Racial/ethnic differences in the acute effects of reduced nicotine content cigarettes among adolescents who smoke.

OBJECTIVE: Reducing the nicotine content in cigarettes decreases their addictiveness and abuse liability, including among adolescents. Whether these effects differ by race/ethnicity is unknown. This study is a secondary analysis of previously published data collected between 2014-2017. We examined racial/ethnic differences in the effects of smoking cigarettes with varying nicotine content levels on subjective effects and tobacco withdrawal among adolescents who smoke daily. METHODS: Across two counterbalanced sessions, 50 adolescents recruited from Rhode Island (ages 15-19; 30 % Underrepresented Minorities [URM], 20 % Asians and Pacific Islanders [API]; 50 % Non-Hispanic Whites) self-administered a very low nicotine content (VLNC; 0.4 mg nicotine/g of tobacco) or normal nicotine content control (NNC; 15.8 mg/g) research cigarette following overnight abstinence. Subjective effects were reported post-administration and tobacco withdrawal outcomes were calculated from pre- to post-administration scores. Multilevel linear models tested main and interactive effects between cigarette nicotine content and race/ethnicity on all study outcomes. RESULTS: Participants reported lower positive subjective effects and reductions in smoking urges after smoking a VLNC cigarette relative to smoking an NNC cigarette (ps < 0.01). A main effect of race/ethnicity emerged, such that API (vs. URM and White) adolescents reported lower positive subjective effects, greater craving reduction, and higher cigarette aversion after smoking, regardless of nicotine content (ps < 0.05). Significant interactions were found between race/ethnicity and nicotine content for cigarette aversion, such that API adolescents rated VLNC (vs. NNC) cigarettes as less aversive than White and URM adolescents did (p = 0.03). CONCLUSIONS: Findings provide evidence that VLNC cigarettes may reduce abuse liability and tobacco withdrawal symptoms for adolescents across racial/ethnic groups and particularly for API youth.

Effects of Very Low Nicotine Content Cigarettes and Nicotine Vaping Device Characteristics on Choices to Smoke, Vape, or Abstain in Early Young Adults.

INTRODUCTION: A national nicotine reduction policy could reduce the public health toll of smoking. However, reducing nicotine in cigarettes may lead to changes in the use of other tobacco products such as nicotine vaping devices, particularly among young people. Product use outcomes may depend on characteristics of available nicotine vaping devices. We aimed to determine the impact of cigarette nicotine content, vaping device nicotine concentration, and vaping device flavors on choices to smoke, vape, or abstain. METHODS: Early young adults (ages 18-20 inclusive, N=80) who reported smoking daily and vaping nicotine at least twice in their lifetime participated in a laboratory study. Participants received either Very Low Nicotine Content (VLNC; 0.4 mg nicotine/g of tobacco) or Normal Nicotine Content (NNC; 15.8 mg/g) cigarettes. First, participants chose between their assigned cigarette or abstaining. Subsequently, participants chose between 2 cigarette puffs, 2 vape puffs, or abstaining. Vaping device nicotine concentration (3mg vs. 18mg/ml) and flavor (tobacco vs. non-tobacco) were manipulated within-subjects. RESULTS: When only cigarettes were available, there were no differences between the VLNC and NNC groups on cigarette choices. When the nicotine vaping device was concurrently available, the VLNC group made fewer choices to smoke than the NNC group. Non-tobacco flavors and lower vaping device nicotine concentration were associated with fewer choices to smoke. CONCLUSIONS: Nicotine vaping device availability reduced choices to smoke VLNC cigarettes, and vaping devices with lower nicotine and non-tobacco flavors led to the fewest choices to smoke. Regulators should consider that the availability and characteristics of alternative tobacco products can moderate the product standard's impact. IMPLICATIONS: The U.S. Food and Drug Administration may enact a reduced nicotine product standard that would affect all commercially-available cigarettes. One important population affected by this policy would be early young adults who smoke. We aimed to determine the impact of cigarette nicotine content, vaping device nicotine concentration, and vaping device flavors on choices to smoke, vape, or abstain. Lower nicotine in cigarettes, along with non-tobacco flavors and lower nicotine concentration in the vaping device, were associated with the fewest choices to smoke. Regulators should consider that the availability and characteristics of alternative tobacco products can moderate the product standard's impact.

Reactions to a Nicotine Reduction Policy Among Adolescents Who Smoke: A Qualitative Study.

INTRODUCTION: The Biden administration is pursuing a nicotine reduction policy in the U.S. to render cigarettes less addictive. In this study, we qualitatively investigated adolescents' subjective responses to very low nicotine content (VLNC) cigarettes, reasons for incomplete adherence to using them, and their expected responses to a nicotine reduction policy. METHODS: Adolescents who smoke cigarettes daily (ages 15-19; N=60) were enrolled in a three-week double-blind randomized clinical trial and assigned to smoke either normal nicotine content (NNC) or VLNC research cigarettes. Following the trial, 52 participants completed qualitative interviews about their reactions to the cigarettes and to the idea of a nicotine reduction policy. We utilized a template style approach to thematic analysis involving immersion in the data, codebook development with both inductive and deductive codes, and iterative refinement of themes. RESULTS: Reasons for incomplete adherence to smoking only research cigarettes focused on dislike for cigarette taste and lower satisfaction compared to usual brand cigarettes. Negative evaluations of research cigarettes were common across both groups. Many participants in both groups reported that they would decrease their smoking or quit entirely if the research cigarettes were the only ones legally available for purchase in the U.S. CONCLUSIONS: Adolescents may respond to a cigarette nicotine reduction policy by decreasing their cigarette smoking and eventually quitting. These findings suggest a need for public health strategies to reduce smoking initiation and progression in young people and to encourage cessation in the context of a nicotine reduction policy. IMPLICATIONS: Participants' negative subjective responses and challenges with research cigarette adherence offer insight into factors that might influence young people's reactions to a real-world nicotine reduction policy. Adolescents who smoke may increase their use of alternative tobacco products, especially e-cigarettes, if this policy were implemented. Specifically, themes identified across participant responses highlight important considerations for how such a policy might be implemented with specific attention to the unique smoking behaviors and needs of this vulnerable population.

"Healthier health in more ways than one": Perspectives on a program for changing both smoking and obesity-related health behaviors.

INTRODUCTION: Individuals with obesity who smoke cigarettes have increased risk of morbidity and mortality. The goal of the current study was to inform the development of a multiple health behavior change intervention designed to facilitate smoking cessation while also targeting weight gain. METHODS: Four qualitative focus groups were conducted with individuals who smoked cigarettes and had overweight or obesity (n = 16) to explore the combined effects of smoking and obesity, past attempts to quit smoking or lose weight, and preferences for a combined health intervention. RESULTS: Focus groups converged on five themes including: the interactive effects of weight and smoking; lack of experience with evidence-based weight loss approaches; a desire and expectation to lose weight quickly; rapid weight gain during past attempts at smoking cessation; and interest in a multiple health behavior change intervention with weight management preceding smoking cessation and an emphasis on planning for the future and receiving encouragement and support. CONCLUSIONS: Groups provided insight into key topics to highlight in a combined intervention and key issues that have interfered with success in both domains.

Effects of mint, menthol, and tobacco-flavored e-cigarettes on tobacco withdrawal symptoms in adults who smoke menthol cigarettes: A laboratory pilot study.

BACKGROUND: Menthol cigarette smoking has remained stable or increased in certain groups, despite an overall decline in cigarette smoking rates in the U.S. Understanding whether e-cigarettes alter patterns of menthol cigarette use is critical to informing efforts for reducing the public health burden of menthol cigarette smoking. This 2019-2020 laboratory pilot study evaluated whether self-administration of mint-, menthol-, or tobacco-flavored e-cigarettes would differentially impact tobacco withdrawal symptoms in e-cigarette-naïve adults who smoke menthol cigarettes daily. METHODS: Participants (N=17; 35.3% Female; mean age=51.8) attended three laboratory sessions after 16-hours of tobacco abstinence. Participants self-administered a study-provided JUUL e-cigarette (0.7mL with 5% nicotine by weight) at each session in which flavor was manipulated (mint vs. menthol vs. tobacco; order randomized). Participants completed pre- and post-e-cigarette administration self-report assessments on smoking urges, nicotine withdrawal, and positive and negative affect states. Multilevel linear regression models tested differences between the three flavor conditions for individual study outcomes. RESULTS: Following overnight tobacco abstinence, vaping either a mint or menthol (vs. tobacco) flavored e-cigarette led to significantly greater reductions in smoking urges over time; menthol (vs. tobacco) flavored e-cigarettes also suppressed urges to smoke for pleasure. Notably, no differences in nicotine withdrawal, positive affect, or negative affect were observed. CONCLUSIONS: In this laboratory pilot study, mint and menthol (vs. tobacco) flavored e-cigarettes provided some negative reinforcement effects via acute reductions in smoking urges during tobacco abstinence, yet only menthol flavored e-cigarettes demonstrated suppressive effects on smoking urges for pleasure in adults who smoke menthol cigarettes daily.

Technology-Based Smoking Cessation for Youth Exiting Foster Care: A Pilot Randomized Trial.

Despite high rates of cigarette use, little attention has been paid to screening and cessation services for youth in foster care. Study aims were to test the feasibility, acceptability, and preliminary efficacy of a technology-based smoking cessation intervention. Study enrollment, satisfaction, and engagement were high in the intervention arm, where readiness to change also significantly increased over time. Intervention and control participants significantly reduced cigarette use at 6-month follow up, though groups did not differ. Technology-based interventions appear to be attractive and offer a potentially scalable link to health care that this vulnerable population may not otherwise seek.

Qualitative reactions to a low nicotine product standard for cigarettes from adolescents and young adults living in the United States who smoke.

The Biden Administration is considering a low nicotine product standard for cigarettes. This qualitative study examined reactions to a nicotine reduction policy among adolescents and young adults (AYA) who smoke cigarettes. After completing a lab study involving masked exposure either to low nicotine or normal nicotine research cigarettes and unmasked exposure to e-cigarettes varying in nicotine concentration and flavor, we conducted follow-up semi-structured interviews (N = 25) to explore participants' knowledge, attitudes, and perceptions of a low nicotine product standard and their anticipated tobacco use behavior after policy implementation. Interviews were audio-recorded, transcribed verbatim, double-coded, and analyzed using reflexive thematic analysis. Nearly half of participants supported the policy because they thought it would prevent young people from starting smoking and/or would help people quit. Reasons some participants opposed the policy included beliefs that adults should have the choice to smoke or that a nicotine reduction policy is counterintuitive because the government benefits from cigarette sales. Others believed the policy would be ineffective because youth could circumvent the policy (e.g., illicit market) or would increase their smoking to maintain the same nicotine level. Almost half of participants said they would quit smoking while the other half said they would continue smoking, although potentially reduce their smoking. Overall, our qualitative findings point to the need for pre-policy media campaigns targeting AYA who smoke to minimize negative reactions, dispel fears, and correct misperceptions as well as encourage quitting and provide information on accessing cessation resources.

The impact of the COVID-19 pandemic on a sample of US young adults who smoke cigarettes: A qualitative analysis.

INTRODUCTION: The ongoing COVID-19 pandemic has been associated with increased negative mood in youth, and a few reports of changes in tobacco use. We sought to increase the depth of knowledge on the effects of the pandemic on early young adult mood states, access to tobacco products and tobacco use behaviors, and knowledge of risks associated with tobacco use and COVID-19 by learning more about the lived experience of the pandemic among young adults early in their smoking trajectories. METHODS: Semi-structured qualitative interviews were conducted with 25 young adults ages 18-20 (M = 19) who smoked cigarettes daily or nearly every day and had used electronic cigarettes (ECs) on ≥ 2 occasions in their lifetime. RESULTS: Our results uncovered several themes: 1) The majority of teens experienced mental health disturbances as a result of the pandemic, which manifested as depression, anxiety, and/or acute loneliness due to social isolation; 2) tobacco purchasing behaviors sometimes changed, with both greater and less access reported among participants; 3) changes in tobacco use were also reported, with some reporting increases in use, others reporting decreases, and a few reporting quitting; and 4) while some youth reported that tobacco use could increase their risk related to COVID-19, the majority reported confusion and uncertainty about how tobacco use impacted their risk. CONCLUSIONS: The themes identified specific factors that may account for the heterogeneity of impacts of the pandemic on tobacco use, and highlight the value of qualitative work for centering the lived experience of youth for understanding larger trends in substance use.

Interactive effects of financial strain and distress tolerance on prequit tobacco withdrawal symptoms in smokers preparing to initiate a quit attempt.

Smokers experiencing greater financial strain are less likely to successfully quit smoking, possibly due to greater severity of tobacco withdrawal. However, limited research has explored whether individual-level psychological factors (i.e., distress tolerance) may buffer the deleterious effects of financial strain on withdrawal. This study examined the main and interactive effects of financial strain and distress tolerance on tobacco withdrawal experienced prior to quitting smoking among smokers preparing to initiate a quit attempt. Fifty-nine adult smokers completed a baseline session including a financial strain measure and subjective and behavioral assessments of distress tolerance. Participants were then instructed to initiate a quit attempt, without any behavioral or pharmacological assistance, 14 days following baseline. Prequit tobacco withdrawal symptoms were assessed once per day for 3 days prior to quit date. Linear regression models tested main and interactive effects between financial strain and distress tolerance on experiences and perceptions of prequit withdrawal. Findings demonstrated significant interactions between financial strain, distress tolerance, and perceptions of tolerating withdrawal. Negative associations found between higher distress tolerance and lower perceptions of tobacco withdrawal and negative mood as being "intolerable" prior to quitting were stronger for those experiencing greater levels of financial strain. Financial strain may negatively impact one's perceived ability to tolerate mood- and tobacco-related withdrawal prior to quitting. Yet, higher distress tolerance may buffer the effects of financial strain on smoking cessation processes. Psychosocial interventions designed to promote tolerance of distress from both internal and external stressors may benefit cessation efforts among smokers experiencing high financial strain. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Reducing Smoking Cessation Disparities: Capacity for a Primary Care- and Technology-Based Approach Among Medicaid Recipients.

While cigarette use among U.S adults has recently decreased, vulnerable subgroups continue to smoke at high rates, including individuals receiving Medicaid insurance. These individuals have also experienced treatment access disparities, highlighting the need for approaches that leverage their strong desire to quit. We conducted interviews with 100 adult primary care patients receiving Medicaid who were current tobacco users about their use, openness to technology-based interventions, and readiness to change. Most (92%) reported current cigarette use and readiness to change averaged 6.98 out of 10 (SD = 2.82). Nearly all were open to completing an iPad-based tobacco screening (95%) and brief intervention (90%) at their next appointment, while 91% and 88% were willing to talk with their provider or a cessation counselor, respectively, about the subsequent results. Results persisted across age, sex, and race/ethnicity. Openness to technology-based interventions in this population provides support for future work that may ultimately reduce disparities.