Tobacco Treatment Knowledge and Practices Among US Psychiatrists.

This study explores the extent to which psychiatrists are familiar with, and utilize, the USPHS guidelines for treating tobacco use and dependence (i.e., the 5A's), deliver cessation treatment, and the barriers they perceive to doing so. An original, national survey of 141 psychiatrists revealed that most Ask patients if they smoke (81.6%). Fewer Advise them to stop (78.7%) and Assess their willingness to quit (73.6%). A minority Assist with a quit plan (15.9%) and Arrange for follow-up (26.4%). Just 11.9% have used the USPHS guidelines in clinical practice; 37% have never heard of them. Even among those who say they have used the USPHS guidelines, implementation of the 5A's is quite low. Time-related factors were the most common barriers to cessation delivery (51.4%). Patient factors (30%) and financial/resource factors (25%) were less common. There is a strong need for increased implementation of clinical guidelines for evidence-based tobacco treatments among psychiatrists.

Assessing Sex, Gender Identity, Sexual Orientation, Race, Ethnicity, Socioeconomic Status, and Mental Health Concerns in Tobacco Use Disorder Treatment Research: Measurement Challenges and Recommendations From a Society for Research on Nicotine and Tobacco Pre-conference Workshop.

This paper reports on topics discussed at a Society for Research on Nicotine and Tobacco pre-conference workshop at the 2019 annual Society for Research on Nicotine and Tobacco meeting. The goal of the pre-conference workshop was to help develop a shared understanding of the importance of several tobacco-related priority groups in tobacco use disorder (TUD) treatment research and to highlight challenges in measurement related to these groups. The workshop focused on persons with minoritized sex, gender identity, and sexual orientation identities; persons with minoritized racial and ethnic backgrounds; persons with lower socioeconomic status (SES); and persons with mental health concerns. In addition to experiencing commercial tobacco-related health disparities, these groups are also underrepresented in tobacco research, including TUD treatment studies. Importantly, there is wide variation in how and whether researchers are identifying variation within these priority groups. Best practices for measuring and reporting sex, gender identity, sexual orientation, race, ethnicity, SES, and mental health concerns in TUD treatment research are needed. This paper provides information about measurement challenges when including these groups in TUD treatment research and specific recommendations about how to measure these groups and assess potential disparities in outcomes. The goal of this paper is to encourage TUD treatment researchers to use measurement best practices in these priority groups in an effort to conduct meaningful and equity-promoting research. Increasing the inclusion and visibility of these groups in TUD treatment research will help to move the field forward in decreasing tobacco-related health disparities. Implications: Tobacco-related disparities exist for a number of priority groups including, among others, women, individuals with minoritized sexual and gender identities, individuals with minoritized racial and ethnic backgrounds, individuals with lower SES, and individuals with mental health concerns. Research on TUD treatments for many of these subgroups is lacking. Accurate assessment and consideration of these subgroups will provide needed information about efficacious and effective TUD treatments, about potential mediators and moderators, and for accurately describing study samples, all critical elements for reducing tobacco-related disparities, and improving diversity, equity, and inclusion in TUD treatment research.

Tobacco/nicotine use among individuals using cannabis for therapeutic purposes.

BACKGROUND AND OBJECTIVES: While the relationship between recreational cannabis and nicotine use is well established, little is known about nicotine use among users of cannabis for therapeutic purposes (CTP). METHODS: Patients attending a medical marijuana dispensary (N = 697; 75.3% White; 60.0% male) completed a survey examining nicotine use, motivation to quit cigarette smoking, routes of administration of nicotine and cannabis, and CTP qualifying conditions. RESULTS: More than one-third (39.3%) of participants reported current nicotine use. Compared to exclusive cigarette smokers, e-cigarette users and non-users of nicotine were approximately four times more likely to vape, rather than to smoke, cannabis. Furthermore, 46.8% of cigarette smokers reported plans to quit smoking in the next 6 months (but not in the next month) and an additional 31.6% planned to quit in the next month. Having a psychiatric condition was associated with nicotine use and higher motivation to quit smoking. DISCUSSION AND CONCLUSIONS: Users of CTP are more likely to use nicotine products than the general population and the route of administration of nicotine products is related to the route of administration of CTP. If aerosolized CTP is a less harmful route of administration than smoked CTP, dispensary staff should be aware of this relationship and take this into account when recommending a noncombustible route. SCIENTIFIC SIGNIFICANCE: This study further characterizes nicotine use behaviors and motivation to quit smoking among users of CTP and may be among the first to examine nicotine use among patients of a medical marijuana dispensary.

Motivational Interviewing Produces Change Talk in Smokers with Serious Mental Illness.

OBJECTIVE: Change talk, or client language that is consistent with making a behavioral change, has been found to improve the efficacy of motivational interviewing (MI). It is not known, however, if change talk helps to explain MI's effect on instigating a quit attempt in smokers with serious mental illness. Methods: We measured change talk in smokers with a serious mental illness (SMI) randomized to receive either a single session adaptation of motivational interviewing or an interactive education intervention. We evaluated relationships between treatment condition, proportion of change talk, and study outcomes of quit attempts and willingness to follow up on treatment provider referrals. Results: Participants receiving the adaptation of motivational interviewing had higher proportions of change talk than participants in the interactive education condition. However, total proportion of change talk did not mediate the relationship between treatment and outcome, nor did it predict making a quit attempt or following up on a referral to contact a treatment provider. Conclusions: Our study found that motivational interviewing has the same change talk augmenting effect in individuals with SMI as those without SMI. Given that anhedonia, negative affect, and depressive symptoms are a major part of serious mental illnesses, it is encouraging that MI can generate change talk in this population. Future smoking cessation intervention trials with larger samples should investigate whether greater amounts of change talk lead to increased quit attempts in this population.

A Pilot Randomized Clinical Trial of Brief Interventions to Encourage Quit Attempts in Smokers From Socioeconomic Disadvantage.

INTRODUCTION: Cigarette smoking disproportionately affects communities of low socioeconomic status where greater smoking prevalence and poorer cessation rates have been observed. Utilizing brief evidence-based interventions to increase cessation attempts may be an effective and easily disseminable means by which to mitigate undue burden in this population. AIMS AND METHODS: The current intervention randomized daily smokers (N = 57) recruited from a local community soup kitchen to receive either Brief (eg, 30 m) Motivational Interviewing, Nicotine Replacement Therapy (NRT) sampling, or a Referral-Only intervention. Approximately half of participants (50.9%) reported not completing high school and many reported either just (41.4%) or not (40.4%) meeting basic expenses. Follow-up was completed approximately 1-month postintervention. RESULTS: Nonsignificant group differences indicated that participants randomized to the NRT sampling condition were more likely to make a quit attempt (moderate effect size). Approximately 40% of the sample reported making a serious quit attempt at follow-up. Significant differences in cigarettes per day at follow-up, controlling for baseline, were observed, with participants in the Motivational Interviewing condition, only, reporting significant reductions. Participants randomized to the NRT condition were significantly more likely to report using NRT patch and lozenge at follow-up (large effect). There were no differences between groups with respect to seeking behavioral support. Finally, we found that subjective financial strain moderated the effect of condition on change in cigarette consumption where NRT sampling was more effective for participants reporting less financial strain. CONCLUSIONS: Findings provide initial evidence for personalizing brief interventions to promote quit attempts in low-income smokers. IMPLICATIONS: While most clinical research on tobacco use and dependence focuses on successful sustained abstinence, the current study is novel because it examined three brief interventions designed to increase the number of quit attempts made by a nontreatment-seeking group suffering from health disparities (ie, smokers from socioeconomic disadvantage). These data suggest that nontreatment-seeking smokers from socioeconomic disadvantage can be influenced by Brief MIs and these interventions should be used to motivate smokers from socioeconomic disadvantage to make a quit attempt. Future studies should examine combined MIs including pharmacological and behavioral interventions.

Defining and Measuring Abstinence in Clinical Trials of Smoking Cessation Interventions: An Updated Review.

BACKGROUND: Changes in tobacco products, use patterns, and assessment technology in the last 15 years led the Society for Research on Nicotine and Tobacco (SRNT) Treatment Research Network to call for an update to the 2003 SRNT recommendations for assessing abstinence in clinical trials of smoking cessation interventions. METHODS: The SRNT Treatment Research Network convened a group of investigators with decades of experience in conducting tobacco treatment clinical trials. To arrive at the updated recommendations, the authors reviewed the recommendations of the prior SRNT Workgroup as well as current literature. Ten additional experts in the field provided feedback on this paper and these recommendations. RESULTS: With respect to defining abstinence, the authors recommend: (1) continuing to use the definition of no use of combustible tobacco products (regardless of use of noncombustible tobacco products [e.g., snus] and alternative products [e.g., e-cigarettes]) and collecting additional data to permit alternate abstinence definitions; (2) no use of combustible or smokeless tobacco products; and (3) no use of combustible or smokeless tobacco products or alternative products, as appropriate for the research question being addressed. The authors also recommend reporting point prevalence and prolonged abstinence at multiple timepoints (end of treatment, ≥3 months after the end of treatment, and ≥6 months postquit or posttreatment initiation). CONCLUSIONS: Defining abstinence requires specification of which products a user must abstain from using, the type of abstinence (i.e., point prevalence or continuous), and the duration of abstinence. These recommendations are intended to serve as guidelines for investigators as they collect the necessary data to accurately describe participants' abstinence during smoking cessation clinical trials. IMPLICATIONS: This paper provides updated recommendations for defining abstinence in the context of smoking cessation treatment clinical trials.

An Adaptation of Motivational Interviewing Increases Quit Attempts in Smokers With Serious Mental Illness.

INTRODUCTION: Smokers with serious mental illness (SMI) have a high smoking prevalence and a low quit rate. Motivational interviewing (MI) is an empirically supported approach for addressing substance use disorders and may motivate smokers with SMI to quit. METHODS: We randomized smokers (N = 98) with SMI to receive a single 45-minute session of (1) MI with personalized feedback or (2) interactive education. We hypothesized that participants receiving the MI intervention would be more likely to follow-up on a referral for tobacco dependence treatment, to make a quit attempt, and to quit smoking than those receiving the interactive educational intervention. RESULTS: Smokers receiving an MI intervention were significantly more likely to make a quit attempt by the 1-month follow-up (34.7% vs. 14.3%; OR = 4.39 [95% CI = 1.44 to 13.34], P = .009); however, these quit attempts did not translate into abstinence. In addition, 32.7% of those receiving MI followed-up on a referral for tobacco dependence treatment (vs. 20.4% receiving interactive education; OR = 2.02 [95% CI = 0.76 to 3.55], P = .157). MI Treatment Integrity Code ratings indicated that the interventions were easily distinguishable from each other and that MI was delivered with proficiency. Despite the intervention's brevity, participants reported high levels of therapeutic alliance with their therapist. CONCLUSIONS: A brief adaptation of MI with personalized feedback appears to be a promising approach for increasing quit attempts in smokers with SMI, but future research is required to determine how to best help smokers with SMI to attain sustained abstinence.

Determining Smoking Cessation Related Information, Motivation, and Behavioral Skills among Opiate Dependent Smokers in Methadone Treatment.

BACKGROUND: Over 80% of people in methadone treatment smoke cigarettes, and existing smoking cessation interventions have been minimally effective. OBJECTIVE: To develop an Information-Motivation-Behavioral Skills (IMB) Model of behavior change based smoking cessation intervention for methadone maintained smokers, we examined smoking cessation related IMB factors in this population. METHODS: Current or former smokers in methadone treatment (n = 35) participated in focus groups. Ten methadone clinic counselors participated in an individual interview. A content analysis was conducted using deductive and inductive approaches. RESULTS: Commonly known IMB factors related to smoking cessation were described. These factors included: the health effects of smoking and treatment options for quitting (information); pregnancy and cost of cigarettes (motivators); and coping with emotions, finding social support, and pharmacotherapy adherence (behavioral skills). IMB factors specific to methadone maintained smokers were also described. These factors included: the relationship between quitting smoking and drug relapse (information), the belief that smoking is the same as using drugs (motivator); and coping with methadone clinic culture and applying skills used to quit drugs to quitting smoking (behavioral skills). IMB strengths and deficits varied by individual. CONCLUSIONS: Methadone maintained smokers could benefit from research on an IMB Model based smoking cessation intervention that is individualized, addresses IMB factors common among all smokers, and also addresses IMB factors unique to this population.

Communicating the benefits of quitting smoking on mental health increases motivation to quit in people with anxiety and/or depression.

BACKGROUND: Although smoking rates have declined over time, this decline has not been observed among those with mental health concerns. It is therefore important to develop effective messaging to support quitting in this population. METHODS: We conducted an online experiment with 419 adults who smoke cigarettes daily. Participants with, or without a lifetime history of anxiety and/or depression were randomized to view a message focused on the benefits of quitting smoking on mental or physical health. Participants then reported motivation to quit smoking, mental health concerns about quitting, and perceived effectiveness of the message. RESULTS: Participants with a lifetime history of anxiety and/or depression who saw the message focused on the benefits of quitting smoking on mental health reported greater motivation to quit than when they saw a message focused on the benefits to physical health. This was not replicated when examining current symptoms instead of lifetime history. Pre-existing beliefs that smoking improves one's mood were greater in those experiencing current symptoms and in those with a lifetime history of anxiety and/or depression. There was no main or interaction (message type X mental health status) effect of message type received on mental health related concerns about quitting. CONCLUSIONS: This study is one of the first to evaluate a smoking cessation message with content specifically targeted to those with mental health concerns about quitting smoking. Additional work is needed to determine how to best target those with mental health concerns with messages focused on the benefits of quitting on mental health.

Smokers with behavioral health comorbidity should be designated a tobacco use disparity group.

Smokers with co-occurring mental illness or substance use disorders are not designated a disparity group or priority population by most national public health and tobacco control groups. These smokers fulfill the criteria commonly used to identify groups that merit special attention: targeted marketing by the tobacco industry, high smoking prevalence rates, heavy economic and health burdens from tobacco, limited access to treatment, and longer durations of smoking with less cessation. A national effort to increase surveillance, research, and treatment is needed. Designating smokers with behavioral health comorbidity a priority group will bring much-needed attention and resources. The disparity in smoking rates among persons with behavioral health issues relative to the general population will worsen over time if their needs remain unaddressed.

Rapid smoking may not be aversive in schizophrenia.

INTRODUCTION: Aversive smoking has been investigated as a smoking cessation technique that involves rapid smoking in a clinic or laboratory and typically involves (a) puffing every 6-10 s or (b) smoking 3 or more cigarettes sequentially in 8-20 min. Rapid smoking usually results in dizziness, sore throat, nausea, and other unpleasant feelings. METHODS: To explore rapid smoking, 161 smokers (75 with schizophrenia [SS]; 86 controls [CON]) were assessed in a single day (24 ± 2 hr), ad libitum smoking topography session using the Clinical Research Support System micro portable topography device. RESULTS: SS smoked significantly more cigarettes in the 24-hr period versus CON and the time between puffs, or interpuff interval (IPI) was shorter in SS versus CON by an average of 6.5 s (p < .001). The median IPI was also significantly shorter in SS versus CON (9.3 vs.15.7 s; p < .001). SS were twice as likely to have IPIs ≤ 6 s than CON (OR = 2.32, 95% CI = 1.68, 3.20; p < .001). SS were also more likely to smoke 3 or more cigarettes in any 20 min during a 24-hr topography session (OR = 2.32, 95% CI = 1.03, 2.44; p < .001). Rapid smoking was associated with baseline characteristics of smoking more cigarettes per day, higher Fagerström score, and higher carbon monoxide level but not with serum cotinine values or trans-3'-hydroxycotinine/cotinine ratios. CONCLUSIONS: Using either definition, SS exhibit patterns of rapid smoking that they seemingly do not experience as aversive, since it reflects their naturalistic pattern of smoking, outside of the laboratory.

Predictors of opioid overdose during the COVID-19 pandemic: The role of relapse, treatment access and nonprescribed buprenorphine/naloxone.

INTRODUCTION: Emerging data indicate a disproportionate increase in overdose deaths since the onset of COVID-19. Speculation about causes for the increase center on rising drug use, illicit drug supply changes, and reduced treatment access. Possible overdose mitigation factors include reduced federal MOUD prescribing restrictions, naloxone distribution programs, and increased use of telehealth. Similarly, nonprescribed buprenorphine (NPB) use, increasingly described as a harm reduction strategy in the absence of treatment, may have moderated overdose risk. This study explored factors associated with pandemic-related overdose in people who use opioids (PWUO) in New Jersey. METHODS: We surveyed 342 PWUO from March to May 2021. Approximately 50 % of our sample was treated at some time since the COVID-19 emergency declaration in March 2020. The risk and protective factors associated with overdose were identified using Pearson's chi square test and ANOVA and tested in a series of multivariable logistic regression models for the full sample and the subsample of PWUO treated during the pandemic. RESULTS: Forty-eight percent of respondents increased their drug use during the pandemic, including 32 % who relapsed after previous abstinence. Fifteen percent overdosed at least once since March 2020. In the full sample, overdose was associated with Hispanic ethnicity (AOR = 3.51; 95 % CI = 1.22-10.11), pre-pandemic overdose (AOR = 6.75; 95 % CI = 3.03-15.02), lack/loss of medical insurance (AOR = 3.02; 95 % CI = 1.01-9.02), relapse (AOR = 2.94; 95 % CI = 1.36-6.36), and nonprescribed use of buprenorphine/naloxone (AOR = 3.16; 95 % CI = 1.49-6.70). The study found similar trends in the treatment sample, with the exceptions that heroin/fentanyl use also predicted overdose (AOR = 3.43; 95 % CI = 1.20-9.78) and the association of overdose with nonprescribed buprenorphine/naloxone was stronger (AOR = 4.91; 95 % CI = 2.01-12.03). Potential mitigating factors, such as take-home methadone and telehealth, were not significant. CONCLUSIONS: Relapse during the pandemic was widespread and a significant contributor to overdose. Lack/loss of medical insurance further exacerbated the risk. Despite the growing literature reporting "therapeutic" use of NPB, people using nonprescribed buprenorphine/naloxone in the current study experienced up to five times the risk of overdose as nonusers. This finding suggests that, despite therapeutic intent, PWUO may be using NPB in ways that are ineffectual for addiction management, especially in the context of changing buprenorphine induction protocols in the context of fentanyl.

Communicating the benefits of quitting smoking on mental health increases motivation to quit in people with anxiety and/or depression: A randomized trial of two health messages.

Background: Although smoking rates have declined over time, this decline has not been observed among those with mental health concerns. It is therefore important to develop effective messaging to support quitting in this population. Methods: We conducted an online experiment with 419 adults who smoke cigarettes daily. Participants with, or without a lifetime history of anxiety and/or depression were randomized to view a message focused on the benefits of quitting smoking on mental or physical health. Participants then reported motivation to quit smoking, mental health concerns about quitting, and perceived effectiveness of the message. Results: Participants with a lifetime history of anxiety and/or depression who saw the message focused on the benefits of quitting smoking on mental health reported greater motivation to quit than when they saw a message focused on the benefits to physical health. This was not replicated when examining current symptoms instead of lifetime history. Pre-existing beliefs that smoking improves one's mood were greater in those experiencing current symptoms and in those with a lifetime history of anxiety and/or depression. There was no main or interaction (message type X mental health status) effect of message type received on mental health related concerns about quitting. Conclusions: This study is one of the first to evaluate a smoking cessation message with content specifically targeted to those with mental health concerns about quitting smoking. Additional work is needed to determine how to best target those with mental health concerns with messages focused on the benefits of quitting on mental health. Implications: These data can begin to inform regulatory efforts to address tobacco use in those with comorbid anxiety and/or depression by providing information on how to effectively communicate the benefits of quitting smoking on mental health.

Nicotine intake and smoking topography in smokers with bipolar disorder.

OBJECTIVES: Cigarette smoking behavior in bipolar disorder (BPD), including the effects of mood-stabilizing medications, has not been well characterized. METHODS: We compared serum nicotine, nicotine metabolite levels, and smoking topography in 75 smokers with BPD to 86 control smokers (CON). For some comparisons, an additional control group of 75 smokers with schizophrenia (SCZ) were included. RESULTS: There were no differences between the BPD and CON groups in baseline smoking characteristics or serum nicotine or cotinine levels. Fifty-one smokers with BPD (68.9%) were taking one of the following mood stabilizers: valproic acid, lamotrigine, carbamazepine, oxcarbazepine, lithium, or topiramate. The 3-hydroxycotinine-to-cotinine ratio, a marker of cytochrome P450 2A6 (CYP2A6) metabolic activity, was significantly higher in BPD versus CON and versus SCZ (0.68 versus 0.49 versus 0.54; p =0.002). The difference between groups, however, was no longer significant when the analysis was repeated with those taking hepatic enzyme-inducing drugs (carbamazepine, oxcarbazepine, and topiramate) included as a covariate. The time between puffs, or interpuff interval (IPI), was shorter in BPD versus CON by an average of 3.0sec (p<0.05), although this was no longer significant when we removed smokers from the analysis of those taking hepatic enzyme inducers. CONCLUSIONS: Smokers with BPD are not different from CON on most measures of nicotine intake and smoking topography. We found an increased rate of nicotine metabolism in smokers taking mood stabilizers that are hepatic enzyme inducers, including carbamazepine, oxcarbazepine, and topiramate. Smokers with rapid nicotine metabolism might be expected to smoke more intensely to compensate for the more rapid disappearance of nicotine from the blood and brain, and may have more difficulty in quitting smoking, although this requires further study.

Evaluation of the CHOICES program of peer-to-peer tobacco education and advocacy.

CHOICES is a consumer driven program for addressing tobacco in people with mental illness that employs mental health peer counselors. Since 2005, CHOICES has conducted over 298 community visits reaching more than 10,000 smokers with mental illness (about 2500/year). A telephone based outcome study was conducted in 102 outpatient smokers who received a CHOICES peer-to-peer session. At 1-month follow up participants (N = 86; 84%) reported smoking an average of 13 cigarettes per day which was significantly reduced from a baseline of 19 (P < 0.001). Twenty-five individuals (29%) tried to quit smoking in the month after the peer session and another 47 (55%) reduced their smoking. Feedback from smokers about the program was positive. Most (N = 59, 71%) said it was a lot easier to talk with a consumer about smoking compared to their psychiatrist or staff. Peer-to-peer communication about tobacco use can be effective to increase awareness and change smoking behaviors.