commonly misused drugs worldwide for which there are known treatments.

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.

[Systematic analysis of the scientific literature on heated tobacco]

INTRODUCTION

The tobacco industry (TI) reports that heated tobacco reduces risk of tobacco use and will replace cigarettes. An analysis of the scientific literature was conducted in order to enlighten professionals and decision-makers.

METHOD

After a Medline query in February 2018, a systematic analysis was conducted.

RESULTS

Of the 100 papers published in 2008-2018, 75 have authors affiliated or linked to TI. Emissions contain gases, droplets and solid particles, so are smokes. The main products are: THS2.2 (Iqos®) which heats mini-cigarettes at 340°C, the THP1.0 (Glo®) which heats at 240°C sticks delivering about half as much nicotine, Ploom® which uses reconstituted tobacco microcapsules heated at 180°C. Under the experimental conditions, there is a reduction of toxic emissions and biological effects, but the expected risk reduction is not demonstrated. Symptoms related to passive smoking are described. The 4 epidemiological articles report that heated tobacco is used in 10 to 45% of cases by non-smokers and demonstrate the effectiveness of TI promotion campaigns. Thus, the THS2.2 is more a gateway to smoking (20%) than an exit door (11%); moreover, it is not expected risk reduction among the 69% who are mixed users.

CONCLUSIONS

While reducing emissions is documented, reducing the risk to the smoker who switches to heated-tobacco remains to be demonstrated. On the other hand, the worsening of the global tobacco risk related to the promotion of the products by the TI is anticipated, justifying that the authorities take the appropriate measures to control the promotion of heated tobacco.