Joanna M. Streck

Addiction Potential of Cigarettes With Reduced Nicotine Content in Populations With Psychiatric Disorders and Other Vulnerabilities to Tobacco Addiction.

Importance A national policy is under consideration to reduce the nicotine content of cigarettes to lower nicotine addiction potential in the United States. Objective To examine how smokers with psychiatric disorders and other vulnerabilities to tobacco addiction respond to cigarettes with reduced nicotine content. Design, Setting, and Participants A multisite, double-blind, within-participant assessment of acute response to research cigarettes with nicotine content ranging from levels below a hypothesized addiction threshold to those representative of commercial cigarettes (0.4, 2.3, 5.2, and 15.8 mg/g of tobacco) at 3 academic sites included 169 daily smokers from the following 3 vulnerable populations: individuals with affective disorders (n = 56) or opioid dependence (n = 60) and socioeconomically disadvantaged women (n = 53). Data were collected from March 23, 2015, through April 25, 2016. Interventions After a brief smoking abstinence, participants were exposed to the cigarettes with varying nicotine doses across fourteen 2- to 4-hour outpatient sessions. Main Outcomes and Measures Addiction potential of the cigarettes was assessed using concurrent choice testing, the Cigarette Purchase Task (CPT), and validated measures of subjective effects, such as the Minnesota Nicotine Withdrawal Scale. Results Among the 169 daily smokers included in the analysis (120 women [71.0%] and 49 men [29.0%]; mean [SD] age, 35.6 [11.4] years), reducing the nicotine content of cigarettes decreased the relative reinforcing effects of smoking in all 3 populations. Across populations, the 0.4-mg/g dose was chosen significantly less than the 15.8-mg/g dose in concurrent choice testing (mean [SEM] 30% [0.04%] vs 70% [0.04%]; Cohen d = 0.40; P < .001) and generated lower demand in the CPT (&agr; = .027 [95% CI, 0.023-0.031] vs &agr; = .019 [95% CI, 0.016-0.022]; Cohen d = 1.17; P < .001). Preference for higher over lower nicotine content cigarettes could be reversed by increasing the response cost necessary to obtain the higher dose (mean [SEM], 61% [0.02%] vs 39% [0.02%]; Cohen d = 0.40; P < .001). All doses reduced Minnesota Nicotine Withdrawal Scale total scores (range of mean decreases, 0.10-0.50; Cohen d range, 0.21-1.05; P < .001 for all), although duration of withdrawal symptoms was greater at higher doses (&eegr;2 = 0.008; dose-by-time interaction, P = .002). Conclusions and Relevance Reducing the nicotine content of cigarettes may decrease their addiction potential in populations that are highly vulnerable to tobacco addiction. Smokers with psychiatric conditions and socioeconomic disadvantage are more addicted and less likely to quit and experience greater adverse health impacts. Policies to reduce these disparities are needed; reducing the nicotine content in cigarettes should be a policy focus.

A Post-Discharge Smoking-Cessation Intervention for Hospital Patients: Helping Hand 2 Randomized Clinical Trial.

INTRODUCTION Hospitalization provides an opportunity for smokers to quit, but tobacco-cessation interventions started in hospital must continue after discharge to be effective. This study aimed to improve the scalability of a proven effective post-discharge intervention by incorporating referral to a telephone quitline, a nationally available cessation resource. STUDY DESIGN A three-site RCT compared Sustained Care, a post-discharge tobacco-cessation intervention, with Standard Care among hospitalized adult smokers who wanted to quit smoking and received in-hospital tobacco-cessation counseling. SETTING/PARTICIPANTS A total of 1,357 daily smokers admitted to three hospitals were enrolled from December 2012 to July 2014. INTERVENTION Sustained Care started at discharge and included automated interactive voice response telephone calls and the patients choice of cessation medication for 3 months. Each automated call advised cessation, supported medication adherence, and triaged smokers seeking additional counseling or medication support directly to a telephone quitline. Standard Care provided only medication and counseling recommendations at discharge. MAIN OUTCOME MEASURES Biochemically confirmed past 7-day tobacco abstinence 6 months after discharge (primary outcome) and self-reported tobacco abstinence and tobacco-cessation treatment use at 1, 3, and 6 months and overall (0-6 months). Analyses were done in 2015-2016. RESULTS Smokers offered Sustained Care (n=680), versus those offered Standard Care (n=677), did not have greater biochemically confirmed abstinence at 6 months (17% vs 16%, p=0.58). However, the Sustained Care group reported more tobacco-cessation counseling and medication use at each follow-up and higher rates of self-reported past 7-day tobacco abstinence at 1 month (43% vs 32%, p<0.0001) and 3 months (37% vs 30%, p=0.008). At 6 months, the difference narrowed (31% vs 27%, p=0.09). Overall, the intervention increased self-reported 7-day abstinence over the 6-month follow-up (relative risk, 1.25; 95% CI=1.10, 1.40; p=0.0006). CONCLUSIONS A 3-month post-discharge smoking-cessation intervention for hospitalized smokers who wanted to quit did not increase confirmed tobacco abstinence at 6 months but did increase self-reported abstinence during the treatment period (3 months). Real-time linkage of interactive voice response calls to a quitline, done in this trial to increase scalability of a previously proven cessation intervention, demonstrated short-term promise but did not sustain long-term intervention effectiveness. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT01714323.

Pain experiences among a population-based cohort of current, former, and never regular smokers with lung and colorectal cancer

Smoking and pain are prevalent and comorbid among patients with cancer. Limited work has compared pain experiences among current, former, and never (regular) smokers with lung and colorectal cancer.

Interactive Voice Response Calls to Promote Smoking Cessation after Hospital Discharge: Pooled Analysis of Two Randomized Clinical Trials

BackgroundHospitalization offers smokers an opportunity to quit smoking. Starting cessation treatment in hospital is effective, but sustaining treatment after discharge is a challenge. Automated telephone calls with interactive voice response (IVR) technology could support treatment continuance after discharge.ObjectiveTo assess smokers’ use of and satisfaction with an IVR-facilitated intervention and to test the relationship between intervention dose and smoking cessation.DesignAnalysis of pooled quantitative and qualitative data from the intervention groups of two similar randomized controlled trials with 6-month follow-up.ParticipantsA total of 878 smokers admitted to three hospitals. All received cessation counseling in hospital and planned to stop smoking after discharge.InterventionAfter discharge, participants received free cessation medication and five automated IVR calls over 3 months. Calls delivered messages promoting smoking cessation and medication adherence, offered medication refills, and triaged smokers to additional telephone counseling.Main MeasuresNumber of IVR calls answered, patient satisfaction, biochemically validated tobacco abstinence 6 months after discharge.Key ResultsParticipants answered a median of three of five IVR calls; 70% rated the calls as helpful, citing the social support, access to counseling and medication, and reminders to quit as positive factors. Older smokers (OR 1.36, 95% CI 1.20–1.54 per decade) and smokers hospitalized for a smoking-related disease (OR 1.65, 95% CI 1.21–2.23) completed more calls. Smokers who completed more calls had higher quit rates at 6-month follow-up (OR 1.49, 95% CI 1.30–1.70, for each additional call) after multivariable adjustment for age, sex, education, discharge diagnosis, nicotine dependence, duration of medication use, and perceived importance of and confidence in quitting.ConclusionsAutomated IVR calls to support smoking cessation after hospital discharge were viewed favorably by patients. Higher IVR utilization was associated with higher odds of tobacco abstinence at 6-month follow-up. IVR technology offers health care systems a potentially scalable means of sustaining tobacco cessation interventions after hospital discharge.Clinical Trial Registration: ClinicalTrials.gov Identifiers NCT01177176, NCT01714323.

Tobacco Withdrawal Among Opioid-Dependent Smokers.

Prevalence of cigarette smoking among opioid-dependent individuals is 6-fold that of the general U.S. adult population and their quit rates are notoriously poor. One possible reason for the modest cessation outcomes in opioid-dependent smokers may be that they experience more severe tobacco withdrawal upon quitting. In this secondary analysis, we evaluated tobacco withdrawal in opioid-dependent (OD) smokers versus smokers without co-occurring substance use disorders (SUDs). Participants were 47 methadone- or buprenorphine-maintained smokers and 25 non-SUD smokers who completed 1 of several 2-week studies involving daily visits for biochemical monitoring, delivery of financial incentives contingent on smoking abstinence, and assessment of withdrawal via the Minnesota Nicotine Withdrawal Scale (MNWS). Prior to quitting smoking, OD smokers presented with higher baseline withdrawal scores than non-SUD smokers (1.7 ± 0.2 vs. 0.7 ± 0.2, respectively; F[1, 63] = 7.31, p < .001). Withdrawal scores in both groups decreased over the subsequent 2-week period with no group differences, F(1, 910) = 0.50, p = .48. A similar pattern was observed on craving (i.e., Desire to Smoke item of MNWS), although the trajectory of decrease over time on this item was also moderated by gender. Overall, there was no difference in withdrawal during biochemically verified smoking abstinence between OD and non-SUD smokers, suggesting that elevated withdrawal severity following quitting may not be a major factor contributing to the poor cessation outcomes consistently observed among OD smokers. Further scientific efforts are needed to improve our understanding of the high smoking rates and modest cessation outcomes in this challenging population.

Examining the effects of illicit drug use on tobacco cessation outcomes in the Helping HAND 2 randomized controlled trial

BACKGROUND Individuals with substance use disorders (SUD) smoke at higher rates and have higher tobacco-related mortality than the general population. Despite having an interest in smoking cessation, smokers with SUDs may have greater difficulty quitting. METHODS Analysis of data from a RCT testing a post-discharge smoking cessation intervention for hospitalized cigarette smokers interested in quitting. Past 7day tobacco abstinence was self-reported at 1, 3, and 6 months and biochemically confirmed at 6 months post-discharge. Other drug use was assessed at baseline by self-report or a past-year discharge diagnosis of SUD. Multiple logistic regression compared tobacco cessation outcomes among participants with no recreational drug use (NDU; n=942) vs. marijuana only (MU; n=284) vs. other illicit drugs (IDU; n=131). RESULTS Groups differed at baseline on age, gender, race, education, other household smokers, alcohol use, and anxiety/depression (all p<0.05). Confirmed 6-month tobacco abstinence was lower among IDU than NDU participants (9% vs 18%, p=0.01; AOR=0.43, CI: 0.22-0.84) after adjustment for study arm, smoking characteristics, demographics, quality of life, alcohol use and MU. Confirmed 6-month abstinence did not differ significantly between MU vs. NDU participants (14% vs 18%, p>0.05; AOR=0.77, CI:0.51-1.14). Counseling and medication use did not differ significantly among groups at any follow-up. CONCLUSIONS Hospitalized smokers who planned to stop smoking after discharge and used cessation assistance were less successful if they had used illicit drugs in the past year, but not if they had only used marijuana. More intensive or tailored interventions may be required to address smoking in this population.

Integrating tobacco treatment into thoracic oncology settings: Lessons learned.

Clinical practice guidelines recommend tobacco treatment for all cancer patients. However, little is known about how to integrate tobacco treatment into cancer care. The results of our pilot study of an evidence-based tobacco treatment integrated into a thoracic oncology clinic demonstrated good feasibility and efficacy, providing an opportunity to inform future tobacco treatment integration efforts. Here, we describe the process of intervention development, clinic integration, patient identification, and patient enrollment. We report on the intervention content and delivery, patterns of quitting for participants in the tobacco treatment group, and changes in smoking-related psychosocial variables. Clinical implications and suggestions for future research are discussed.

Nondaily Cigarette Smoking Is Increasing Among People With Common Mental Health and Substance Use Problems in the United States: Data From Representative Samples of US Adults, 2005–2014

OBJECTIVE The current study estimated trends in the prevalence of daily and nondaily cigarette smoking among United States adults with any common mental health or substance use problem (MHSUP), compared to US adults without MHSUP, from 2005 to 2014. METHODS Data were drawn from the years 2005 to 2014 from the public use data files for the annually conducted National Survey on Drug Use and Health. Linear time trends of current, daily, and nondaily cigarette smoking among adults (age 18 years and older) with and without MHSUP were assessed using logistic regression models with continuous year as the predictor. RESULTS In 2014, the prevalence of current cigarette smoking among those with MHSUP was more than twice that of those without MHSUP. Nondaily cigarette smoking increased significantly from 2005 to 2014 among those with MHSUP (P = .001) in contrast to a decline in nondaily cigarette smoking among those without MHSUP (P < .01). The rate of change differed significantly (P < .001). Daily cigarette smoking declined significantly from 2005 to 2014 among those with and without MHSUP (P values < .001). CONCLUSIONS The prevalence of nondaily cigarette smoking is increasing among US adults with common mental health and substance use problems, while it continues to decline among those without these vulnerabilities. The disparity in prevalence of daily cigarette smoking between those with and without MHSUP remains substantial. Conclusions about how to reach the tobacco endgame may need to be reconsidered to develop targeted tobacco control public health approaches that address common MHSUP.

Response to reduced nicotine content cigarettes among smokers with chronic health conditions

Individuals with chronic health conditions persist in smoking despite the presence of smoking-related illness. The aim of this study was to examine whether chronic health conditions moderate response to reduced nicotine content cigarettes (0.4, 2.4, 5.2, 15.8 mg/g of tobacco). This is a secondary analysis of a controlled clinical laboratory study that examined the acute effects of cigarettes varying in nicotine content among individuals especially vulnerable to smoking and tobacco dependence. Participants in the present study were categorized as having 0, 1–2, or ≥3 smoking-related chronic health conditions (i.e., chronic condition severity, CCS). Repeated-measures analysis of variance was used to examine whether CCS moderated response to cigarettes across measures of addiction potential (i.e., concurrent choice testing between nicotine dose pairs, Cigarette Purchase Task (CPT) performance, positive subjective effects), tobacco withdrawal, cigarette craving, and smoking topography. No main effects of CCS or interactions of CCS and nicotine dose were observed for concurrent choice testing, positive subjective effects, tobacco withdrawal, or smoking topography. Main effects of CCS were noted on the CPT with greater CCS being associated with less persistent demand. There was an interaction of CCS and nicotine dose on Factor 1 of the Questionnaire on Smoking Urges with the effects of dose significant only among those with 1–2 chronic conditions. Overall, we see minimal evidence that chronic condition severity affects response to reduced nicotine content cigarettes. A policy that reduces the nicotine content of cigarettes to minimally addictive levels may benefit smokers already experiencing smoking-related chronic conditions.

Promoting smoking abstinence among patients with chronic obstructive pulmonary disease: Initial feasibility

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the U.S., with the majority of COPD deaths attributable to cigarette smoking. Despite this, individuals with COPD have a higher prevalence of smoking, poorer quit rates, and higher relapse rates compared to smokers without a COPD diagnosis. We examined the feasibility of an incentives-based intervention for producing an initial period of biochemically-verified smoking abstinence among daily smokers with COPD. Participants were randomly assigned to a Contingent (n = 13) or Noncontingent (n = 16) incentives condition and visited the clinic for 14 consecutive days. Contingent participants earned vouchers with monetary value contingent on breath carbon monoxide (CO) levels during Study Days 1–5 and urinary cotinine during Days 6–14. Voucher earnings began at