Marina Unrod

Expectancies for Cigarettes, E-Cigarettes, and Nicotine Replacement Therapies Among E-Cigarette Users (aka Vapers)

INTRODUCTION Use of e-cigarettes has been increasing exponentially, with the primary motivation reported as smoking cessation. To understand why smokers choose e-cigarettes as an alternative to cigarettes, as well as to US Food and Drug Administration (FDA)--approved nicotine replacement therapies (NRT), we compared outcome expectancies (beliefs about the results of drug use) for the three nicotine delivery systems among vapers, i.e., e-cigarette users, who were former smokers. METHODS Vapers (N = 1,434) completed an online survey assessing 14 expectancy domains as well as perceived cost and convenience. We focused on comparisons between e-cigarettes and cigarettes to determine the attraction of e-cigarettes as a smoking alternative and between e-cigarettes and NRT to determine perceived advantages of e-cigarettes over FDA-approved pharmacotherapy. RESULTS Participants believed that e-cigarettes, in comparison to conventional cigarettes, had fewer health risks; caused less craving, withdrawal, addiction, and negative physical feelings; tasted better; and were more satisfying. In contrast, conventional cigarettes were perceived as better than e-cigarettes for reducing negative affect, controlling weight, providing stimulation, and reducing stress. E-cigarettes, compared to NRT, were perceived to be less risky, cost less, cause fewer negative physical feelings, taste better, provide more satisfaction, and be better at reducing craving, negative affect, and stress. Moderator analyses indicated history with ad libitum forms of NRT was associated with less positive NRT expectancies. CONCLUSIONS The degree to which expectancies for e-cigarettes differed from expectancies for either tobacco cigarettes or NRT offers insight into the motivation of e-cigarette users and provides guidance for public health and clinical interventions to encourage smoking-related behavior change.

Gender differences in use and expectancies of E-cigarettes: Online survey results

INTRODUCTION Given the rapid increase in e-cigarette use, it is important to understand factors that may contribute to their initiation and maintenance. Because gender differences in tobacco use, product preferences, and expectancies are well established, similar gender differences may exist with e-cigarettes. The aim of this study was to identify gender differences among e-cigarette users in patterns of use, reasons for initiation and maintenance, and outcome expectancies regarding e-cigarettes. METHODS Participants (N=1815) completed an online survey from August through November, 2013. We assessed sociodemographics, smoking and e-cigarette history and use, and expectancies about e-cigarettes. RESULTS We found gender differences in type of e-cigarette used, flavors used, nicotine dosage, source of information about e-cigarettes, place of purchase, and use of e-cigarettes where smoking is prohibited. In addition, males were more likely to report initiating e-cigarette use to quit smoking due to health concerns, whereas females were more likely to report initiation based on recommendations from family and friends. Males reported higher attributions for maintenance of e-cigarette use related to positive reinforcement (enjoyment), whereas females reported higher negative reinforcement attributions (stress reduction or mood management). Males reported more positive expectancies about e-cigarettes, including taste, social facilitation, and energy, whereas women rated e-cigarettes higher for weight control. Males also reported greater addiction-related e-cigarette expectancy than females. CONCLUSIONS Many of the gender differences with e-cigarettes parallel those previously found with traditional cigarette smoking. Although effect sizes associated with these differences were small, the results may help advance research and intervention development with respect to e-cigarette initiation, maintenance and cessation.

Decline in cue-provoked craving during cue exposure therapy for smoking cessation.

INTRODUCTION Based on the principles of Pavlovian learning and extinction, cue exposure therapy (CET) involves repeated exposure to substance-associated cues to extinguish conditioned cravings and reduce the likelihood of relapse. The efficacy of CET is predicated on successful extinction, yet the process of extinction in CET trials has rarely been demonstrated. This study explored the extinction process using a cue-reactivity paradigm in smokers undergoing multiple CET sessions as part of a comprehensive smoking cessation treatment. METHODS The sample comprised 76 moderately dependent, treatment-seeking smokers who completed at least 4 CET sessions and 6 counseling sessions. The CET and counseling sessions were scheduled twice weekly, and participants began using transdermal nicotine replacement therapy on their quit day, which occurred prior to initiation of CET. Each CET session consisted of presentation of 140 images on a computer screen, with self-reported craving as the primary measure of cue reactivity. RESULTS Mixed-model analyses revealed a progressive decline in cue-provoked craving both within and across 6 sessions of CET. Moderator analyses showed that the decline in craving was greatest among those who displayed initial cue reactivity. CONCLUSIONS These data are consistent with the premise that CET can produce extinction of laboratory-based cue-provoked smoking cravings and highlight important individual differences that may influence extinction. Implications for conducting cue exposure research and interventions are discussed.

E-cigarette use in adults: a qualitative study of users' perceptions and future use intentions.

Abstract Background There has been an exponential increase in the prevalence of e-cigarette use, particularly among youth. However, adult use is also rising, and there have been relatively few qualitative studies with adult users to understand their reasons for use and future use intentions. Such information is needed to inform both prevention and cessation approaches. Method Thirty-one e-cigarette users participated in one of several focus groups assessing the appeal of e-cigarettes as well as comparisons to combustible cigarettes and approved smoking cessation aids. We also obtained perspectives on future use intentions and interest in e-cigarette cessation interventions. Verbatim transcripts were analyzed using the constant comparative method. Results Participants reported several aspects of e-cigarette appeal as compared to approved cessation treatment options. These included similarities to combustible cigarettes, fewer side effects, and control of e-cigarettes to suit personal preferences. Participants were split on whether they preferred flavors that mimicked or contrasted with their combustible cigarettes (i.e. tobacco vs. alternative flavors, such as candy). Some participants who were unmotivated to quit smoking reported an unanticipated disinterest in continuing use of combustible cigarettes shortly after initiating e-cigarettes. Despite strong interest in reducing nicotine dosage, the majority did not intend to fully discontinue e-cigarettes. Conclusions Understanding e-cigarette users’ perspectives can inform policy and treatment development. Regulatory and policy initiatives will need to balance the appealing characteristics of e-cigarettes with the potential for negative public health outcomes.

Outdoor smoking ban at a cancer center: attitudes and smoking behavior among employees and patients.

Policies restricting indoor worksite tobacco use began being implemented more than a decade ago. More recently, the scope of these policies has been expanding to outdoors, with hospitals leading the trend in restricting smoking throughout their grounds. However, research on the effects such bans have on employees is scarce. The purpose of the current study was to examine the impact of a campus-wide smoking ban on employees and patients at a cancer center. Employees completed anonymous questionnaires during the months before (n = 607; 12% smokers) and 3 months after the ban implementation (n = 511; 10% smokers). Patients (n = 278; 23% smokers) completed an anonymous questionnaire preban. Results showed that 86% of nonsmokers, 20% of employees who smoke, and 57% of patients who smoke supported the ban. More than 70% of smokers were planning or thinking about quitting at both time points and nearly one-third were interested in cessation services following the ban. Before the ban, 32% expected the ban to have a negative effect on job performance and 41% thought their smoking before and after work would increase. Postban, 22% reported a negative impact on job performance, 35% increased smoking before and after work, and 7% quit. Overall, these data revealed an overwhelming support for an outdoor smoking ban by nonsmoker employees and patients. Although a majority of employee smokers opposed the ban, a significant proportion was interested in cessation. Compared with preban expectations, a lower proportion experienced negative effects postban. Findings suggest a need for worksite cessation programs to capitalize on the window of opportunity created by tobacco bans, while also addressing concerns about effects on work performance.

Extended Self-Help for Smoking Cessation

INTRODUCTION Far too few smokers receive recommended interventions at their healthcare visits, highlighting the importance of identifying effective, low-cost smoking interventions that can be readily delivered. Self-help interventions (e.g., written materials) would meet this need, but they have shown low efficacy. The purpose of this RCT was to determine the efficacy of a self-help intervention with increased duration and intensity. DESIGN Randomized parallel trial design involving enrollment between April 2010 and August 2011 with follow-up data for 24 months. SETTING/PARTICIPANTS U.S. national sample of daily smokers (N=1,874). INTERVENTION Participants were randomized to one of three arms of a parallel trial design: Traditional Self-Help (TSH, n=638), Standard Repeated Mailings (SRM, n=614), or Intensive Repeated Mailings (IRM, n=622). TSH received an existing self-help booklet for quitting smoking. SRM received eight different cessation booklets mailed over a 12-month period. IRM received monthly mailings of ten booklets and additional material designed to enhance social support over 18 months. MAIN OUTCOME MEASURES The primary outcome was 7-day point-prevalence abstinence collected at 6, 12, 18, and 24 months. RESULTS Data were analyzed between 2013 and 2015. A dose-response effect was found across all four follow-up points. For example, by 24 months, IRM produced the highest abstinence rate (30.0%), followed by SRM (24.4%) and TSH (18.9%). The difference in 24-month abstinence rates between IRM and TSH was 11.0% (95% CI=5.7%, 16.3%). Cost analyses indicated that, compared with TSH, the incremental cost per quitter who received SRM and IRM was

Perceived Medication Assignment during a Placebo-Controlled Laboratory Study of Varenicline: Temporal Associations of Treatment Expectancies with Smoking-Related Outcomes

560 and

Relapse-Prevention Booklets as an Adjunct to a Tobacco Quitline: A Randomized Controlled Effectiveness Trial

361, respectively. CONCLUSIONS Self-help interventions with increased intensity and duration resulted in significantly improved abstinence rates that extended 6 months beyond the end of the intervention. Despite the greater intensity, the interventions were highly cost effective, suggesting that widespread dissemination in healthcare settings could greatly enhance quitting. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT01352195.

Facilitated Extinction Training to Improve Pharmacotherapy for Smoking Cessation: A Pilot Feasibility Trial

RationaleExpectancies regarding treatment assignment may influence outcomes in placebo-controlled trials above and beyond actual treatment assignment. For smoking pharmacotherapies, guessing enrollment in the active medication treatment is associated with higher abstinence rates. However, placebo-controlled trials of smoking pharmacotherapies rarely assess perceived treatment assignment and those that do only collect this information after reaching full dosage.ObjectivesTo determine the temporal relationship between treatment expectancies and smoking-related variables, we assessed the impact of treatment guess during a placebo-controlled laboratory study of varenicline on measures of craving, smoking reward, and smoking reinforcement. We hypothesized that treatment guess at mid-titration would influence smoking-related measures at full dosage, above and beyond actual medication effects. We also explored factors related to guess stability and differences in blind fidelity between mid-drug titration and full dosage.MethodsEighty-eight participants completed laboratory assessments at baseline, mid-titration, and full dosage that involved self-report and behavioral measures of tonic craving, cue-provoked craving, smoking reward, and smoking reinforcement. Participants guessed treatment assignment at mid-titration and full dosage.ResultsGeneralized linear models confirmed that, beyond actual treatment assignment, treatment guess improved model fit for both self-report and behavioral smoking-related measures. Further, accuracy of treatment guess improved from titration to full dosage, and specific demographic factors (e.g., gender, race) were associated with type of treatment guess and guess stability across time.ConclusionsThese results reinforce the importance of assessing perceived treatment assignment repeatedly during placebo-controlled trials and suggest that treatment expectancies during titration can affect outcomes once full dosage has been reached.

A randomized clinical trial of self-help intervention for smoking cessation: Research design, interventions, and baseline data

INTRODUCTION Relapse prevention (RP) remains a major challenge to smoking cessation. Previous research found that a set of self-help RP booklets significantly reduced smoking relapse. This study tested the effectiveness of RP booklets when added to the existing services of a telephone quitline. METHODS Quitline callers (N = 3458) were enrolled after their 2-week quitline follow-up call and randomized to one of three interventions: (1) Usual Care: standard intervention provided by the quitline, including brief counseling and nicotine replacement therapy; (2) Repeated Mailings (RM): eight Forever Free RP booklets sent to participants over 12 months; and (3) Massed Mailings: all eight Forever Free RP booklets sent upon enrollment. Follow-ups were conducted at 6-month intervals, through 24 months. The primary outcome measure was 7-day-point-prevalence-abstinence. RESULTS Overall abstinence rates were 61.0% at baseline, and 41.9%, 42.7%, 44.0%, and 45.9% at the 6-, 12-, 18- and 24-month follow-ups, respectively. Although RM produced higher abstinence rates, the differences did not reach significance for the full sample. Post-hoc analyses of at-risk subgroups revealed that among participants with high nicotine dependence (n = 1593), the addition of RM materials increased the abstinence rate at 12 months (42.2% vs. 35.2%; OR = 1.38; 95% CI = 1.03% to 1.85%; P = .031) and 24 months (45% vs. 38.8%; OR = 1.31; 95% CI = 1.01% to 1.73%; P = .046). CONCLUSIONS Sending self-help RP materials to all quitline callers appears to provide little benefit to deterring relapse. However, selectively sending RP booklets to callers explicitly seeking assistance for RP and those identified as highly dependent on nicotine might still prove to be worthwhile.