Smoking Cessation Outcomes and Predictors Among Individuals With Co-occurring Substance Use and/or Psychiatric Disorders

Objective: Individuals with substance use and psychiatric disorders have a high prevalence of tobacco use disorders and are disproportionately affected by tobacco-related morbidity and mortality. However, it is unclear how having co-occurring disorders affects tobacco cessation. Our aim was to examine smoking cessation outcomes and relevant predictors of smoking cessation among smokers with substance use and/or psychiatric disorders. Methods: Data from medical records of 674 participants in a tobacco treatment program within mental health and addictions services in Vancouver, Canada, were analyzed. The 26-week treatment program included an 8-week structured behavioral counseling group, an 18-week support group, and 26 weeks of no-cost pharmacotherapy. Information on demographics, tobacco use and history, type of pharmacotherapy received, nicotine dependence, importance of and confidence in quitting smoking, expired carbon monoxide level, substance use and psychiatric disorder history, and total program visits were gathered. Results: Approximately 67% (n = 449) of participants had co-occurring substance use and psychiatric disorders, while 20% (n = 136) had substance use disorder only, 10% (n = 67) had psychiatric disorder only, and 3% (n = 22) had tobacco dependence only. Rates of tobacco cessation (i.e., 7-day point prevalence of abstinence verified by expired carbon monoxide of ≤8 ppm) by group in the 522 people who completed treatment were as follows: 38.2% for those with co-occurring disorders, 47.1% for those with tobacco dependence only, 47.1% for those with substance use disorder only, and 41.8% for those with psychiatric disorder only. Length of treatment was a significant predictor of smoking cessation for those with co-occurring disorders and substance use disorder only. In the final stratified multivariate analysis, for individuals with co-occurring disorders, having an opiate use disorder (as compared to an alcohol use disorder) and higher nicotine dependence scores at baseline were predictive of poor cessation outcomes, while greater length of treatment was predictive of successful smoking cessation. Conclusions: Tobacco cessation treatment for individuals with co-occurring substance use and psychiatric disorders is likely to be as effective as for smokers with either disorder alone. Treatment duration predicts success among these smokers so strategies to enhance engagement and retention are needed.     

Impact of E-cigarettes on Smoking and Related Outcomes in Veteran Smokers With Psychiatric Comorbidity

Objective: Compared to the general U.S. population, smokers with comorbid psychiatric and/or substance use disorders have lower quit rates after evidence-based treatments and disproportionately high smoking-related deaths. Improved modalities for reducing tobacco-related harm in this subpopulation are needed. Because electronic cigarettes (e-cigarettes) can now deliver physiologically relevant levels of nicotine to consumers, they represent an additional nicotine delivery system that could be used in cessation interventions. While current data suggest that the use of e-cigarettes by smokers promotes a reduction in combustible cigarette use, smoking quit rates through use of e-cigarettes appears to be low. The goal of this study was to examine impact of e-cigarette use on combustible tobacco use as well as on the readiness to quit smoking and changes in nicotine dependence in a multimorbid population. Methods: We conducted a 4-week, open-label study in 43 military veteran smokers who had no immediate intention to stop smoking and were currently receiving psychiatric services from the Department of Veterans Affairs health care system. Participants were provided with a study e-cigarette they could use ad libitum along with other tobacco products and were encouraged to attend weekly laboratory visits and a one-month follow-up visit. Main outcome measures were number of cigarettes smoked per day (CPD), the frequency of e-cigarette use, the amount of money spent on combustible cigarettes (U.S. dollars/week), alveolar carbon monoxide (CO) levels, and urine cotinine levels. Results: Mean e-cigarette use was 5.7 days per week and only 9% of participants used the e-cigarette for fewer than 4 days per week. Significant reductions in breath CO (9.3 ppm to 7.3 ppm, p < .02) and CPD (from 16.6 to 5.7, p < .001) were observed across study weeks, and no serious adverse events were reported. Three participants (10% of completers) reported smoking cessation that was corroborated biochemically. At one-month follow-up, motivation to quit smoking remained significantly higher and the level of nicotine dependence was significantly lower than at baseline. Conclusions: E-cigarettes are acceptable to smokers with psychiatric comorbidities, as indicated by sustained and frequent e-cigarette use by 90% of participants, and may promote reduction and/or cessation of combustible cigarette use. E-cigarettes appear to be a viable harm reduction modality in smokers with psychiatric comorbidities.     

Characteristics associated with smoking in a Hispanic college student sample

This study examined the smoking related behaviors of Hispanic young adult college students as part of a larger study that assessed characteristics of Hispanic smokers in a metropolitan area on the U.S./México border. One hundred seventy-four English-speaking Hispanic college students completed questionnaires that assessed tobacco use, drug/alcohol use, body mass index, weight concerns, acculturation, depressive symptoms, and expired carbon monoxide level. Of the 74 smoking participants (42.5% of the sample), 77% reported light or intermittent smoking. Univariate analyses and a backward elimination logistic regression model were used to compare smokers' and nonsmokers' characteristics. Significant univariate differences between smokers and nonsmokers were higher reported weekly alcohol use and ever use of marijuana. Logistic regression findings indicated smokers reported heightened odds of being younger, lower acculturation, ever use of drugs, and weekly drinking. These results suggest a drug and alcohol use component is important to cessation interventions targeted toward Hispanic college student smokers.     

Smoking, nicotine dependence and psychiatric comorbidity--a population-based study including smoking cessation after three years

BACKGROUND: Evidence suggests that nicotine-dependent smokers are at increased risk for psychiatric comorbidity but general population data that included the number of nicotine dependence and withdrawal symptoms according to DSM-IV, the Fagerstrom Test for Nicotine Dependence (FTND), somatoform disorders and the number of psychiatric diagnoses are rare. The goal of the present study was to analyse relationships of smoking and nicotine dependence with psychiatric disease and whether psychiatric disease predicts the sustaining of smoking after three years. METHODS: Cohort study with a random adult population sample in a northern German region (N = 4075) including a baseline measurement of ever daily smokers aged 18-64 (n = 2458), a first follow-up of the current smokers at baseline (n = 1552) after 30 months and a second follow-up after 36 months. Measures included DSM-IV diagnoses by the Composite International Diagnostic Interview, FTND, smoking cessation by interview. RESULTS: Current daily smokers showed higher odds of a substance use disorder other than nicotine dependence compared with never smokers (odds ratio, OR, 4.6; confidence interval, CI, 2.9-7.2), affective (OR 1.8; CI 1.4-2.5), anxiety (OR 1.6; CI 1.2-2.0) or somatoform disorder (OR 1.4; CI 1.0-1.8). DSM-IV nicotine dependence and the FTND were positively related with the number of psychiatric diagnoses. Psychiatric comorbidity did not predict the maintenance of smoking or quitting. CONCLUSIONS: Findings of increased rates of mental disorders among smokers and nicotine-dependent smokers in the adult general population are supported by this study. The number of nicotine dependence and withdrawal symptoms are related to mental disorders. In addition, somatoform disorders show relationships with smoking similar to relationships with depressive or anxiety disorders. The intention to stop smoking should be proactively supported among these comorbid patients.     

Smoking, drugs, and other behavioral health problems among multiethnic adolescents in the NHSDA

Data from the NHSDA (2000) which contained screening measures for assessing risk for DSM-IV psychiatric disorders, were used to estimate smoking prevalence and its association with these disorders, among European American, Hispanic, and African American adolescents. Prevalence estimates, odds ratios, and hazard models were used to compare ethnic subgroups. European American and Hispanic adolescents born in the U.S. had a higher prevalence of smoking and DSM-IV tobacco dependence, and girls were higher than boys. Lifetime smokers had statistically significant odds ratios for anxiety, affective, substance use, and any behavior disorder, while Current smokers had a similar risk pattern except anxiety disorder. The increased risk for substance use disorder among smokers was notably higher. A hazard analysis showed that early onset of smoking (before 12 years) was related to earlier illicit drug use initiation as contrasted with later onset (12 years +), and non-smoking sharply reduced risk and delayed initiation into drug use. African American and Hispanic immigrants had lower risk of smoking initiation and tobacco dependence, however, ethnic group adolescents who initiated smoking shared increased risk of addictive and non-addictive disorders.     

Development of a screening questionnaire for tobacco/nicotine dependence according to ICD-10, DSM-III-R, and DSM-IV.

A 10-item questionnaire (the Tobacco Dependence Screener; TDS) for screening of tobacco/nicotine dependence according to ICD-10, DSM-III-R, and DSM-IV was newly developed. The reliability and validity were assessed in three samples of smokers in Japan. A total of 58 male smokers completed the TDS and the Fagerstrom Tolerance Questionnaire (FTQ), and they were interviewed using the World Health Organization's Composite International Diagnostic Interview (Sample 1). A total of 118 male and 36 female smoking outpatients completed the TDS and the FTQ and provided a breath sample for carbon monoxide measurement (Sample 2). A total of 194 male smokers joined a health education program using a health risk appraisal (HRA) and reported their smoking status and completed the TDS 6 months after receiving the HRA results (Sample 3). The Cronbach's alpha coefficients for the TDS ranged from .74 to .81 among the samples, whereas those for the FTQ ranged from .41 to .64. Receiver operator characteristic analyses indicated that the TDS had a better screening performance for ICD-10, DSM-III-R, and DSM-IV diagnoses than did the FFQ. The TDS score significantly and positively correlated with the severity of the diagnoses, the carbon monoxide levels, number of cigarettes smoked per day, and years of smoking. The TDS score was significantly lower in those who quit smoking than in those who did not quit smoking after the HRA. It is suggested that the TDS is a reliable and useful screening questionnaire for tobacco/nicotine dependence according to ICD-10, DSM-III-R, and DSM-IV.     

Weight gain following smoking cessation: a possible role for nicotine replacement in weight management

This study examined nicotine dependence as a factor in weight gain following smoking cessation in a group of 104 recent ex-smokers. Nicotine dependence was measured using the eight-item Fagerstrom Tolerance Questionnaire. Findings support the hypothesis that weight gain following smoking cessation is greater among more nicotine dependent persons. Heavier smokers (greater than or equal to 26 cigs/day), those who reported smoking when they are ill, and those who reported smoking their first cigarette of the day within 30 minutes of waking up reported the greatest increases in weight one month after quitting. Twenty subjects reported using nicotine gum to help them quit smoking. A significant inverse correlation (r = -.17) was found between weight gain and the number of pieces of nicotine gum chewed per day. Stratification by the number of cigarettes smoked daily (greater than or equal to 26 cigs/versus less than 26 cigs/day) indicated that the correlation between weight gain and the number of pieces of nicotine gum chewed per day was significant only for heavy smokers (r = -.37 versus r = -.08). This finding suggests that nicotine replacement may help prevent weight gain following smoking cessation, especially for the more dependent smokers.     

Bupropion for the treatment of tobacco dependence: guidelines for balancing risks and benefits

Tobacco use, particularly cigarette smoking, is now a global pandemic. The expected morbidity and mortality from smoking-attributable diseases will continue to rise for the next 30 years. In order to reduce this negative impact on worldwide health, effective therapy to aid smoking cessation must be provided to current smokers. Treatment for tobacco dependence involves the combination of behavioural therapies and pharmacological treatment. The most common pharmacological treatments include nicotine replacement therapy and non-nicotine medications, including antidepressants. The antidepressant with the greatest weight of evidence for efficacy in the treatment of tobacco dependence is bupropion. Sustained-release bupropion is approved for the treatment of tobacco dependence in over 50 countries worldwide. The efficacy of bupropion for the treatment of tobacco dependence is attributed to the blockage of dopamine reuptake in the mesolimbic dopaminergic system. This area of the brain is believed to mediate reward for nicotine use and for other drugs of dependence. Randomised, controlled clinical trials have shown that bupropion approximately doubles abstinence rates compared with placebo. In addition, long-term treatment with bupropion may reduce or delay smoking relapse. Bupropion also appears to be effective in the treatment of smokers who have recently relapsed and smokers with other comorbid psychiatric conditions. Bupropion has a good adverse events profile, but the risk exists for serious adverse effects such as seizures. Recent postmarketing surveillance reports have raised safety concerns about bupropion, although no causal relationship between bupropion and the reported serious adverse events or death has been established.     

Nicotine dependence subtypes: association with smoking history, diagnostic criteria and psychiatric disorders in 5440 regular smokers from the Vietnam Era Twin Registry

Studies suggest empirically derived subtypes of nicotine dependence exist in young adult populations with short smoking careers. It is not known if classes of dependence exist in middle aged smokers with longer smoking careers and whether these classes reflect quantitative or qualitative differences. It is not known if psychiatric disorders are associated with classes of nicotine dependence. Nicotine dependence symptoms were obtained from a 1992 administration of the Diagnostic Interview Schedule. Latent Class Analyses (LCA) was computed using data from 5440 members of the Vietnam Era Twin Registry. LCA was used to derive significantly different classes of nicotine dependence, which were assessed for their association with smoking history, nicotine dependence, and other psychiatric disorders. The LCA model which best fit the data was a 4 class solution characterized by severity. Age onset of regular smoking decreased with more severe classes. Cigarette consumption, failed cessation and psychiatric disorders were associated with more severe classes. Empirically derived subtypes of nicotine dependence are mostly characterized by increasing severity. Suggestions for refinement of nicotine dependence diagnostic criteria are discussed.     

Quitting cigarette smoking produces minimal loss of chronic tolerance to nicotine

RATIONALE: Long-term exposure to nicotine is associated with chronic tolerance to its acute effects, adaptation that may lead to tobacco dependence. The time course for loss of this tolerance after cessation of exposure is not known in humans but could relate to risk of smoking relapse. OBJECTIVES: We examined changes in responses to nicotine as a function of days, weeks, or years of smoking cessation in formerly dependent smokers to determine at what point sensitivity to nicotine is reinstated (i.e., loss of tolerance). METHODS: Acute subjective, cardiovascular, performance, and reinforcing (self-administration) effects of nicotine nasal spray (0-20 microg/kg) were assessed prospectively in men and women smokers before and then day-by-day (study 1) or 3 weeks (study 2) after stopping smoking. A smoking resumption period (study 1) and a group of non-quitting smokers (study 2) were included to control for the passage of time. These effects were also compared cross-sectionally between those who had quit for 1-4 years and those who had for 6-19 years in a separate sample of long-time ex-smokers to determine whether lengthier abstinence causes greater loss of tolerance (study 3). RESULTS: No clear loss of tolerance was observed on any measure in studies 1 or 2, suggesting that chronic tolerance is fully maintained for at least weeks after quitting smoking. Sensitivity to nicotine's effects was also not different as a function of years quit in study 3. CONCLUSIONS: Chronic tolerance to nicotine is not lost within several weeks of quitting smoking and may not change even after years of abstinence from tobacco use.     

Mechanisms of adolescent smoking cessation: roles of readiness to quit, nicotine dependence, and smoking of parents and peers

Multiple levels of influence should be considered in interventions aimed at the adolescent smoker, including psychological, addiction, peer and parental influences. However, the mechanism by which these variables influence the process of smoking cessation in adolescents is not well elucidated. Therefore, this prospective study tested two models among 850 adolescent smokers, specifying the direct and indirect relations between adolescents' readiness to quit smoking, levels of nicotine dependence, and smoking behavior of their parents and friends. One year later smoking cessation was assessed. Results showed that, among adolescent smokers, readiness to quit was positively associated with quit attempts, while nicotine dependence was inversely associated with successful cessation. Instead of a direct relation, parental and peers' smoking were inversely related to smoking cessation through nicotine dependence. The findings emphasize that interventions should be developed and tested within and outside the school setting, as well as within the family situation. In addition, the strong impact of nicotine dependence on successful cessation indicates that a more direct approach is needed to lower nicotine dependence among adolescents.     

Relationships Between Stress,Negative Emotions,Resilience, and Smoking: Testing a Moderated Mediation Model

Objective: More effective tobacco prevention and cessation programs require in-depth understanding of the mechanism by which multiple factors interact with each other to affect smoking behaviors. Stress has long been recognized as a risk factor for smoking. However, the underlying mediation and moderation mechanisms are far from clear. The purpose of this study was to examine the role of negative emotions in mediating the link between stress and smoking and whether this indirect link was modified by resilience. Methods: Survey data were collected using audio computer-assisted self-interview (ACASI) from a large random sample of urban residents (n = 1249, mean age = 35.1, 45.3% male) in Wuhan, China. Perceived stress, negative emotions (anxiety, depression), resilience were measured with reliable instruments also validated in China. Self-reported smoking was validated with exhaled carbon monoxide. Results: Mediation analysis indicated that two negative emotions fully mediated the link between stress and intensity of smoking (assessed by number of cigarettes smoked per day, effect =.082 for anxiety and.083 for depression) and nicotine dependence (assessed by DSM-IV standard, effect =.134 for anxiety and.207 for depression). Moderated mediation analysis demonstrated that the mediation effects of negative emotions were negatively associated with resilience. Conclusions: Results suggest resilience interacts with stress and negative emotions to affect the risk of tobacco use and nicotine dependence among Chinese adults. Further research with longitudinal data is needed to verify the findings of this study and to estimate the effect size of resilience in tobacco intervention and cessation programs.     

Nicotine dependence among African American light smokers: a comparison of three scales

Approximately 50% of African American (AA) smokers are light smokers (smoke 相似文献   

Experimenting and daily smokers: Episodic patterns of alcohol and cigarette use

Alcohol use may facilitate the development of nicotine dependence. Alcohol is often paired with cigarette smoking, particularly in those experimenting with smoking. However, little research has examined episodic patterns of alcohol and cigarette use. This study examined patterns of alcohol and cigarette use in a college-aged sample (n = 237) designated as experimenters or smokers based on their smoking history. Participants reported their consumption of drinks and cigarettes by hour, for each hour, of a typical drinking and smoking episode. Self-reported pleasure and desire associated with smoking generally and while drinking was assessed. No group difference was observed in total number of drinks. However, experimenters delayed smoking until more drinks were consumed, suggesting they smoked after reaching binge levels of alcohol. By contrast, smokers smoked after fewer drinks. Both groups reported increased smoking while drinking and increased pleasure and desire when smoking while drinking. The increase was greater in experimenters. Concurrent alcohol and cigarette use may facilitate the development of tobacco dependence and interventions interrupting their pairing might impede the transition from experimenter to smoker.     

Smoking cessation treatment in community-based substance abuse rehabilitation programs

Nicotine dependence is highly prevalent among drug- and alcohol-dependent patients. A multisite clinical trial of smoking cessation (SC) treatment was performed at outpatient community-based substance abuse rehabilitation programs affiliated with the National Drug Abuse Treatment, Clinical Trials Network. Cigarette smokers (N=225) from five methadone maintenance programs and two drug and alcohol dependence treatment programs were randomly assigned in a 2:1 ratio to receive either (1) SC treatment as an adjunct to substance abuse treatment-as-usual (TAU) or (2) substance abuse TAU. Smoking cessation treatment consisted of 1 week of group counseling before the target quit date and 8 weeks of group counseling plus transdermal nicotine patch treatment (21 mg/day for Weeks 1-6 and 14 mg/day for Weeks 7 and 8) after the target quit date. Smoking abstinence rates in SC, 10%-11% during treatment and 5%-6% at the 13- and 26-week follow-up visits, were significantly better than those in TAU during treatment (p< .01). In addition, SC was associated with significantly greater reductions as compared with TAU in cigarettes smoked per day (75% reduction, p< .001), exhaled carbon monoxide levels (p< .001), cigarette craving (p< .05), and nicotine withdrawal (p< .05). Smoking cessation did not differ from TAU on rates of retention in substance abuse treatment, abstinence from primary substance of abuse, and craving for primary substance of abuse. Compliance with SC treatment, moderate at best, was positively associated with smoking abstinence rates. Smoking cessation treatment resulted in significant reductions in daily smoking and modest smoking abstinence rates without having an adverse impact on substance abuse rehabilitation when given concurrently with outpatient substance abuse treatment. Substance abuse treatment programs should not hesitate to implement SC for established patients.     

Prevalence and correlates of tobacco use and nicotine dependence among psychiatric patients in India

Tobacco use among psychiatric patients in developing countries has not been well-investigated. To address this issue, we screened consecutive admissions to a major psychiatric hospital in southern India, and assessed the prevalence and correlates of tobacco use and nicotine dependence. Patients (n=988) provided information about their use of tobacco products, and participated in an interview that included the Fagerström Test for Nicotine Dependence as well as measures of other substance use. Three hundred and fifty-one patients (36%) reported current tobacco use, with 227 (65% of all users) reporting moderate to severe nicotine dependence. Current tobacco use as well as nicotine dependence were associated with male gender, a diagnosis of bipolar disorder, and risk of other substance use problems. The cultural context of these findings, and the implications for tobacco control among psychiatric patients, are discussed.